Learning from practice Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region Executive summary LIVERPOOL U N I V E R S I T Y O F Environmental Assessment and Management RESEARCH CENTRE WHO Collaborating Centre on Health in Impact Assessments © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition: Learning from practice: case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region. Executive summary. Copenhagen: WHO Regional Office for Europe; 2022”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Learning from practice: case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region. Executive summary. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design: 4PLUS4 Acknowledgements This report was prepared by: • Ryngan Pyper (Ben Cave Associates Ltd, and WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom); • Thomas B Fischer (WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom); • Tara Muthoora (WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom); • Ben Cave (Ben Cave Associates Ltd, and WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom). WHO would like to thank the reviewer, Dr Gabriel Gulis, WHO Consultant, University of Southern Denmark, for his input and helpful comments on drafts of the publication. Julia Nowacki and Sinaia Netanyahu, WHO Regional Office for Europe, supported designing the scope of the project at an early stage, provided comments on various drafts and coordinated the production of the report. Comments were also provided by Francesca Racioppi, WHO Regional Office for Europe. This report was produced with financial assistance from the German Federal Ministry of Health. WHO/EURO:2022-4882-44645-63360 Executive Summary Introduction Human health and the environment are inextricably linked, and can be affected by human activities, such as in agriculture, infrastructure and industry. There is a well-consolidated body of national and international instruments that govern the conduct of assessments of the potential impacts that prospective projects, plans and programmes may have on human health and the environment, with the aim of identifying, preventing, mitigating and managing such impacts. While the assessment of environmental impacts is by and large well established, both in regulatory terms and in practice, the assessment of the impacts on health remains less clearly defined and regulated. One key dimension relates to the definition of “health” adopted in these assessments, often restricted only to its biophysical aspects, and ignoring other important determinants, including health inequalities, healthy lifestyles, safe and cohesive communities, socioeconomic conditions, and health and social-care services. This report is the first review to focus on the way that human health is considered in environmental assessment reports across all the Member States of the WHO European Region. It investigates how human health is interpreted and covered in strategic environmental assessment (SEA) and environmental impact assessment (EIA) within the 53 Member States of the Region (1). It presents a set of good practices that document the benefits of adopting a “broad” definition of health in these assessments to reach better informed decisions and to improve the identification of health impacts and opportunities to prevent, mitigate and manage them. 1 Learning from practice. Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region Audience The report is intended for practitioners from environmental, health and planning sectors at all levels of governments. It can also support intergovernmental processes related to relevant conventions and protocols. This report does not discuss basic terminology in impact assessment. Research question The primary research question asks how statutory SEA and EIA requirements for the coverage of human health are interpreted and expressed through practices across the WHO European Region. A key aim is to identify whether SEA and EIA cases adopt a broad definition of health, which is consistent with that in the WHO Constitution1. “Broad” or “wide” is used to describe a perspective that considers the social, economic, behavioural and institutional aspects of health, as well as the biophysical. “Narrow” is used to describe a perspective that is limited to the biophysical. Method The work includes a search for SEA and EIA reports that address human health. A total of 106 separate searches – 53 on EIA and 53 on SEA – were undertaken across the 53 Member States of the Region. Typically, 50–500 results per Member State were reviewed. The review aimed to identify a sample of cases, not an exhaustive list of all cases. The timeframes for the SEA and EIA reports were dictated by the relevant legislation. SEA reports were included if they were published after the country became subject to the Protocol on Strategic Environmental Assessment to the Convention on Environmental Impact Assessment in a Transboundary Context (Espoo Convention), hereafter the “Protocol on SEA”, that is July 2010 or the date of ratification if later. EIA reports were included if they were published after the country’s implementation of the 2014 European Union (EU) EIA Directive, that is post 16 May 2017. This report also includes a literature review of academic articles on the consideration of health in SEA and EIA. 1 “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Constitution of the World Health Organization (2). 