The aim ofhealth impact assessment (HIA) is to assist policymakers and other decision-makers to formulate "healthier" decisions and thus maximize population health gain and, whcre possible, reduce health inequalities. In 1999, the WHO Regional Office for Europe published the Gothenburg Consensus Paper (GCP), establishing a general framework for HIA based upon a social model of health and the values of democracy, equity and sustainability (1). HIA can be undertaken at the project, programme, and national or even supra-national policy level. Much early experience with HIA focused on project-level activity. Throughout Europe, however, HIA is now regarded as a key means for measuring the impacts of policy on health determinants and fulfilling European Union (EU) treaty obligations (2). In 1997, the Treaty of Amsterdam declared that community policies and activities in all sectors, not only in health, should ensure "a high level of human health protection" (3). In June 2000, the European Commission issued its health strategy, which announced that public health measures should address the social determinants of health, "notably harmful factors linked to lifestyle ... single market, consumer protection, social protection, employment and the environment" (4).
Sweden and the Netherlands were the first EU Member States to experiment with policy-linked HIA. In the Netherlands, HIA was the responsibility of the Department for Intersectoral Policy, an office within the Netherlands School of Public Health, which screened national government policy for health impacts (5). in Sweden, the county councils (which manage local schools, social care, the environment and care of the elderly) and local authorities (which administer regional development, public transport and public health) were given responsibility for conducting HIA (6). However, both encountered serious difficulties. In the Netherlands, decision-makers found it "impossible to get clear-cut answers" from HIA (5). In Sweden, one-third of all government proposals were referred for in-depth HIA (7). In both countries, HL& did not perform well in a competitive, dynamic, and often opportunistic, policymaking environment (8-10). Currently, WHO is working to redress the deficiencies of HL& by promoting dialogue among academics and policy-makers (11, 12), and has mooted the option of institutionalizing HIA as part of strategic environment assessment (13, 14).
What is strategic environmental assessment?
Strategic environmental assessment (SEA) is an evaluation of the environmental effects of a policy, which determines the scope of any subsequent environmental impact assessments (EIA) and the extent of public participation (14). Whereas EIA focuses at the level of individual projects, SEA takes a strategic overview of broad high-level decisions that decide the action--i.e. the projects--required to develop and implement policy. Thus, SEA is undertaken in the early stages of the policy-making process. The Espoo Convention (1991) requires the Members of the European Community to conduct EIA on major projects likely to have cross-boundary effects (I5). More recently, the Convention adopted a protocol on SEA. In May 2003, at the fifth Ministerial Conference "Environment for Europe" in Kiev, 36 countries signed a Protocol for Strategic Environmental Assessment, requiring them to assess the environmental consequences of major programmes and policies likely to have cross-boundary effects (i 6, 12). SEA and EIA are triggered by biophysical rather than "social" concerns, and thus have traditionally focused on a "narrow" model of health. Incorporating HIA into SEA would offer increased scope for the consideration of the determinants of health and well-being in policy-making. And, given that HL& lacks both a ready place in the policy process and serviceable methods for screening policies, SEA may also provide a convenient, widely-accepted, and well-understood framework into which policy-linked HIA can fit (13, 18). …