Cross-sector collaboration has emerged as a critically important way to ensure that investments outside the health sector contribute to improving well-being rather than creating unintended risks. In this context, health impact assessment, or HIA, has emerged as one of the most effective means to build interagency partnerships, develop appropriate metrics to measure outcomes, and capitalize on opportunities to improve health.
As HIA has gained momentum in the United States, agencies and organizations have begun to establish the systems, relationships, and funding mechanisms needed to implement stable HIA programs that endure beyond the completion of specific grant-funded projects. Some of these programs have come about through formalized interagency cooperation and funding agreements, in which a public agency finances a sustainable HIA program through permit fees, internal budget restructuring, or collaborative agreements. Others are developing through local, state, or regional HIA networks, where nonprofit community organizations, public health institutes, and public agencies share responsibility for promoting, conducting, and evaluating HIAs; build and allocate resources; and train students and practitioners. Though few such laws have been enacted to date, legislation that mandates or creates incentives for or supports HIA may be another approach to implementing an enduring HIA practice. HIA practitioners have also used the basic principles of HIAs to develop new, more streamlined methods that make it simpler for decision-makers to incorporate health considerations in the policymaking process, and thus more likely that health will become a routine consideration.
The examples below illustrate a range of approaches that agencies and organizations are using to make HIAs a routine part of their core work and highlight the potential for adapting the basic HIA strategy to seamlessly and stably integrate health into the wide range of legislative, planning, and regulatory decisions that these assessments seek to inform. Ultimately, each organization or agency must develop a program that meets its needs and functions well within the practical and political context, funding structure, and desired characteristics of the program. The Health Impact Project’s HIA Program Grants are intended to spark innovative approaches and to help cities, states, and regions develop robust, sustainable, self-supporting HIA programs.
Metropolitan Planning Organizations, or MPOs, are federally designated entities that work in conjunction with local governments and are charged with prioritizing transportation investments in urban areas across the United States. Serving an area of approximately 1.5 million people, members of the Nashville Area MPO include 22 city and county government entities, regional transit authorities, and the Tennessee Department of Transportation. The MPO is responsible for programming federal transportation dollars from a variety of funding sources for regional transportation projects that help to increase the efficient movement of people and goods throughout the region and to accommodate future growth in population and employment.
In December 2010, the MPO adopted its 2035 Regional Transportation Plan. For the first time, the regional plan included health-based criteria for prioritizing transportation projects for funding. Sixty of the 100 points on which transportation projects are scored are now based on how the project will support better air quality, increase opportunities for active transportation (such as new or improved sidewalks and bike lanes), reduce injuries, and ensure equitable distribution of these benefits to residents in underserved areas. Four hundred roadway projects proposed by MPO members were scored and prioritized based on the new criteria, and the group approved approximately $6 billion in funding over the next several decades for the top-scoring projects in the fiscally constrained plan.
Two important changes occurred as a result of the new criteria. First, nearly 75 percent of the proposed projects included an active transportation element such as a bikeway, sidewalk, or greenway, a substantial increase from prior versions of the plan. Second, in the final Regional Transportation Plan, 70 percent of the adopted roadway projects have active transportation infrastructure, compared with approximately 2 percent of projects in the 2030 plan.
Integrating feedback from the public, stakeholders, and elected officials who approve the plan, MPO staff developed a vision for the region’s future and created scoring criteria to prioritize transportation investments reflecting this vision. The inclusive approach yielded support and pride in the plan. The inclusion of health considerations in the development process for the plan, helped educate decision-makers and the public about the relation of wellness to a healthy regional economy through transportation investments.
The Minnesota Department of Health, or MDH, began providing technical assistance for health impact assessments in the state in 2009 when it was awarded a two-year HIA capacity-building grant by the Centers for Disease Control and Prevention’s Healthy Community Design Initiative. With at least 20 HIAs completed or in process as of early 2014, Minnesota is among the leaders in the rapid growth of HIA practice across the country. In addition to its support and training of practitioners and promotion of HIA programs across the state, the MDH also provides technical assistance to practitioners in other states and has been involved in nine HIAs to date. In 2013, the Health Impact Project awarded the MDH a program grant to build on these efforts.
The MDH has a three-pronged strategy to develop its HIA program: (1) continuing its leadership role in providing technical assistance and training to public agencies and community organizations; (2) championing statewide use of HIAs through a coalition of practitioners and stakeholders from the public, private, and nonprofit sectors; and (3) working internally within Minnesota state government to promote the use of HIAs through an interagency workgroup.
The interagency workgroup includes representatives from the Minnesota Departments of Education, Natural Resources, Agriculture, Transportation, Administration, Public Safety, Education, Commerce, and Employment and Economic Development; Metropolitan Council; Minnesota Management and Budget; Minnesota Pollution Control Agency; and Minnesota Housing. Agencies with some demonstrated familiarity or interest in HIA methodology were among the first members, which initially convened in fall 2013. For example, the Minnesota Pollution Control Agency has worked with the MDH on a community engagement toolkit for populations that are disproportionately affected by air pollution. The Minnesota Department of Transportation has previously collaborated on Complete Streets and Safe Routes to Schools initiatives, aimed at improving sidewalk and street infrastructure to encourage physical activity.