2 Executive Summary Results The team reviewed content from across the WHO European Region in multiple languages. In total, 136 SEAs and 197 EIAs were identified as being suitable for inclusion in further review. Each of these 333 candidate case studies was analysed in relation to the “meaning” of health within the assessment. Finally, 12 cases were purposively selected to be written up to reflect good practice for the coverage of health in SEA and EIA across a range of countries, sectors and scales of proposal. Overall, around 10% of the 333 candidate cases showed a “broad” wider determinants of health interpretation within the assessments (i.e. assessing social, economic, behavioural and institutional drivers of health, as well as environmental factors). Another 10% provided definitions of health that acknowledged wider determinants. Of the12 case studies written up, 6 were SEAs and 6 were EIAs. SEA case studies have been written up in this report for Belgium, Estonia, France, Ireland, Sweden, and the United Kingdom. The relevance of the EU SEA Directive 2001/42/EC and the Protocol on SEA is noted in each case. Case studies cover spatial plan making at municipal and neighbourhood scales, regional waste policy and national transport plan making. EIA case studies have been written up for Finland, Georgia, Hungary, Ireland, Lithuania and Portugal. The relevance of the EU EIA Directive 2014/52/EU is noted in each case. Case studies cover energy, industry, transport, and urban development. A search was also made of academic databases to inquire how health is considered in SEA and EIA. This identified 35 articles which were reviewed for this report. 3 Learning from practice. Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region Discussion The case studies show current practice, and they provide examples of the ways in which determinants of health are being considered in SEA and in EIA across countries and sectors, for both public and private sector proposals. The case studies and the literature review demonstrate that SEAs and EIAs use wider determinants of health to define human health within their scoping and assessment. They also show how defining health in a way that is consistent with the WHO constitution allows a proportionate assessment2 to be conducted. Furthermore, it is proportionate for guidance on human health in SEA and EIA to require the consideration of health inequalities, healthy lifestyles, safe and cohesive communities, socioeconomic conditions, environmental conditions and health and social-care services. The case studies indicate that this approach is consistent with current practice. It is also consistent with: • the EU EIA Directive (3), which has a key objective to “ensure a high level of protection of the environment and of human health”; • the EU SEA Directive (4), which states a key aim that “policy on the environment is to contribute to, inter alia, the preservation, protection and improvement of the quality of the environment, [and] the protection of human health…”; • the emphasis on health under the United Nations Economic Commission for Europe (UNECE) Protocol on SEA, as expressed by the objective that “environmental, including health, considerations are thoroughly taken into account in the development of plans and programmes” (5). The use of a definition of health that is consistent with the WHO constitution enables the range of likely significant health effects of any given proposal to be properly understood. The EU SEA and EIA directives are silent on how to meet their respective requirements to consider human health. The authors of this report note that use of the wider determinants of health supports good practice in other aspects of the assessment, for example: • The EIA Directive requires assessment of “the direct and indirect significant effects of a project on … human health”. • The SEA Directive requires assessment of “the likely significant effects [including secondary effects] on the environment, including on issues such as … human health”. The EU SEA and EIA directives require health to be considered in its own right as a factor affected by the proposal and in terms of the interaction between health, population and listed environmental factors. There is discrepancy within practice as to whether a narrow or broad interpretation of health is appropriate within SEA and EIA. The case studies presented show 2 A proportionate assessment is one that focusses on those factors that are important. From a health perspective, this means focusing on the determinants of health that are relevant to the assessment of a particular plan, programme or project and keeping that focus on determinants that have the potential for likely and significant effects on population health. 