Jean Simos

The role of health impact assessment in Phase V of the Healthy Cities European Network

Health impact assessment (HIA) is a prospective decision-making aid tool that aims to improve the quality of policies, programmes or projects through recommendations that promote health. It identifies how and through which pathways a decision can impact a wide range of health determinants and seeks to define the distribution of effects within populations, thereby raising the issue of equity. HIA was introduced to the WHO European Healthy Cities Network as one of its four core themes during the Phase IV (2004-08). Here we present an evaluation of the use of HIA during Phase V (2009-13), where HIA was linked with the overarching theme of health and health equity in all local policies and a requirement regarding capacity building. The evaluation was based on 10 case studies contributed by 9 Healthy Cities in five countries (France, Hungary, Italy, Spain and the UK). A Realist Evaluation framework was used to collect and aggregate data obtained through three methods: an HIA factors analysis, a case-study template analysis using Nvivo software and a detailed questionnaire. The main conclusion is that HIA significantly helps promote Health in All Policies (HiAP) and sustainability in Healthy Cities. It is recommended that all Healthy City candidates to Phase VI (2014-18) of the WHO Healthy Cities European Network effectively adopt HIA and HiAP.

L’évaluation d’impact sur la santé (EIS) : une démarche intersectorielle pour l’action sur les déterminants sociaux, économiques et environnementaux de la santé

Health Impact Assessment (HIA) is a practice that has grown in popularity worldwide, since the end of the 1990s. Originally used in the framework of Environmental Impact Assessments (EIAs), HIA has become enriched through the addition of knowledge and principles based on the social determinants of health and the tackling of health inequalities, and has been brought to bear on the policy-planning process at all levels of government. HIA has three overlapping objectives: to assess the potential effects of a policy on health, to encourage citizen and stakeholder participation in the impact analysis process, and to inform the decision-making process. This article briefly defines HIA; defines its standardized process in successive steps, which allows users to give structure to their actions and to establish the steps to be followed (detection, framing, analysis, recommendations and evaluation); and offers three examples of HIA in three different situations: the Geneva canton of Switzerland; Rennes, France; and in the Montérégie region of Quebec, Canada. Together, these illustrations show that HIA is a promising strategy to influence local decisions and to integrate health into projects and policies at the local and regional levels.L’évaluation d’impact sur la santé (EIS) est un courant de pratique qui connaît une popularité croissante partout dans le monde depuis la fin des années 1990. D’abord utilisée dans le cadre des évaluations d’impact environnemental (EIE), elle s’est enrichie des connaissances et des principes portés par le courant des déterminants sociaux de la santé et par celui de l’action sur les inégalités sociales de santé pour être transposée dans le contexte de l’élaboration de politiques publiques et ce, à tous les échelons de prise de décision gouvernementale. Dans les faits, l’EIS poursuit trois objectifs concomitants : estimer les effets potentiels d’un projet de politique sur la santé, favoriser la participation citoyenne et de parties prenantes au processus d’analyse d’impact et informer le processus de décision. L’article définit brièvement ce qu’est l’EIS, sa démarche standardisée en étapes successives, ce qui permet de structurer l’action et d’établir clairement les pas à franchir : dépistage, cadrage, analyse, recommandations, évaluation et contrôle ; et propose trois exemples d’EIS dans trois situations différentes : dans le Canton de Genève en Suisse, à Rennes en France, et en Montérégie au Québec, au Canada. La synthèse de ces illustrations montre que l’EIS est une stratégie intéressante pour influencer les décisions locales et intégrer de la santé dans les projets et politiques du palier local ou régional.

