1 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 27 th Session of WHO South-East Asia Advisory Committee on Health Research 15-18 April 2002, Dhaka, Bangladesh SEA/ACHR/27/11 9 April 2002 Agenda Item 2.3 Ecology & Health: Health Impact Assessment AN EVALUATION OF HEALTH IMPACT ASSESSMENT RESEARCH NEEDS FOR THE COUNTRIES OF SOUTH-EAST ASIA TABLE OF CONTENTS 1. INTRODUCTION......................................................................................................... 1 2. HEALTH IMPACT ASSESSMENT, A TOOL FOR MONITORING DEVELOPMENT PROJECTS ................................................................................................................. 1 3. HIA DEVELOPMENT IN THE REGION ...................................................................... 1 3.1 High Prevalence of Hazardous Conditions and Environmentally Linked Diseases.......................................................................................................... 2 3.2 Fragmented or Absent Policy Basis for HIA .................................................... 2 3.3 Varying Degree of Infrastructure to Support HIA............................................. 3 3.4 Potential Capacity for Undertaking HIA........................................................... 3 3.5 Potential for Inter-sectoral Collaboration in HIA .............................................. 3 4. CONCLUSIONS.......................................................................................................... 4 1 1. INTRODUCTION Health is inextricably linked to the environment, which is influenced by development projects. A range of unintended impacts on the human health invariably accompanies the development projects. Uncontrolled toxic pollutants from development find their ways in air, water, food and soil. Currently, environmental hazards cause or contribute to the premature death of millions of people worldwide and result in the ill health or disablement of hundreds of millions more each year. Some possible explanations for these negative health effects are: 1) lack of understanding of the exact role of the different agencies involved, 2) weak or non-existent policy on health impact assessment, 3) varying degrees of infrastructure, and 4) the lack of standardized methodologies for assessing the impact of development projects. Environmental Impact Assessment (EIA) has been traditionally used to evaluate the impact of development projects. However, most EIA procedures are confined to environmental impact and have a narrow focus on assessment of health impact. Furthermore, EIA is limited to project level and do not assess policy or programme. Therefore, what is needed is a common tool that can be shared by policy makers and implementers from the health and non-health sectors alike. The health impact assessment (HIA) method provides a crosscutting tool that can be used to mitigate the negative health impact of development projects. 2. HEALTH IMPACT ASSESSMENT, A TOOL FOR MONITORING DEVELOPMENT PROJECTS HIA can inform policy and decision makers to maximize the benefits and minimize the negative impacts on health. It uses a combination of procedures, methods and tools to evaluate the potential health effects of policy development, project planning or programme implementation. Specifically, the main applications of HIA are: 1) Producing evidence required by law to evaluate impacts of large development/infrastructure project; 2) evaluating different policy scenarios of assessment; 3) providing estimate of expected morbidity for local evaluation of suspected disease clusters; 4) analyzing local pollution situation, and 5) undertaking projects to calculate cost-benefits of risk management. Health Impact Assessment can be used at any stage of the developmental project’s life cycle. Thus, it can be used prospectively during planning stage; concurrently during implementation, or retrospectively to assess the impact of projects that have been in existence for a while. The preferred method is to conduct a prospective health impact assessment. 3. HIA DEVELOPMENT IN THE REGION Realizing the importance of health impact assessment in non-health sectors, WHO participated in the World Summit of the UNCEDs’ agenda 21 and each region has developed its own framework for implementation. As a first step towards the implementation of HIA, in 1999, SEARO hosted an intercountry consultation on the “ Adverse Effects of Development Projects on Mosquito-Borne Diseases”. However, the number of health impact assessment of development projects has not subsequently increased, thus indicating the presence of impeding factors. Therefore, to assess current gaps and set priorities in HIA, in 2001, SEARO conducted a situation analysis of HIA in nine countries of the region, namely Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. The information that was collected pertained to HIA on policy and framework, existing infrastructure, capacity for undertaking HIA and existing 2 arrangement for intersectoral collaboration. For an objective and valid comparison across all the countries, a uniform numerical composite index was designed: Each of the component was given a score depending on the presence or absence of the criteria that were assessed then combined to obtain the composite indicator score that was set for a maximum numerical value of 10. This paper reviews the findings and assesses the research gap needs in this area. The conclusions are tempered by limitations in the data resulting from lack of reporting-system or incompleteness. Nonetheless, the results of the survey showed the following interesting observations. 