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Appendix A
Experiences with Health
Impact Assessment
To develop a framework and guidance for the practice of health impact as-
sessment (HIA) in the United States, the committee felt that it was critical to
review the HIA experience of the international community given its use of HIA
over the last several decades. The international experience in implementing HIA
has involved different institutional arrangements, mechanisms for knowledge
transfer, tools, and capacity. On examination of the international experience, the
committee identified three main mechanisms for introducing HIA. The first is to
incorporate HIA into existing assessment processes—for example, environ-
mental impact assessment (EIA) under the National Environmental Policy Act
(NEPA)—and thus make human health an explicit consideration in the mecha-
nisms for approval of policies, plans, programs, and projects. The second is to
require HIA explicitly by law or regulation or in response to defined triggers.
The third is to use HIA voluntarily but to provide various degrees of government
support and resources. In this appendix, the committee examines how the inter-
national community has used those mechanisms and what lessons the global
experience offers for one who is considering a framework and guidance for HIA
in the United States.
This appendix is not a comprehensive review, but it seeks to summarize
HIA experience in Canada, Europe, Australia, and Thailand. It also looks at the
use of HIA by indigenous people and multilateral organizations. The committee
reviews HIA experience in the United States and discusses the relationship be-
tween HIA and the process of EIA. The appendix concludes with comments on
the use of HIA in the private sector and some important lessons learned from the
experience to date that are relevant to the future use of HIA in the United States.
The committee notes that this appendix uses the terms health and health impact
assessment. To examine the international experience, the committee recognized
that it was important to consider the wider policy context and to view HIA as
one among many methods by which health is incorporated into decision-making.
130
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131
Appendix A
CANADA
In the early 1970s, a central government think tank, the Long Range
Health Planning Branch, identified the effects of lifestyle and environment on
public health and began to consider policy solutions to improve public health
(Laframboise 1973; McKay 2000). That activity culminated in a report that
identified objectives for the health-care system and for the prevention of health
problems and promotion of good health (Lalonde 1974). A combination of re-
search and advocacy was introduced to support and validate the notion that pub-
lic policies affect determinants of health (Milio 1981; WHO 1986, 1988).
Healthy Public Policy
Health and environment are under provincial jurisdiction in Canada. Two
provinces, British Columbia and Québec, have formalized HIA as a component
of policy-making, and they offer different experiences (Banken 2001, 2004;
Kwiatkowski 2004; Gagnon et al. 2008). In British Columbia, attention to the
health of the population was advanced by a group of government officials who
had an interest in health promotion. From 1989 to 1995, structures and policies
for HIA were starting to be included in British Columbia’s health-care policy,
and it was proposed that HIA of all government projects, programs, and laws be
conducted. Guidelines were produced, and a series of workshops were held to
raise awareness of and develop capacity for HIA1 (Banken 2004). By 1999, the
values underpinning the reform of health care had changed, and resources for
HIA were redeployed. The guidelines that required the use of HIA in govern-
ment decisions were not changed, but they were no longer seen as mandatory.
Banken (2004) concluded that the rise of HIA in that short time had been accel-
erated by key persons in the British Columbia Ministry of Health, that it did not
benefit from wide ownership, and that it had become closely identified with a
particular policy orientation. Banken contended that if other institutions had
been more involved in examining the value of and establishing structures for
HIA, support for HIA would not have withered as quickly after the policy direc-
tion changed and after key persons left the ministry.
Québec had a different experience in using HIA as part of healthy public
policy. Banken (2001) traced the linking of environment and health to robust
public-health input during hearings on the use of pesticides (BAPE 1983). That
input led to a memorandum of understanding (MOU) between Québec’s Minis-
tries of Health and Environment. A framework was developed to support the
memorandum and led to the systematic practice of integrating health and the
environment into projects and policies (Banken 2001, 2004). In the 1990s, pol-
1
The committee is not aware of any examples of HIA from this period. Therefore, al-
though it is documented that HIA was a part of the policy discussion, it is not possible to
evaluate how HIA was conducted in British Columbia.
