Case study: Systematically introducing the health factor in decision-making is possible: the successful case story of Andalusia

Implementing the health-in-all-policies (HiAP) agenda is challenging, and tools such as health impact assessment (HIA) enable policy-makers to predict and optimize action needed and govern its consequences on population well-being.

The inclusion of a stand-alone HIA report in environmental assessments has been compulsory in Andalusia, Spain, for the last five years. In illustrating consistently better outcome delivery, it has proven to be a successful tool for implementing the HiAP strategy.

Health in all policies and HIA

WHO and other health agencies have long been promoting intersectoral action between the health and other sectors of society to address the major upstream determinants of health. HIA is an established approach towards achieving this goal. Building on different disciplines and expertise, it includes a broad range of measures aimed at estimating and predicting the consequences and impact of proposed policies and plans. The ultimate goal is to influence decision-making in a more health-friendly, equitable, legitimate and sustainable direction.

HIA is a challenging practice, which has been evolving in Europe over the last 20 years and more. It has delivered handsomely in some countries, or regions in countries, while it is still struggling to become established in others.

The successful case story of Andalusia

Over the last five years, the Regional Ministry of Health in Andalusia has been implementing HIA with a focus on the development of tools and procedures. At the same time, this process has identified elements of success, as well as challenges and windows of opportunity. In 2011, the Andalusian Government published Act 16/2011 on Public Health in Andalusia (APHA) in which HiAP and HIA have significant roles. The Act provides for the mandatory and binding inclusion of health-impact reports in most procedures leading to the authorization of regional government policies, urban planning projects and private or public projects subject to environmental impact assessment.

APHA has led to the systematic integration of HIA into decision-making processes and, thus, the incorporation of a conceptual health-determinants and health-equity framework. Implementation of APHA has required the integration of HIA not only into authorization procedures, but also into technical guidelines, training programmes for interdisciplinary working groups on public health, and dissemination and training seminars for developers.

In defining the depth of an assessment, the so-called preliminary analysis is the key stage, during which the following elements are assessed:

• possible direct and indirect health impact of action taken (for example, building a highway) that may cause other unwanted changes in the system (for example, traffic risks, environmental pollution);
• existing mechanisms for ameliorating health impact;
• potential population of concern, with a focus on identifying vulnerable groups and the uneven distribution of the health impact;
• the population’s perception of the health impact and the developers’ fostering of population involvement.

Decision-making would be based on an assessment of the contribution of these factors to the convenience (or lack thereof) of carrying out further in-depth analysis of the impact of the relevant project on population health.

A flexible, effective methodology for promoting health equity

The implementation of HIA over the last five years has been a very positive experience in Andalusia:

1. it is flexible and effective, adapting seamlessly to all kinds of activities, regardless of environment and the relevance of health impact;
2. the process is easy to put into practice – virtually all developers are using it, tailoring it to suit their needs;
3. it recognizes the social determinants of health and equity as crucial aspects of the analysis, especially the identification of vulnerable groups;
4. it promotes the involvement of civil society in decision-making and the use of a common language among sectors and stakeholders; and
5. it raises awareness about the importance of health-related decisions taken outside the health-care sector.

Forthcoming RHN publication

RHN is preparing a publication that will provide an in-depth analysis of the HIA-implementation process in Andalusia, with a focus on elements of success, challenges, windows of opportunity and lessons learnt. It will also include brief case studies of similar experiences in other regions participating in RHN. The publication will be launched in autumn 2019.