3.1 High Prevalence of Hazardous Conditions and Environmentally Linked Diseases Three main sectors that were assessed included agriculture, industries and transport. A high emission load was associated with all sectors, in particular high consumption of pesticides in agriculture, and air pollution from industries and transport sectors. Monitoring data on air pollution showed that the main air pollutants included tiny suspended particles (TSP), Oxides of Nitrogen (NO x ), and Oxides of Sulphur (SOx). In many countries these levels exceed the recommended WHO Air Quality Guidelines values or the prevailing national Air Standards. This was particularly noted for the mega-cities of the region, including Kathmandu, Jakarta, Bangkok, Colombo, Delhi, Calcutta and Dhaka. An examination of disease burden over the last five years, showed a high prevalence of disease that could be linked with development projects, in particular respiratory morbidity and mortality as well as road traffic accidents. Also prevalent were: diseases due to human behavior such as STD associated with the transport sector, diseases of unsanitary conditions such as diarrhoea associated with urban slum, and vector-borne diseases such as malaria and dengue fever associated with water-development projects. Thus, uncontrolled development projects can potentially amplify and propagate these hazardous conditions and diseases and therefore, there is an urgent need for advocating the implementation of HIA. 3.2 Fragmented or Absent Policy Basis for HIA One of the major requirements for health impact assessment is the existence of firm policy on HIA. Ideally, such policies should encompass: legislation, guidelines and procedures, environmental standards, well-formulated action plan, and mechanisms for monitoring and implementation of HIA. However, in almost all countries, there is no explicit legislation pertaining to HIA and HIA is not conducted routinely. In instances where HIA is practiced it is part of Environmental Impact Assessment (EIA) using the legislation, guidelines and methods of EIA, which are too broad or fragmented to address specific health issues. The existence of a national plan of action or specially designated departments for conducting HIA within the relevant ministries was present in countries like India, Indonesia and Thailand, but not in others. The existing policy and guidelines address the protection of the human environment by controlling hazards from air, water and food and do not explicitly address human health issues. Using a composite score for these criteria, the countries could be categorized into three classes: India, Indonesia and Thailand exemplified one type, in which most of the EIA criteria were met; another type was exemplified by Bangladesh, Sri Lanka and Nepal and Maldives in which a moderate number of the EIA criteria were partially met, whereas, Bhutan and Myanmar represented 3 another category where only a minimum number of these criteria were met. Thus, there is an urgent need for explicit HIA policy in all member countries. 3.3 Varying Degree of Infrastructure to Support HIA Existing policy without an enabling infrastructure is of limited application in health impact assessment. An integrated and functioning network provides a ready source of hazard levels and associated diseases as parameters for Health Impact Assessment. A composite score was designed to assess the existence of systems for environmental and biological monitoring as well as disease surveillance. Using this composite score, it was observed that all countries require strengthening of the infrastructure. However, some variations within the countries were noted, for example countries like Thailand, Sri Lanka, Bangladesh and India, have a fairly good network of monitoring air pollution, water supply and noise at the central levels but this is not so at the intermediate or peripheral levels of administration. Surveillance for the environmentally linked diseases is not routinely done; in most member states such diseases and injuries are not reported unless they form part of an environmental outbreak investigation. In the absence of base-line data on environmental hazards and health risks, it becomes plausible for developers to argue that development projects are not associated with a concomitant increase in disease burden. 3.4 Potential Capacity for Undertaking HIA Regular undertaking of HIA requires a critical capacity. Using the composite score criteria, we assessed the development of human resources through education and training, as well as the existence of research Institutes and the role-played by them, including active publication in HIA research. Indonesia showed the highest potential for conducting HIA followed by Nepal, Sri Lanka, Thailand and Bangladesh and the remaining countries showed less capacity in this respect. There is fair number of research institutes involved in HIA research, but the number of publications is limited indicating either a lack of an enabling environment or an incentive to publish. 3.5 Potential for Inter-sectoral Collaboration in HIA HIA is an exercise that cannot be done in isolation. A clear understanding of the role of each of the sector and private organization is required. This ideally starts with a multidisciplinary-task force consisting of environmentalists, policy makers, engineers, epidemiologists and licensed assessors using standard methods. A composite score was used to assess the presence of central authorities, the roles played by government or donors and the existence of public participation HIA. Most of the countries including Indonesia, Sri Lanka, Nepal and Maldives and Myanmar show a high potential for intersectoral collaboration. Our observation shows that the existence coordination committee remains to be improved in most member states including India and Thailand. In Thailand, there was an apparent duplication or redundancy for the task forces of the coordinating committee whereas in India such committees were virtually absent at the central levels. Intersectoral collaboration must be improved at the Central levels in all countries. 