Health Impact Assessment (HIA) refers to a combination of tools and procedures used to evaluate a proposed program or policy and its potential effects on the health of a community (Ratner et al., 1997). However, the World Health Organization extends this definition and argues that HIA is a combination of tools, procedures, or methods used to judge a proposed program or project and its potential effects on the health of a community and the dispersion of the effects within the community (Diwan et al., 1999). Health impact assessment should not be confused with environmental impact assessment although the two have many similarities. HIA is a tool that helps in decision-making by drawing knowledge from a scientific pool though it is not a scientific process in itself. Although the procedures of HIA still need development, their potential application as tools for enhancing sustainable development has been recognized (Diwan et al., 1999). According to Scot-Samuel (1998), HIA process should strictly adhere to ethical use and be anchored on the following principles:
A clear focus on equality and social justice
Use of multidisciplinary and inclusive approach
Application of quantitative and qualitative data
Openness to public scrutiny.
From these principles, it could be argued that HIA is anchored on a holistic social theory of health that recognizes that the health of a community is influenced by various economic, social, and environmental factors. Equity has a significant role in the explicit value system that justifies HIA. Here, equity encompasses moral and ethical dimension in relation to preventable inequalities in the health sector. In other words, equity focuses on creating even opportunities for health and reducing health disparities to minimum levels (Whitehead, 1990).
The emphasis on equity demonstrates a shift in the process of evaluation of environmental, economic, and social programs. In the United Kingdom, the focus of carrying out HIA on all public policies has been embraced by the health administration as evidenced by the first recommendation of the Acheson report on disparities in health (UK Secretary of State for Health, 1999). Also, the recognition of the significance of HIA is demonstrated by Article 152 of the European Unions Amsterdam Treaty which asserts that "a high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities," (Nistor, 2011 p 279). According to Scot-Samuel, Arden, and Birley (2001), HIA should be conducted prospectively to guarantee that measures are instituted at the planning stage of a project hence minimizing the undesirable effects. However, this is not always possible due to the several factors affecting the process of policy development. In fact, HIA is today conducted simultaneously with the project to support the ongoing development of relevant information. Health impact assessment can be carried at different levels either as a rapid process or an in-depth study depending on the available resources. Since there lacks a formal methodology for HIA, the Merseyside Guidelines for Health Impact Assessment are the commonly used models in the UK (Scot-Samuel, Arden, and Birley, 2001;12). This approach to HIA involves the application of a screening procedure to choose policies for assessment, definition of the scope of the HIA depending on the depth, duration and spatial boundaries, analysis of the policy, preparation of the profile of the location and population likely to be affected, and evaluation of the significance, magnitude, and likelihood of potential effects. The approach also entails a search for an evidence base to support data, appraisal of options and development of recommendations for action, and observation and evaluation of impacts after the implementation of the project.
New Deal for Communities Program in South London
Majority of the HIA activities in the UK in the recent past has focused on urban regeneration programs and similar projects aimed to solve inequality and social exclusion problems that have been dominant since 1997. These programs include the New Deal for Communities, the Single Regeneration Budget, and Healthy Living Centers. The Single Regeneration Budget was initiated in 1994 harmonize several projects from different government departments with the aim of directing the resources to regeneration. The program funds initiatives by local regeneration partnerships to improve the quality of life of people living in disadvantaged locations by bridging the gap between such places and in other areas with different population groups (Tallon, 2013). The objectives of the Single Regeneration Budget include:
Promotion of equal opportunities through increased job opportunities, skills, and education of local people particularly the most disadvantaged and the youth.
Facilitation of sustainable economic growth and wealth generation through increased competitiveness of the local economy.
Protection and improvement of the environment and promotion of good designs for infrastructure.
Improvement of housing and living conditions for the local population through better management, better maintenance, and availability of a variety of housing options.
Address social exclusion through the promotion of programs that benefit the minority groups (Ward, 1997).