The workgroup members will champion the practice of health impact assessments within their respective agencies as well as with other agencies with which they regularly engage, developing partnerships, capacity, and funding options. Among the group’s first undertakings, members will conduct an inventory of policies and projects within their agencies that might be candidates for HIAs. Members also have expressed interest in collaborating on a state-level HIA that integrates the responsibilities of several agencies, with the ultimate goal of increasing the number of agencies that perform their own HIAs and consider health in many of their policies. The MDH has committed to providing support to workgroup members to help promote HIA within each agency.
In 2005, the North Slope Borough, or NSB, and the Alaska Inter-Tribal Council, or AITC, began to work on integrating HIA into the federal environmental impact statement, or EIS, process for oil and gas and mining projects. Discussions between the tribes and federal agency representatives ultimately resulted in an agreement by two federal agencies to incorporate HIAs led by the NSB and the AITC into three different oil- and gas-leasing decisions. The HIAs were conducted collaboratively during the EIS process: Two were submitted as comments on draft EISs already in progress and integrated into the final EISs. A third was conducted as an integral part of the EIS, with the HIA participants functioning as part of the analytic team that led the EIS. In the course of these first efforts, a widening circle of state, federal, and tribal agencies became engaged in HIA. A workshop intended to develop a consensus-based approach to conducting HIAs in Alaska was held in 2008 in Anchorage and included representatives from five federal regulatory agencies, the Centers for Disease Control and Prevention, state and local governments, tribal health authorities, the Alaska Native Tribal Health Consortium, and national and international HIA experts. A basic framework for conducting HIAs was established during the conference, and attendees then established a working group that developed a toolkit to provide technical guidance for Alaska-specific HIA practice.[i] Working group participants also identified a clear need for one agency to maintain and update the HIA toolkit, respond to public feedback, and lead ongoing efforts to develop Alaska’s capacity for HIA. In response to this need and with support from partners, the Alaska Department of Health and Social Services, or DHSS, established an HIA program in July 2010 and now participates as a member of the state’s multiagency large project permit team. [ii] The program now conducts HIAs for all large natural resource development projects in the state. [iii]
The National Environmental Policy Act requires an EIS for large projects with a potential for significant environmental effects. At or before the start of an EIS, the federal agency in charge of the study contacts the DHSS for an opinion regarding the need for and appropriate scope of the HIA. The DHSS responds with a recommendation, and the HIA is built into the work plan for the EIS. The DHSS then works with a contractor to develop a “stand-alone” HIA. The federal agency or the contractor preparing the EIS in turn integrates relevant sections of the HIA into the EIS. In certain situations, the DHSS may conduct HIAs on projects that do not require an EIS, if the health concerns appear to warrant a robust consideration of health effects.
Funding for the state’s HIA program comes primarily from the state and federal permit fee structure. State permits require baseline environmental studies which are paid for by the permit applicant; when baseline health studies are required, the funding for these may be built into the state permit fee structure. Funding is used in two ways: One stream provides project-specific funds to the state program to facilitate and oversee the HIA process; the other stream supports HIA contractors who perform data-gathering activities and document production. Environmental impact statements for large projects are paid for by the company applying for a permit, but the study is controlled by the lead federal agency, and the applicant is not permitted to review or comment on the results until the formal public comment period. The costs of the HIA recommended by the DHSS are built into the costs of the EIS.
The Massachusetts Department of Transportation established a Healthy Transportation Compact in Chapter 25 of the Act of 2009, “an act modernizing the transportation systems of the Commonwealth,” which requires HIAs to assess the effect of transportation projects on public health and vulnerable populations. Legislation to support or require HIAs has also been proposed in other states. The interagency compact includes the secretaries of Transportation, Health and Human Services, Energy and Environmental Affairs, the Highway Administrator, the Transit Administrator, and the Commissioner of Public Health. The compact is designed to facilitate transportation decisions that balance the needs of all transportation users, expand mobility, improve public health, support a cleaner environment, and create stronger communities. It institutes an HIA program for planners, transportation administrators, public health administrators, and developers to meet these goals.
In Massachusetts, a working group composed of agency members from each of the three Secretariats met regularly to plan the operations of the program and to identify potential possible HIA targets. The first question discussed by the group was how to define HIA, and whether a Massachusetts-specific definition was necessary. The agencies then screened a number of pending transportation decisions as potential HIA topics and ultimately selected the McGrath Highway Corridor, which will develop plans for removing a section of elevated freeway.