4 Executive Summary that a broad approach is successfully being taken in current practice in a range of countries, sectors and scales of proposal. The broad interpretation of health provides decision-makers with information on how health is affected directly by environmental change, and indirectly by the social, economic, behavioural and institutional consequences of environmental change. It also allows decision- makers to identify any trade-offs that will potentially be made between environmental, social, economic, behavioural and institutional determinants of health. Responding to any such trade-offs is an essential element of delivering the key objectives of SEAs and EIAs, which can be summarized as the protection of the environment and human health. The focus of this review is on the 10% of SEAs and EIAs that took the consideration of wider determinants of health through to the full assessment. The authors note that 64% of SEAs and 45% of EIAs acknowledged the importance of social and economic aspects of the proposals in addition to considering environmental impacts. Linking these existing social and economic elements of the assessment to a discussion of population health outcomes would be consistent with the aims of environmental assessment (3–5). Protecting and improving population health has intrinsic value and it is ultimately cost saving for society and governments (6,7). Changes in the design of a proposal, or delays arising from challenges to a proposal, are expensive to address when they come late. The early adoption of a broad meaning of health within SEA and EIA, and a consideration of likely significant health effects, is likely to be cost saving for the proponent and for wider society. Assessments are conducted while the proposal is being developed and so this broad definition supports better decision-making and, therefore, health improvement, health protection and sustainable development that is just and inclusive. It also ensures that the scope of the health component of the assessment is responsive to present and future challenges, such as the changing climate and pandemics. The findings of this report suggest that the following actions to build capacity for health in environmental assessment will be beneficial: • promoting international and national good practice on health in environmental assessment which aligns with recent publications on health in SEA (8), health in EIA (9) and health impact assessment (10); • increasing public health knowledge and experience within the private sector that conducts impact assessment, including through education, training and competency requirements; • clarifying the mandate for national health stakeholders’ formal engagement in SEA and EIA. 5 Learning from practice. Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region References 1. Countries. In: WHO Regional Office for Europe [website]. Copenhagen: WHO Regional Office for Europe; 2021 (https://www.euro.who.int/en/countries, accessed 17 November 2021). 2. Constitution of the World Health Organization. In: Basic documents. Forty-ninth edition. Geneva: World Health Organization; 2020 (https://apps.who.int/gb/bd/, accessed 17 November 2021). 3. European Parliament, Council of the European Union. Directive 2014/52/EU of the European Parliament and of the Council of 16 April 2014 amending Directive 2011/92/ EU on the assessment of the effects of certain public and private projects on the environment. Official Journal of the European Union. 2014;L124/1 (https://eur-lex.europa. eu/legal-content/EN/TXT/?uri=celex%3A32014L0052, accessed 17 November 2021). 4. European Parliament, Council of the European Union. Directive 2001/42/EC of the European Parliament and of the Council of 27 June 2001 on the assessment of the effects of certain plans and programmes on the environment. Official Journal of the European Union. 2001;L197 (http://data.europa.eu/eli/dir/2001/42/oj, accessed 17 November 2021). 5. Convention on Environmental Impact Assessment in a Transboundary Context. Geneva: United Nations Economic Commission for Europe; 2015 (https://unece.org/fileadmin/ DAM/env/eia/Publications/2015/ECE.MP.EIA.21_Convention_on_Environmental_Impact_ Assessment.pdf, accessed 17 November 2021). 6. The case for investing in public health. A public health summary report for EPHO 8. Copenhagen: WHO Regional Office for Europe; 2014 (https://www.euro.who.int/__data/ assets/pdf_file/0009/278073/Case-Investing-Public-Health.pdf, accessed 17 November 2021). 7. McGuire F, Vijayasingham L, Vassall A, Small R, Webb D, Guthrie T et al. Financing intersectoral action for health: a systematic review of co-financing models. Glob Health. 2019;15. doi: 10.1186/s12992-019-0513-7. 8. Draft guidance on assessing health impacts in strategic environmental assessment. Geneva: United Nations Economic Commission for Europe; 2020 (https://www.unece. org/fileadmin/DAM/env/eia/documents/WG.9_2020/Final_documents/2004508E.pdf, accessed 17 November 2021). 6 Executive Summary 9. Cave B, Claßen T, Fischer-Bonde B, Humboldt-Dachroeden S, Martín-Olmedo P, Mekel O et al. Human health: ensuring a high level of protection. A reference paper on addressing human health in environmental impact assessment as per EU Directive 2011/92/EU amended by 2014/52/EU. Fargo: International Association for Impact Assessment and European Public Health Association; 2020 (https://www.iaia.org/uploads/pdf/Human%20 Health%20Ensuring%20Protection%20Summary.pdf, accessed 17 November 2021). 10. Pyper R, Cave B, Purdy J, McAvoy H. Health impact assessment guidance: a manual and technical guidance. Dublin and Belfast: Institute of Public Health in Ireland; 2021 (https:// publichealth.ie/hia-guidance/, accessed 17 November 2021). 7 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. WHO European Centre for Environment and Health Platz der Vereinten Nationen 1 D-53113 Bonn Germany Tel.: +49 228 815 0400 Fax: +49 228 815 0440 Email: euroeceh@who.int Website: www.euro.who.int WHO/EURO:2022-4882-44645-63360 Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Member States