On the other hand, the New Deal for Communities was initiated in 1998 as part of the governments plan to direct resources to small disadvantaged locations, some of which comprised of the most deprived areas in the country (Benington, 2013). Each NDC program was anchored on four themes which included health, the safety of the community, employment opportunities, and education. These programs were implemented through collaborations with the local people, voluntary organizations, public agencies, and business entities which were interested and committed to long-term sustainable development. Since the NDC programs were targeted at disadvantaged and deprived areas, they attracted funding under several initiatives. Thus, the partnerships were required to work together with organizations delivering services and running similar programs.
When analyzing HIA activities carried out in the UK, an equity-oriented public policy remains a strong theme. This is because equity is a critical value that underpins the HIA methodology and HIA processes explicitly focus on distributional equity as a determinant of health. Importantly, health impact assessment has been conducted in numerous regeneration projects and public policies that address social exclusion. Although regeneration programs mostly target disadvantaged groups in terms of education and income, the equity aspect of these projects often remains indirect. Consequently, some equity aspects are overlooked while developing the program. Thus, after implementation, concerns about inequality between the target group and other groups or within the target population might not be addressed. To make matters worse, inequality issues between groups and within communities might be heightened by the regeneration projects. Therefore, it is paramount that the HIA methodology assesses the existing health disparities and the distribution of the potential effects in accordance with the relevant guidelines.
Evaluation of New Deal for Communities Program in South London
To describe the scope of a health impact assessment, there is the need to assess whether the program or project under evaluation is designed for the population of the targeted area or for the location itself and its future occupants. Also, the groups compared to determine inequalities must be defined explicitly as well as the time scale (whether the health impact assessment analyzes long-term or short-term impacts). The NDC program in South London focused on the development of education, development of training programs, and creation of job opportunities (Tallon, 2013). The primary aim was to increase the populations employment opportunities thus elevating the average income and lowering the unemployment rate in the target areas.
During the implementation of the program, the assumption was that the whole target population that lived in the disadvantaged locations would experience equal effects of the program. However, if this assumption was incorrect and there were differences in uptake of education, job opportunities, and training within the population, several scenarios might have happened. When carrying out health impact assessments, such situations help in identification of inequities through the application of qualitative methods.
In one scenario, the majority of the population might remain in the area though a small group will benefit unequally from the initiative. Resultantly, the average income of target location might increase, unemployment rates drop, and the overall health status might improve as identified by several factors associated with health determinants. These changes will be concrete and measurable. However, it might not be easy to measure the increase in inequalities and the extent of decrease in social cohesion within the population.
In an alternate scenario identified by the HIA, there is no evident improvement of the area holistically. Instead, there is the maintenance of the status quo which could even deteriorate. With the different rates of uptake of opportunities created by education, employment, and training, some members of the initial population might benefit to the extent that they can relocate. The group left could be defined as the core of the disadvantaged which is hard to reach. The vacuum created by this migration could then be filled by individuals with socioeconomic characteristics similar to the remaining population.
In all these scenarios, education, employment, and training initiatives were evaluated exclusively from other activities bounded by many regeneration programs. In reality, the NDC program was aimed at improving the environment, the housing conditions of the population near the infrastructure projects, and the income of the population by promoting their businesses. After the HIA, it was noted that the timing of the program and its component programs was essential to ensure its success in enhancing the health status and quality of life of the target group. If the training and education elements lag behind the other components of the initiative, or if they are implemented concurrently, the target group will not have the relevant skills for employment opportunities stimulated in the location. If, at the same time, there is reduced supply of government-subsidized rental houses and new apartments are constructed for private buyers (which was argued to have happened at one point), a portion of the population will be forced to move out due to their inability to afford the new houses.
Resultantly, there would be improvements in the physical appearance of the area and changes in the demographic profile due to the environmental activities. The demographic changes would be caused by moving out of a large proportion of the original population which will be replaced by a new and wealthier group. This would result in the overall enhancement of the socioeconomic and health status indicators of the area. The effect of these improvements on inequalities is unclear. However, it is likely that the members of the original population who were the most disadvantaged, like those living in temporal structures, would comprise the majority of those moving out. Also, the new population would consist of homogeneous strata of socioeconomic groups with reduced levels of inequalities compared to the outgoing and incoming populations.
As demonstrated here, it is imperative to note that health impact assessment is critical at early stages of development. Althou...
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