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132 Improving Health in the U.S.: The Role of Health Impact Assessment
icy documents recognized the need for intersectoral initiatives to improve health
(Government of Québec 1998, 1999) and explicitly recommended the systematic
assessment of the impacts of public policies on health. The assessments were to
be conducted by the Study Commission for Health and Social Services (Com-
mission d’Étude sur les Services de Santé et les Services Sociaux), which ana-
lyzes health services.
HIA was included in Québec’s 2001 Public Health Act, which requires
government ministries and agencies to ensure that legislative provisions do not
adversely affect the health of the population. It also requires that the minister of
public health be consulted on all policies that could have an important health
effect (Section 54, Government of Québec 2001). Figure A-1 shows the number
of requests for consultations from other ministries. In 2011, the national public
health director and the assistant deputy minister in the Ministry of Health and
Social Services (Ministère de la Santé et des Services Sociaux) of Québec stated
that there were 434 requests for advice from 2003 to 2011 (Poirier 2011a). Al-
though the demands of the legislative calendar influence the number of requests
from year to year, the figure indicates a clear upward trend. The trend is ascribed
to the Ministry of Health and Social Service’s efforts to develop an understand-
ing of Section 54 across the government, improvements in how the ministry
processes requests for consultation and provides its advice, and the application
of a public-health perspective to a wider array of policies.
120
107
Number of Requests for Consultation
100
80 73
65
62
60
41 41
36
40
20
9
0
2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010 2010-2011
FIGURE A-1 Number of requests for consultation received by the Québec Ministry of
Health and Social Services, 2003-2008. Source: L. Jobin, Ministry of Health and Social
Services, Québec, personal communication, 2011.
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133
Appendix A
The Québec public-health law is noteworthy because it focuses on the
processes by which the government will request assistance on health issues and
on how that assistance will be provided by the Ministry of Health (for more in-
formation, see NCCHPP 2008). Clearly defining the process has helped to en-
sure that government departments request health input when writing policy. The
Ministry of Health and Social Services has also worked to heighten awareness
and to gain the support of other government ministries and agencies (NCCHPP
2008). Although changes are occurring slowly, channels of communication be-
yond government departments covered by the law are being opened, and this has
led to the integration of the health sector (and health consideration) into the po-
litical-administrative process. Furthermore, the government’s knowledge devel-
opment and transfer strategy to support the implementation of the law has
strengthened research capacity on healthy public policy in academic sectors and
in the Institut National de Santé Publique du Québec (L. St-Pierre, National Col-
laborating Centre for Public Policy and Health, Québec, personal communica-
tion, 2010).
Some issues, however, still need to be resolved. Many government minis-
tries do not comply with the law, and most requests to the Ministry of Health
come from the Executive Committee, which is well versed in the importance of
health effects. In addition, the process does not specify a particular method of
conducting a health assessment (L. St-Pierre, National Collaborating Centre for
Public Policy and Health, Québec, personal communication, 2010). Further ef-
forts clearly are required to foster responsibility for health in some parts of gov-
ernment, such as economics and finance. The next steps envisaged include feed-
back mechanisms to monitor and evaluate how support is offered and taken and
how recommendations are implemented. Continued support for changes in prac-
tice is needed through high-quality and strategic evaluations that facilitate ac-
tions early in the decision-making process, knowledge transfer, and strategic
monitoring (Héroux de Sève et al. 2008; Poirier 2011b).
Examining Human Health in Environmental Impact Assessment
In 1995, the Federal-Provincial-Territorial Committee on Environmental
and Occupational Health convened a task force in response to reviews that dem-
onstrated that health aspects were inconsistently or only partially addressed in
EIA. The task force was asked to develop a definition of HIA that would be ac-
ceptable to all jurisdictions, a public-health framework appropriate to HIA,
guidance and training material for HIA, and strategies for increasing awareness
about HIA, EIA, and the relationship between human health and the environ-
ment (Kwiatkowski 2004). The task force concluded that HIA should be pro-
moted within the existing legislated federal or provincial EIA processes; that
HIA was not the responsibility of any one government department or agency in
that many factors—including environmental, social, economic, and occupational
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134 Improving Health in the U.S.: The Role of Health Impact Assessment
ones—affect public health; and that HIA should use a multidisciplinary ap-
proach informed by the many determinants of health rather than a narrow defini-
tion of health (Kwiatkowski 2004). A review by Davies and Sadler (1997) was
influential in establishing a case for examining human health in environmental
assessment in Canada. A major output of the initiatives was the Canadian
Handbook on Health Impact Assessment, a comprehensive resource that was
first published in 1998 and has since been updated (Health Canada 2004a,b,c,d).