4 4. CONCLUSIONS It is clear that the member countries are at varying stages for undertaking HIA; hence the implementation of HIA is at rudimentary stage. Many countries are implicitly using EIA as a substitute for HIA and are not able to comprehensively address the full health impacts of development projects. This situation truly represents a window of opportunity for sharing of experiences in the region. From the foregoing summary, a number of gaps is apparent in our knowledge to understand why HIA has not been universally used in our region. One of the key issues identified in this survey is that many development projects are outside the scope of the health ministries and there is often little or no intersectoral collaboration. Therefore, it is critical to identify mechanism for influencing policy and decision-makers to address the negative health impact of development project. The main areas for considerations are: • Mechanisms for enhancing intersectoral collaboration of policy makers and implementers are the keys to the successful implementation of HIA. • Capacity building in the area of HIA for undertaking research on promoting HIA in all sectors. • Formulation of a simplified regional method for conducting HIA is needed to facilitate the implementation of HIA. • It is imperative to establish sentinel surveillance sites for gathering evidence on prevalence and incidence of burden of diseases associated with development to provide information for action by policy makers. REFERENCES AND SUGGESTION FOR FURTHER READING (1) Adverse Effects of Development Projects on Mosquito-Borne Diseases – Report of an Intercountry Consultation, Bangkok, Thailand, 18-22 October 1999 (SEA-VBC-74). (2) World Health Organization Working Group. Evaluation and use of epidemiological evidence for environmental health risk assessment: WHO guidance document. Environment Health Perspectives 200; 108: 997-1002. (3) Health impact assessment – theory into practice. J. Epidemiol Community Health, 1998; Vol. 52: pp. 704-705, Alex Scott-Samuel, Liverpool Public Health Observatory, Liverpool. (4) HIA Development in Thailand: Approach, Experiences, Challenges, and Considerations for Future Plan. Mr Decharut Sukkumnoed, Kasetsart University, Thailand (5) Guidelines for Strategic Environmental Assessment (SEA) in South Africa: Potential Applications to the Health Sector, Michelle Audouin, CSIR, South Africa. (6) Executive Summary: Health Impact Assessment: Measuring the Effect of Public Policy on Variations in Health, University of Liverpool, Department of Civic Design and Department of Public Health.
1 WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR SOUTH-EAST ASIA 27 th Session of WHO South-East Asia Advisory Committee on Health Research 15-18 April 2002, Dhaka, Bangladesh SEA/ACHR/27/11 9 April 2002 Agenda Item 2.3 Ecology & Health: Health Impact Assessment AN EVALUATION OF HEALTH IMPACT ASSESSMENT RESEARCH NEEDS FOR THE COUNTRIES OF SOUTH-EAST ASIA TABLE OF CONTENTS 1. INTRODUCTION......................................................................................................... 1 2. HEALTH IMPACT ASSESSMENT, A TOOL FOR MONITORING DEVELOPMENT PROJECTS ................................................................................................................. 1 3. HIA DEVELOPMENT IN THE REGION ...................................................................... 1 3.1 High Prevalence of Hazardous Conditions and Environmentally Linked Diseases.......................................................................................................... 2 3.2 Fragmented or Absent Policy Basis for HIA .................................................... 2 3.3 Varying Degree of Infrastructure to Support HIA............................................. 3 3.4 Potential Capacity for Undertaking HIA........................................................... 3 3.5 Potential for Inter-sectoral Collaboration in HIA .............................................. 3 4. CONCLUSIONS.......................................................................................................... 4 1 1. INTRODUCTION Health is inextricably linked to the environment, which is influenced by development projects. A range of unintended impacts on the human health invariably accompanies the development projects. Uncontrolled toxic pollutants from development find their ways in air, water, food and soil. Currently, environmental hazards cause or contribute to the premature death of millions of people worldwide and result in the ill health or disablement of hundreds of millions more each year. Some possible explanations for these negative health effects are: 1) lack of understanding of the exact role of the different agencies involved, 2) weak or non-existent policy on health impact assessment, 3) varying degrees of infrastructure, and 4) the lack of standardized methodologies for assessing the impact of development projects. Environmental Impact Assessment (EIA) has been traditionally used to evaluate the impact of development projects. However, most EIA procedures are confined to environmental impact and have a narrow focus on assessment of health impact. Furthermore, EIA is limited to project level and do not assess policy or programme. Therefore, what is needed is a common tool that can be shared by policy makers and implementers from the health and non-health sectors alike. The health impact assessment (HIA) method provides a crosscutting tool that can be used to mitigate the negative health impact of development projects. 