The Massachusetts Department of Public Health, or MDPH, used the McGrath Highway Corridor HIA to operate a pilot of the Healthy Transportation Compact (HTC) HIA program. Through conducting this HIA, the departments developed the procedures, collaborative partnerships, data sources and metrics, and analytic approaches needed for a successful HIA partnership on future projects. According to the MDPH, the work on the HIA contributed to building new partnerships and strengthening others. These affiliations include public health, transportation, and energy and environmental regulators, as well as legislators, local health officials, and the general public. Agency staff to the compact proposed to HTC members that the HIA work be incorporated into the overall transportation planning process. HTC members supported this idea and work is underway to determine how best to move this enhancement to transportation planning.
HIA staff from the MDPH will work with transportation planners, consultants and others to help support data needs and other assistance needed to promote the use of HIAs in transportation planning.
Michigan’s Meridian Township has adopted a checklist-based tool that evaluates proposed development projects according to health-based criteria. The criteria address nine domains important to health that can be affected by projects: water quality; wastewater, air quality; solid and hazardous waste; noise; social capital; physical activity and injury; health equity and food systems; and regional growth objectives. Planners work with each developer based on the findings of this brief evaluation to incorporate design elements that will improve health. Over the 10 years since implementation, this simple approach has resulted in dozens of health-supportive modifications. Examples include:
According to planning staff, this system has not only produced tangible benefits for community health, but also benefited developers: The early incorporation of important elements reduces costs by shortening project review time and addressing potentially problematic issues or conflicts that could delay implementation.
The Los Angeles County Department of Public Health is developing a rapid HIA-based policy analysis procedure that will allow the department to undertake systematic but rapid assessments in response to requests from the board of supervisors, other county departments, community groups, or departmental colleagues for information about the health implications of proposed policies. Proposed rapid HIA analyses could, for example:
Based on the decision-making timeline—ranging from several days to several months—department staff will use criteria to determine the feasibility, priority, and potential impact of a rapid HIA, as well as the ways the standard HIA process could be streamlined.
The Northwest Health Impact Assessment Network is a participant-led community of practice that promotes the pursuit of health equity in decision-making processes through the use of HIA or other related tools. The Network supports regular and occasional HIA practitioners and creates venues for training, relationship-building, and strategic collaboration on project and funding opportunities.
The Network traces its beginnings to Portland, Oregon in 2008, when an informal group of staff members from public and non-profit organizations—including health advocacy groups, a foundation, and county and state agencies—began meeting to learn more about HIA. After collaborating on an HIA, the group recognized a growing local interest in HIA and over the next year, the group continued to meet and launched a listserv. The Network built HIA capacity in the region through the volunteer and grant-funded activities of participating organizations. Awards from the Association of State and Territorial Health Officials and the Centers for Disease Control and Prevention granted to the Oregon Health Authority supported the creation of a state-level HIA program which provides training and technical assistance to local health jurisdictions. Additional funds from the Health Impact Project and regional foundations, including Kaiser Permanente Oregon and the Northwest Health Foundation helped support HIA projects by Network participants.
An HIA program grant from the Health Impact Project to Oregon Health Authority and Upstream Public Health (both Network members) in 2013 helps support, among other activities, Network strategic planning, website development, and creation of sector-specific educational and outreach materials. Through its regular meetings, members continue to have an opportunity to discuss current HIAs, identify and screen potential new projects, and share lessons learned and challenges. The Network—which includes approximately 250 listserv subscribers—recently expanded from the state to the regional level to reflect contributions by close partners in neighboring states.
Collectively, members have contributed to a robust community of leadership and innovation in HIA within Oregon and to the field overall. In addition to completing over 20 HIAs—on topics ranging from climate change, to housing, school foods, and transportation—participants have delivered a graduate-level HIA course, trained numerous new practitioners, contributed to national-scope HIAs, and one organization developed a regional technical assistance and training center.
[i] Available at http://www.epi.alaska.gov/hia.
[ii] Aaron Wernham, “Building a Statewide Health Impact Assessment Program: A Case Study From Alaska,” Northwest Public Health, fall/winter (2009): 16–17, http://www.nwpublichealth.org/docs/nph/f2009/wernham_fw2009.pdf.
[iv] Portland Health Impact Assessment Workgroup, “Columbia River Crossing Health Impact Assessment (Portland, OR: Multnomah County Health Department, June 2008), http://www.healthimpactproject.org/hia/us/hia-report/HIA-Report-1-5-Columbia-River-Crossing.pdf.
[vi] Rajiv Bhatia, “Protecting Health Using an Environmental Impact Assessment: A Case Study of San Francisco Land Use Decision-making,” American Journal of Public Health 97, no. 3 (2007): 406–13, http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2005.073817.
[viii] Leslie Meehan, “Nashville Area MPO 2035 Regional Transportation Plan: Impacts of Transportation Policy on Prevention and Health” (Dec. 2010), http://www.nashvillempo.org/docs/Health/HealthSummary_June2012.pdf.