About 6,000 projects a year undergo EIA under the Canadian Environ-
mental Assessment Act, so it is no small feat to ensure that potential health ef-
fects are considered for each project (Kwiatkowski and Ooi 2003). EIAs are
characterized as screening, comprehensive study, or public-panel review. As
implied by its name, screening is less intensive than the other types and accounts
for over 95% of EIAs conducted (Kwiatkowski and Ooi 2003).
What is the current experience of incorporating HIA into EIA? Social ef-
fects are considered in EIA in Canada; this makes it somewhat easier to include
a wide array of health determinants in assessments (M. Orenstein and M. Lee,
Habitat Health Impact Consulting, personal communication, 2011). Noble and
Bronson (2005, 2006) reviewed three mining case studies and conducted a sur-
vey of environmental-assessment practitioners, health practitioners, administra-
tors, and special-interest groups in northern Canada. They found that health has
typically been considered only in the early stages of the environmental-
assessment process and that only physical health effects associated with project-
related environmental damage have generally been considered. As a rule, health
and social determinants have not been considered or have been considered only
in the context of factors—such as employment opportunities and worker health
and safety—that the project sponsor directly controls. The authors acknowl-
edged, however, that the scope of attention to health in EIA has more recently
been expanded to reflect a wider array of health determinants that includes a
group’s culture and its traditional land use. They concluded that there is a need
to adopt measures to mitigate adverse effects and optimize beneficial effects that
the community is sensitive to, to ensure that the measures are effective, and to
monitor and evaluate the effects after project approval (Noble and Bronson
2005, 2006). The committee notes that the somewhat bleak assessment by the
authors is based on a small sample and may be unduly harsh.
Although systematic collaboration between public health and the envi-
ronment sector can be improved, research indicates that health is being consid-
ered to some extent in EIA. Overall, Canada has some of the most extensive and
successful experiences of including HIA in EIA and of analyzing and improving
HIA practice. This work is not always labeled as HIA, but health is increasingly
a component of an integrated approach to environmental assessment (Orenstein
et al. 2010; M. Orenstein and M. Lee, Habitat Health Impact Consulting, per-
sonal communication, 2011).
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135
Appendix A
THE EUROPEAN UNION
HIA has been practiced in the European Union (EU) since the 1980s. Dur-
ing the 1990s, there were developments in HIA methodology and practice in
Germany, the Netherlands, Sweden, and the United Kingdom. In the late 1990s,
the WHO European Centre for Health Policy played a key strategic role in
European HIA policy development, and its 1999 Gothenburg consensus confer-
ence produced the first universally accepted definition of HIA.
Although requirements and practice have differed, there are examples of
health assessment in the environmental-assessment framework,2 in stand-alone
HIAs, and in all types of policies—from local policies to policies covering the
EU. Explicit policies for HIA exist, but its practice is often advanced through
the actions of committed individuals. Research grants from the EU play an im-
portant role in enabling research and in developing techniques and capacity for
HIA. The grants have funded multicenter studies that involve universities, the
public sector, and occasionally private-sector bodies across the EU (see, for
example, Abrahams et al. 2004; Hilding-Rydevik et al. 2005; WHO 2005a,b,c,d;
Wismar et al. 2007; Gulis et al. 2008; HEIMTSA consortium 2010; and
INTARESE consortium 2010).
In the EU, HIA is recognized as a process that sits within the broader
sphere of public-health policy and sustainable development. It is one of the ways
in which partnerships are developed between municipalities and health authori-
ties and is increasingly used as a mechanism by which land-use or spatial plan-
ning can work in partnership with public health. Although skills and capacity for
HIA are not widespread, there are isolated examples of universities’ incorporat-
ing HIA as part of a curriculum to train planners and public-health professionals.
In a study of HIA across Europe, Wismar et al. (2007) showed that HIA has
been used in various countries, at various levels, and in various sectors. They
noted that participation and equity considerations have played substantial roles
in the practice of HIA and concluded that despite the reported variations, HIA
can be used prospectively, cover all stages of the policy process, and use differ-
ent types of approaches.