Introducing Health Impact Assessment (HIA) in Switzerland

In the Spring of 1994, we were in the process of adding the fi nishing touches to Geneva’s Application for the European Healthy Cities Network sponsored by the World Health Organisation (WHO). In order to better familiarise ourselves with the practical aspects of what actual involvement the implementation of such a programme meant for local authorities, we called on our colleagues in Rennes who already had considerable experience in this area. What struck me immediately during our discussion with Annette Sabouraud, the Mayor’s Assistant in charge of the project, was the realistic long term objective she had set for the Healthy Cities Programme for her city: see to it that any decision taken by the City Council is in line with or even improves the population’s health. They were already considering using “a grid through which all Council decisions would be analysed from a health and social point of view before being implemented”. A decade later, with the change in mentalities deriving from the knowledge and the experience gained, this objective can be met in the medium term due to advances in the fi eld of methodology and a favourable confi guration of the institutional context. The methodology that allows us to envisage – with reasonable optimism – this extraordinary and promising prospect is the Health Impact Assessment (HIA) Process. HIA is a set of procedures, methods and tools, that ensure that a law, a public policy, a programme or a project is assessed according to its potential impacts (positive or negative, direct or indirect) on the population’s health. It also takes into consideration how the impact is dispatched throughout the population (European Centre for Health Policy 1999) HIA must be considered as a tool to facilitate decisionmaking since it offers the possibility to minimise negative impacts and to strengthen benefi cial effects on health before the decision-making process is completed. At the same time, it helps to better inform decision-makers and planners and it improves the transparency of the process for the benefi t of the public. In most cases, it applies to objects outside the fi eld of health in a strict sense. Thus, it is a powerful means for cooperation between sectors. It is built on an approach based on health determinants, it takes into account data provided by actors coming from non-health areas and it also raises their awareness. There are six major stages in the HIA Process: • Screening which determines whether or not a HIA should be carried out • Scoping which sets the terms of reference for the HIA • Appraisal which assesses the proposal’s potential to affect health, either positively or negatively • Reporting which conveys the fi ndings of the assessment and includes the evidence base • Decision-making which prompts decisions about changing the proposal to minimise the negative impacts and maximise the positive impacts • Monitoring and evaluation which assesses the extent to which the changes to the proposal have been made and evaluates the HIA process itself as well.

HIA in Switzerland: strategies for achieving Health in All Policies

Summary The purpose of this article is to review the status of Health Impact Assessment (HIA) in Switzerland and assess whether HIA can be used to implement Health in All Policies (HiAP) in this highly decentralized country. The methods include expert opinion and an extensive literature review, as well as targeted interviews with key informers in the cantons of Geneva, Jura and Ticino. HIA has been implemented successfully since the early 2000s in Switzerland. However, integration has been heterogeneous with only a few cantons taking the lead. Integration of HIA at the federal level was attempted in 2012 but failed due to resistance from a pro-business lobby. HIA in Switzerland has the potential to contribute to HiAP, but success depends on a wider dissemination of HIA and on some form of integration at the national level. In this respect, a ‘bottom-up’ approach based on inter-cantonal collaborations appears more promising than the ‘top-down’ federal level approach.

Utiliser les synergies entre évaluation environnementale stratégique (EES) et évaluation d’impact sur la santé (EIS) pour promouvoir la prise en compte de l’environnement et de la santé dans les processus décisionnels publics

Summary.Using the synergies between strategic environmental evaluation and HIA to advance the integration of environmental and health issues in public decision-making processesThe Geneva rule was the first one in Switzerland to introduce the concept of Strategic Environmental Assessment (SEA). This assessment constitutes a decision making aid which describes the process set up to allow evaluation of potential environmental impact and comparison of possible variants, recommends the choice for the best option and suggests the precautions to take. It presents much resemblances to HIA.In this case therefore the application of SEA in the urban planning project MICA has been presented. It is in this framework that a first experience of integration HIA to the SEA process was realized. In an additional way to SEA, HIA is focused on the following fields of potential impact: transport and movements, housing, public facilities, water management.Zusammenfassung.Das Genfer Reglement führte als erstes in der Schweiz das Konzept des Strategic Environmental Assessment (SEA) ein. Dieses Assessment bietet Hilfe bei Entscheiden im Evaluationsprozess potentieller Umwelteinflüsse und beim Vergleich möglicher Varianten. Es ermöglicht Empfehlungen für die beste Option und Vorschläge zu begleitenden Vorsichtsmassnahmen. Insofern ist dieses Assessment mit dem Health Impact Assessement (HIA) vergleichbar.Dieser Beitrag präsentiert die Andwendung des SEA im Stadtplanungsprojekt MICA. In diesem Rahmen wurden erste Erfahrungen mit der Integration von HIA in SEA gesammelt. HIA fokussiert (zusätzlich zu SEA) noch auf folgende Bereiche möglicher Auswirkungen: Transport und Umsiedlung, Wohnen, öffentliche Einrichtungen und Wasserversorgung.Résumé.La réglementation genevoise a été la premiére en Suisse à introduire le concept d’évaluation environnementale stratégique (EES). Cette évaluation constitue une aide à la décision qui décrit le processus mis en place pour permettre l’évaluation des atteintes probables à l’environnement et la comparaison des variantes possibles, recommande le choix de la meilleure option et fixe les précautions à prendre. Elle présente donc beaucoup de similitudes avec l’EIS.Le cas d’application de l’EES dans le projet d’aménagement MICA est présenté. C’est dans ce cadre qu’une premiére expérience d’intégration de l’EIS dans la démarche EES a été réalisée. De maniére complémentaire à l’EES, l’EIS s’est focalisée sur les domaines d’impacts potentiels suivants : transports et déplacements, logements, équipements locaux, espaces publics, gestion des eaux.