Learning from practice Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region Executive summary LIVERPOOL U N I V E R S I T Y O F Environmental Assessment and Management RESEARCH CENTRE WHO Collaborating Centre on Health in Impact Assessments © World Health Organization 2022 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition: Learning from practice: case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region. Executive summary. Copenhagen: WHO Regional Office for Europe; 2022”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/). Suggested citation. Learning from practice: case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region. Executive summary. Copenhagen: WHO Regional Office for Europe; 2022. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Design: 4PLUS4 Acknowledgements This report was prepared by: • Ryngan Pyper (Ben Cave Associates Ltd, and WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom); • Thomas B Fischer (WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom); • Tara Muthoora (WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom); • Ben Cave (Ben Cave Associates Ltd, and WHO Collaborating Centre on Health in Impact Assessments, University of Liverpool, United Kingdom). WHO would like to thank the reviewer, Dr Gabriel Gulis, WHO Consultant, University of Southern Denmark, for his input and helpful comments on drafts of the publication. Julia Nowacki and Sinaia Netanyahu, WHO Regional Office for Europe, supported designing the scope of the project at an early stage, provided comments on various drafts and coordinated the production of the report. Comments were also provided by Francesca Racioppi, WHO Regional Office for Europe. This report was produced with financial assistance from the German Federal Ministry of Health. WHO/EURO:2022-4882-44645-63360 Executive Summary Introduction Human health and the environment are inextricably linked, and can be affected by human activities, such as in agriculture, infrastructure and industry. There is a well-consolidated body of national and international instruments that govern the conduct of assessments of the potential impacts that prospective projects, plans and programmes may have on human health and the environment, with the aim of identifying, preventing, mitigating and managing such impacts. While the assessment of environmental impacts is by and large well established, both in regulatory terms and in practice, the assessment of the impacts on health remains less clearly defined and regulated. One key dimension relates to the definition of “health” adopted in these assessments, often restricted only to its biophysical aspects, and ignoring other important determinants, including health inequalities, healthy lifestyles, safe and cohesive communities, socioeconomic conditions, and health and social-care services. This report is the first review to focus on the way that human health is considered in environmental assessment reports across all the Member States of the WHO European Region. It investigates how human health is interpreted and covered in strategic environmental assessment (SEA) and environmental impact assessment (EIA) within the 53 Member States of the Region (1). It presents a set of good practices that document the benefits of adopting a “broad” definition of health in these assessments to reach better informed decisions and to improve the identification of health impacts and opportunities to prevent, mitigate and manage them. 1 Learning from practice. Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region Audience The report is intended for practitioners from environmental, health and planning sectors at all levels of governments. It can also support intergovernmental processes related to relevant conventions and protocols. This report does not discuss basic terminology in impact assessment. Research question The primary research question asks how statutory SEA and EIA requirements for the coverage of human health are interpreted and expressed through practices across the WHO European Region. A key aim is to identify whether SEA and EIA cases adopt a broad definition of health, which is consistent with that in the WHO Constitution1. “Broad” or “wide” is used to describe a perspective that considers the social, economic, behavioural and institutional aspects of health, as well as the biophysical. “Narrow” is used to describe a perspective that is limited to the biophysical. Method The work includes a search for SEA and EIA reports that address human health. A total of 106 separate searches – 53 on EIA and 53 on SEA – were undertaken across the 53 Member States of the Region. Typically, 50–500 results per Member State were reviewed. The review aimed to identify a sample of cases, not an exhaustive list of all cases. The timeframes for the SEA and EIA reports were dictated by the relevant legislation. SEA reports were included if they were published after the country became subject to the Protocol on Strategic Environmental Assessment to the Convention on Environmental Impact Assessment in a Transboundary Context (Espoo Convention), hereafter the “Protocol on SEA”, that is July 2010 or the date of ratification if later. EIA reports were included if they were published after the country’s implementation of the 2014 European Union (EU) EIA Directive, that is post 16 May 2017. This report also includes a literature review of academic articles on the consideration of health in SEA and EIA. 1 “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Constitution of the World Health Organization (2). 