2. HEALTH IMPACT ASSESSMENT, A TOOL FOR MONITORING DEVELOPMENT PROJECTS HIA can inform policy and decision makers to maximize the benefits and minimize the negative impacts on health. It uses a combination of procedures, methods and tools to evaluate the potential health effects of policy development, project planning or programme implementation. Specifically, the main applications of HIA are: 1) Producing evidence required by law to evaluate impacts of large development/infrastructure project; 2) evaluating different policy scenarios of assessment; 3) providing estimate of expected morbidity for local evaluation of suspected disease clusters; 4) analyzing local pollution situation, and 5) undertaking projects to calculate cost-benefits of risk management. Health Impact Assessment can be used at any stage of the developmental project’s life cycle. Thus, it can be used prospectively during planning stage; concurrently during implementation, or retrospectively to assess the impact of projects that have been in existence for a while. The preferred method is to conduct a prospective health impact assessment. 3. HIA DEVELOPMENT IN THE REGION Realizing the importance of health impact assessment in non-health sectors, WHO participated in the World Summit of the UNCEDs’ agenda 21 and each region has developed its own framework for implementation. As a first step towards the implementation of HIA, in 1999, SEARO hosted an intercountry consultation on the “ Adverse Effects of Development Projects on Mosquito-Borne Diseases”. However, the number of health impact assessment of development projects has not subsequently increased, thus indicating the presence of impeding factors. Therefore, to assess current gaps and set priorities in HIA, in 2001, SEARO conducted a situation analysis of HIA in nine countries of the region, namely Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. The information that was collected pertained to HIA on policy and framework, existing infrastructure, capacity for undertaking HIA and existing 2 arrangement for intersectoral collaboration. For an objective and valid comparison across all the countries, a uniform numerical composite index was designed: Each of the component was given a score depending on the presence or absence of the criteria that were assessed then combined to obtain the composite indicator score that was set for a maximum numerical value of 10. This paper reviews the findings and assesses the research gap needs in this area. The conclusions are tempered by limitations in the data resulting from lack of reporting-system or incompleteness. Nonetheless, the results of the survey showed the following interesting observations. 3.1 High Prevalence of Hazardous Conditions and Environmentally Linked Diseases Three main sectors that were assessed included agriculture, industries and transport. A high emission load was associated with all sectors, in particular high consumption of pesticides in agriculture, and air pollution from industries and transport sectors. Monitoring data on air pollution showed that the main air pollutants included tiny suspended particles (TSP), Oxides of Nitrogen (NO x ), and Oxides of Sulphur (SOx). In many countries these levels exceed the recommended WHO Air Quality Guidelines values or the prevailing national Air Standards. This was particularly noted for the mega-cities of the region, including Kathmandu, Jakarta, Bangkok, Colombo, Delhi, Calcutta and Dhaka. An examination of disease burden over the last five years, showed a high prevalence of disease that could be linked with development projects, in particular respiratory morbidity and mortality as well as road traffic accidents. Also prevalent were: diseases due to human behavior such as STD associated with the transport sector, diseases of unsanitary conditions such as diarrhoea associated with urban slum, and vector-borne diseases such as malaria and dengue fever associated with water-development projects. Thus, uncontrolled development projects can potentially amplify and propagate these hazardous conditions and diseases and therefore, there is an urgent need for advocating the implementation of HIA. 3.2 Fragmented or Absent Policy Basis for HIA One of the major requirements for health impact assessment is the existence of firm policy on HIA. Ideally, such policies should encompass: legislation, guidelines and procedures, environmental standards, well-formulated action plan, and mechanisms for monitoring and implementation of HIA. However, in almost all countries, there is no explicit legislation pertaining to HIA and HIA is not conducted routinely. In instances where HIA is practiced it is part of Environmental Impact Assessment (EIA) using the legislation, guidelines and methods of EIA, which are too broad or fragmented to address specific health issues. The existence of a national plan of action or specially designated departments for conducting HIA within the relevant ministries was present in countries like India, Indonesia and Thailand, but not in others. The existing policy and guidelines address the protection of the human environment by controlling hazards from air, water and food and do not explicitly address human health issues. Using a composite score for these criteria, the countries could be categorized into three classes: India, Indonesia and Thailand exemplified one type, in which most of the EIA criteria were met; another type was exemplified by Bangladesh, Sri Lanka and Nepal and Maldives in which a moderate number of the EIA criteria were partially met, whereas, Bhutan and Myanmar represented 3 another category where only a minimum number of these criteria were met. Thus, there is an urgent need for explicit HIA policy in all member countries. 