Healthy Cities Phase V evaluation: further synthesizing realism

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phases.

HIA in Switzerland: considerations concerning the experience of the Cantons of Geneva, Jura and Ticino

This article is intended to be an initial report on the experiences gained while using HIA. Although it is provisional and pragmatic, it ought to provide useful elements for comparison with other territorial situations, both Swiss and foreign. The large differences between the three cantonal political-institutional contexts probably explain the profound differences in the way that HIA processes were introduced in each canton. Nevertheless, the article - through the concept of institutionalization - seeks to identify supracantonal elements. Finally, by presenting HIA implementation methods in different Cantons, it endeavours to demonstrate the existence of a common matrix in the Swiss context beyond the differences arising from the actual political-institutional situations linked to them.

Is HIA the most effective tool to assess the impact on health of climate change mitigation policies at the local level? A case study in Geneva, Switzerland

This study aims to understand how the health dimension is integrated into four impact assessment tools used in Geneva, Switzerland: environmental impact assessment (EIA), strategic environmental assessment (SEA), sustainability assessment (SA) and health impact assessment (HIA). We have chosen as a case study greenhouse gas (GHG) emissions reduction policies chosen by the city of Geneva. The methodological approach consists in analysing EIA, SEA, SA and HIA conducted on three projects in three topic areas: urban planning, heating and transportation. These projects are: a complex urbanisation plan in an urban neighbourhood in Geneva (the Gare des Eaux-Vives project), a sustainable transportation plan for a central district in Geneva (the St-Gervais transportation project) and a strategy to encourage the City’s employees to use sustainable transport for local business travel. The results show some shortcomings in the consideration of health in SEA, EIA and SA. This work highlights a narrow vision of health in SEA and EIA, limiting itself to a review of the effects of projects on the determinants of the physical environment as required by the legislation relating to these tools. EIA does not require the integration of the health dimension. As for SA, our research found that health is treated much more superficially than in HIA and primarily through the analysis of ‘health and safety’ criteria. It appears from this work that HIA is the tool which provides the most elaborate assessment, compared to SA, SEA or EIA, of the consequences for health of the GHG reduction policies chosen by the local decision-makers of a city. However, our study suggests that the HIA community should identify the situations in which HIA should be carried out and in which cases it is better to include health issues within an integrated analysis.

The GREENH-City interventional research protocol on health in all policies

BackgroundThis paper presents the research protocol of the GoveRnance for Equity, EnviroNment and Health in the City (GREENH-City) project funded by the National Institute for Cancer (Subvention N°2017–003-INCA). In France, health inequities have tended to increase since the late 1980s. Numerous studies show the influence of social, economic, geographic and political determinants on health inequities across the life course. Exposure to environmental factors is uneven across the population and may impact on health and health inequities. In cities, green spaces contribute to creating healthy settings which may help tackle health inequities. Health in All Policies (HiAP) represents one of the key strategies for addressing social and environmental determinants of health inequities. The objective of this research is to identify the most promising interventions to operationalize the HiAP approaches at the city level to tackle health inequities through urban green spaces. It is a participatory interventional research to analyze public policy in real life setting (WHO Healthy Cities).Method/designIt is a mixed method systemic study with a quantitative approach for the 80 cities and a comparative qualitative multiple case-studies of 6 cities. The research combines 3 different lens: 1/a political analysis of how municipalities apply HiAP to reduce social inequities of health through green space policies and interventions 2/a geographical and topological characterization of green spaces and 3/ on-site observations of the use of green spaces by the inhabitants.ResultsCity profiles will be identified regarding their HiAP approaches and the extent to which these cities address social inequities in health as part of their green space policy action. The analysis of the transferability of the results will inform policy recommendations in the rest of the Health City Network and widely for the French municipalities.Discussion/conclusionThe study will help identify factors enabling the implementation of the HiAP approach at a municipal level, promoting the development of green spaces policies in urban areas in order to tackle the social inequities in health.

Climate change: an opportunity for health promotion practitioners?

At present climate change is recognized as a major threat to human health by the world’s international organizations. Some experts consider that ‘‘the predicted effects of extreme global heating (about 4 C above its pre-industrial values by 2100) would probably exceed the limits of human adaptation’’ (Woodward 2014). On the short run, data suggest that climate change dramatically increases health inequities affecting most fragile populations mainly through its effects on the social determinants of health. There is need for action. And action has to be coordinated and collaborative (WHO 2014). Health professionals might play a central role in the process. Especially health promotion practitioners might be key persons. Why ‘‘especially’’ health promotion practitioners? For several reasons one might argue.