2 Executive Summary Results The team reviewed content from across the WHO European Region in multiple languages. In total, 136 SEAs and 197 EIAs were identified as being suitable for inclusion in further review. Each of these 333 candidate case studies was analysed in relation to the “meaning” of health within the assessment. Finally, 12 cases were purposively selected to be written up to reflect good practice for the coverage of health in SEA and EIA across a range of countries, sectors and scales of proposal. Overall, around 10% of the 333 candidate cases showed a “broad” wider determinants of health interpretation within the assessments (i.e. assessing social, economic, behavioural and institutional drivers of health, as well as environmental factors). Another 10% provided definitions of health that acknowledged wider determinants. Of the12 case studies written up, 6 were SEAs and 6 were EIAs. SEA case studies have been written up in this report for Belgium, Estonia, France, Ireland, Sweden, and the United Kingdom. The relevance of the EU SEA Directive 2001/42/EC and the Protocol on SEA is noted in each case. Case studies cover spatial plan making at municipal and neighbourhood scales, regional waste policy and national transport plan making. EIA case studies have been written up for Finland, Georgia, Hungary, Ireland, Lithuania and Portugal. The relevance of the EU EIA Directive 2014/52/EU is noted in each case. Case studies cover energy, industry, transport, and urban development. A search was also made of academic databases to inquire how health is considered in SEA and EIA. This identified 35 articles which were reviewed for this report. 3 Learning from practice. Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region Discussion The case studies show current practice, and they provide examples of the ways in which determinants of health are being considered in SEA and in EIA across countries and sectors, for both public and private sector proposals. The case studies and the literature review demonstrate that SEAs and EIAs use wider determinants of health to define human health within their scoping and assessment. They also show how defining health in a way that is consistent with the WHO constitution allows a proportionate assessment2 to be conducted. Furthermore, it is proportionate for guidance on human health in SEA and EIA to require the consideration of health inequalities, healthy lifestyles, safe and cohesive communities, socioeconomic conditions, environmental conditions and health and social-care services. The case studies indicate that this approach is consistent with current practice. It is also consistent with: • the EU EIA Directive (3), which has a key objective to “ensure a high level of protection of the environment and of human health”; • the EU SEA Directive (4), which states a key aim that “policy on the environment is to contribute to, inter alia, the preservation, protection and improvement of the quality of the environment, [and] the protection of human health…”; • the emphasis on health under the United Nations Economic Commission for Europe (UNECE) Protocol on SEA, as expressed by the objective that “environmental, including health, considerations are thoroughly taken into account in the development of plans and programmes” (5). The use of a definition of health that is consistent with the WHO constitution enables the range of likely significant health effects of any given proposal to be properly understood. The EU SEA and EIA directives are silent on how to meet their respective requirements to consider human health. The authors of this report note that use of the wider determinants of health supports good practice in other aspects of the assessment, for example: • The EIA Directive requires assessment of “the direct and indirect significant effects of a project on … human health”. • The SEA Directive requires assessment of “the likely significant effects [including secondary effects] on the environment, including on issues such as … human health”. The EU SEA and EIA directives require health to be considered in its own right as a factor affected by the proposal and in terms of the interaction between health, population and listed environmental factors. There is discrepancy within practice as to whether a narrow or broad interpretation of health is appropriate within SEA and EIA. The case studies presented show 2 A proportionate assessment is one that focusses on those factors that are important. From a health perspective, this means focusing on the determinants of health that are relevant to the assessment of a particular plan, programme or project and keeping that focus on determinants that have the potential for likely and significant effects on population health. 