3.3 Varying Degree of Infrastructure to Support HIA Existing policy without an enabling infrastructure is of limited application in health impact assessment. An integrated and functioning network provides a ready source of hazard levels and associated diseases as parameters for Health Impact Assessment. A composite score was designed to assess the existence of systems for environmental and biological monitoring as well as disease surveillance. Using this composite score, it was observed that all countries require strengthening of the infrastructure. However, some variations within the countries were noted, for example countries like Thailand, Sri Lanka, Bangladesh and India, have a fairly good network of monitoring air pollution, water supply and noise at the central levels but this is not so at the intermediate or peripheral levels of administration. Surveillance for the environmentally linked diseases is not routinely done; in most member states such diseases and injuries are not reported unless they form part of an environmental outbreak investigation. In the absence of base-line data on environmental hazards and health risks, it becomes plausible for developers to argue that development projects are not associated with a concomitant increase in disease burden. 3.4 Potential Capacity for Undertaking HIA Regular undertaking of HIA requires a critical capacity. Using the composite score criteria, we assessed the development of human resources through education and training, as well as the existence of research Institutes and the role-played by them, including active publication in HIA research. Indonesia showed the highest potential for conducting HIA followed by Nepal, Sri Lanka, Thailand and Bangladesh and the remaining countries showed less capacity in this respect. There is fair number of research institutes involved in HIA research, but the number of publications is limited indicating either a lack of an enabling environment or an incentive to publish. 3.5 Potential for Inter-sectoral Collaboration in HIA HIA is an exercise that cannot be done in isolation. A clear understanding of the role of each of the sector and private organization is required. This ideally starts with a multidisciplinary-task force consisting of environmentalists, policy makers, engineers, epidemiologists and licensed assessors using standard methods. A composite score was used to assess the presence of central authorities, the roles played by government or donors and the existence of public participation HIA. Most of the countries including Indonesia, Sri Lanka, Nepal and Maldives and Myanmar show a high potential for intersectoral collaboration. Our observation shows that the existence coordination committee remains to be improved in most member states including India and Thailand. In Thailand, there was an apparent duplication or redundancy for the task forces of the coordinating committee whereas in India such committees were virtually absent at the central levels. Intersectoral collaboration must be improved at the Central levels in all countries. 4 4. CONCLUSIONS It is clear that the member countries are at varying stages for undertaking HIA; hence the implementation of HIA is at rudimentary stage. Many countries are implicitly using EIA as a substitute for HIA and are not able to comprehensively address the full health impacts of development projects. This situation truly represents a window of opportunity for sharing of experiences in the region. From the foregoing summary, a number of gaps is apparent in our knowledge to understand why HIA has not been universally used in our region. One of the key issues identified in this survey is that many development projects are outside the scope of the health ministries and there is often little or no intersectoral collaboration. Therefore, it is critical to identify mechanism for influencing policy and decision-makers to address the negative health impact of development project. The main areas for considerations are: • Mechanisms for enhancing intersectoral collaboration of policy makers and implementers are the keys to the successful implementation of HIA. • Capacity building in the area of HIA for undertaking research on promoting HIA in all sectors. • Formulation of a simplified regional method for conducting HIA is needed to facilitate the implementation of HIA. • It is imperative to establish sentinel surveillance sites for gathering evidence on prevalence and incidence of burden of diseases associated with development to provide information for action by policy makers. REFERENCES AND SUGGESTION FOR FURTHER READING (1) Adverse Effects of Development Projects on Mosquito-Borne Diseases – Report of an Intercountry Consultation, Bangkok, Thailand, 18-22 October 1999 (SEA-VBC-74). (2) World Health Organization Working Group. Evaluation and use of epidemiological evidence for environmental health risk assessment: WHO guidance document. Environment Health Perspectives 200; 108: 997-1002. (3) Health impact assessment – theory into practice. J. Epidemiol Community Health, 1998; Vol. 52: pp. 704-705, Alex Scott-Samuel, Liverpool Public Health Observatory, Liverpool. (4) HIA Development in Thailand: Approach, Experiences, Challenges, and Considerations for Future Plan. Mr Decharut Sukkumnoed, Kasetsart University, Thailand (5) Guidelines for Strategic Environmental Assessment (SEA) in South Africa: Potential Applications to the Health Sector, Michelle Audouin, CSIR, South Africa. (6) Executive Summary: Health Impact Assessment: Measuring the Effect of Public Policy on Variations in Health, University of Liverpool, Department of Civic Design and Department of Public Health.