4 Executive Summary that a broad approach is successfully being taken in current practice in a range of countries, sectors and scales of proposal. The broad interpretation of health provides decision-makers with information on how health is affected directly by environmental change, and indirectly by the social, economic, behavioural and institutional consequences of environmental change. It also allows decision- makers to identify any trade-offs that will potentially be made between environmental, social, economic, behavioural and institutional determinants of health. Responding to any such trade-offs is an essential element of delivering the key objectives of SEAs and EIAs, which can be summarized as the protection of the environment and human health. The focus of this review is on the 10% of SEAs and EIAs that took the consideration of wider determinants of health through to the full assessment. The authors note that 64% of SEAs and 45% of EIAs acknowledged the importance of social and economic aspects of the proposals in addition to considering environmental impacts. Linking these existing social and economic elements of the assessment to a discussion of population health outcomes would be consistent with the aims of environmental assessment (3–5). Protecting and improving population health has intrinsic value and it is ultimately cost saving for society and governments (6,7). Changes in the design of a proposal, or delays arising from challenges to a proposal, are expensive to address when they come late. The early adoption of a broad meaning of health within SEA and EIA, and a consideration of likely significant health effects, is likely to be cost saving for the proponent and for wider society. Assessments are conducted while the proposal is being developed and so this broad definition supports better decision-making and, therefore, health improvement, health protection and sustainable development that is just and inclusive. It also ensures that the scope of the health component of the assessment is responsive to present and future challenges, such as the changing climate and pandemics. The findings of this report suggest that the following actions to build capacity for health in environmental assessment will be beneficial: • promoting international and national good practice on health in environmental assessment which aligns with recent publications on health in SEA (8), health in EIA (9) and health impact assessment (10); • increasing public health knowledge and experience within the private sector that conducts impact assessment, including through education, training and competency requirements; • clarifying the mandate for national health stakeholders’ formal engagement in SEA and EIA. 5 Learning from practice. Case studies of health in strategic environmental assessment and environmental impact assessment across the WHO European Region References 1. Countries. In: WHO Regional Office for Europe [website]. Copenhagen: WHO Regional Office for Europe; 2021 (https://www.euro.who.int/en/countries, accessed 17 November 2021). 2. Constitution of the World Health Organization. In: Basic documents. Forty-ninth edition. Geneva: World Health Organization; 2020 (https://apps.who.int/gb/bd/, accessed 17 November 2021). 3. European Parliament, Council of the European Union. Directive 2014/52/EU of the European Parliament and of the Council of 16 April 2014 amending Directive 2011/92/ EU on the assessment of the effects of certain public and private projects on the environment. Official Journal of the European Union. 2014;L124/1 (https://eur-lex.europa. eu/legal-content/EN/TXT/?uri=celex%3A32014L0052, accessed 17 November 2021). 4. European Parliament, Council of the European Union. Directive 2001/42/EC of the European Parliament and of the Council of 27 June 2001 on the assessment of the effects of certain plans and programmes on the environment. Official Journal of the European Union. 2001;L197 (http://data.europa.eu/eli/dir/2001/42/oj, accessed 17 November 2021). 5. Convention on Environmental Impact Assessment in a Transboundary Context. Geneva: United Nations Economic Commission for Europe; 2015 (https://unece.org/fileadmin/ DAM/env/eia/Publications/2015/ECE.MP.EIA.21_Convention_on_Environmental_Impact_ Assessment.pdf, accessed 17 November 2021). 6. The case for investing in public health. A public health summary report for EPHO 8. Copenhagen: WHO Regional Office for Europe; 2014 (https://www.euro.who.int/__data/ assets/pdf_file/0009/278073/Case-Investing-Public-Health.pdf, accessed 17 November 2021). 7. McGuire F, Vijayasingham L, Vassall A, Small R, Webb D, Guthrie T et al. Financing intersectoral action for health: a systematic review of co-financing models. Glob Health. 2019;15. doi: 10.1186/s12992-019-0513-7. 8. Draft guidance on assessing health impacts in strategic environmental assessment. Geneva: United Nations Economic Commission for Europe; 2020 (https://www.unece. org/fileadmin/DAM/env/eia/documents/WG.9_2020/Final_documents/2004508E.pdf, accessed 17 November 2021). 6 Executive Summary 9. Cave B, Claßen T, Fischer-Bonde B, Humboldt-Dachroeden S, Martín-Olmedo P, Mekel O et al. Human health: ensuring a high level of protection. A reference paper on addressing human health in environmental impact assessment as per EU Directive 2011/92/EU amended by 2014/52/EU. Fargo: International Association for Impact Assessment and European Public Health Association; 2020 (https://www.iaia.org/uploads/pdf/Human%20 Health%20Ensuring%20Protection%20Summary.pdf, accessed 17 November 2021). 10. Pyper R, Cave B, Purdy J, McAvoy H. Health impact assessment guidance: a manual and technical guidance. Dublin and Belfast: Institute of Public Health in Ireland; 2021 (https:// publichealth.ie/hia-guidance/, accessed 17 November 2021). 7 The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. WHO European Centre for Environment and Health Platz der Vereinten Nationen 1 D-53113 Bonn Germany Tel.: +49 228 815 0400 Fax: +49 228 815 0440 Email: euroeceh@who.int Website: www.euro.who.int WHO/EURO:2022-4882-44645-63360 Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan Member States