The following sections provide background on the EU and on the inte-
grated assessment framework used for EU policy. Approaches for integrating
health into environmental assessment across Europe are discussed next,3 and
then other approaches that have been put into place across Europe to enable HIA
to be conducted are reviewed.
2
Regarding environmental assessment in the EU, human-health measures are included
in directives and legislation that regulate the effects of development on the environment.
3
This summary does not examine legislation for equality and human rights in the EU,
which also leads to policy assessment and can incorporate health issues.
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136 Improving Health in the U.S.: The Role of Health Impact Assessment
Incorporation of Health into Policies, Plans, Programs,
and Projects in the European Union
In 2010, the EU had 27 member states and four applicants for membership
(see Box A-1). Policies and laws that apply throughout the EU are produced
mainly by the joint work of three institutions: the European Commission, the
European Parliament, and the Council of the European Union. The European
Commission, which proposes new laws and then works with member states to
implement them, is divided into departments and services (EC 2011a). Public
health falls under the Directorate-General for Health and Consumers, and envi-
ronmental stewardship falls under the Directorate-General for the Environment.
Public health is a relatively new policy topic at the EU level, and member states
continue to hold the main responsibility for national health policy.4 Actions at
the EU level complement actions at the national level, for example, by address-
ing major health threats and issues that have a cross-border or international im-
pact, such as pandemics and bioterrorism; by addressing health threats related to
the free movement of goods, services, and people; by promoting healthier life-
styles; and by supporting the work of national authorities. It is recognized that
public health is not solely an issue for health policy. For example, in 1997, the
Amsterdam Treaty of the EU required that all European Community policies
protect health. Thus, the “health in all policies” approach is required for internal
and external policies, and support is given for the use of impact assessment and
other tools that evaluate health (CEC 2007).
The European Commission assesses initiatives for their potential eco-
nomic, social, and environmental consequences before it proposes them (EC
2011b). Health is considered in that process as one of several topics in an inte-
grated impact assessment framework. The guidelines for the framework were
updated in 2009 to review public health and safety and to enhance the considera-
tion of social impacts, including access to and effects on social protection,
health, and educational systems (EC 2009a). Specific attention has been given to
distributional effects and effects on poverty and social inclusion in the EU and
developing countries (EC 2009b). Reviews show a small increase in the number
of mentions of the word health in the European Commission’s impact assess-
ment reports; thus, although progress is slow, consideration of health in the
framework is increasing (Ståhl 2010). However, the framework for impact
4
Before 1992, health was addressed in the context of health and safety in the work-
place and as an issue of consumer safety. The 1992 Maastricht Treaty (EC 1992) was the
first treaty to feature an article on public health and to explain the added value of Europe-
wide approaches to common challenges in health while confirming that health care re-
mains the mandate of national authorities. Later reform treaties (EC 1997, 2007) en-
hanced the role of the EU in supporting member states in cooperating and sharing good
practice, such as in health-technology assessment, and in tackling cross-border health
threats and disease prevention.
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137
Appendix A
BOX A-1 European Union Members and When They Joined
1952 – Belgium, France, Germany, Italy, Luxembourg, and Netherlands
1973 – Denmark, Ireland, and United Kingdom
1981 – Greece
1986 – Portugal and Spain
1995 – Austria, Finland, and Sweden
2004 – Cyprus, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland,
Slovakia, and Slovenia
2007 – Bulgaria and Romania
Candidate Countries: Croatia, Turkey, the Former Yugoslav Republic of Macedonia,
and Iceland.
Source: EU 2011a,b.
assessment has been criticized for failing to improve the consideration of public
health, for example, in focusing on specific health services rather than the wider
health of the general public (Ståhl 2010), in placing a low priority on health so
that it is not seen as a factor that can differentiate between policy options (Ståhl
2010), in focusing on the effects on the economy or the business environment,
and in being open to undue influence from corporate interests (Smith et al.
2010a,b).
Environmental-Assessment Directives
As noted, one of the roles of the Directorate-General for the Environment
is to ensure that member states comply with the requirements of the environ-
mental directives. Environmental assessment is a key mechanism for evaluating
individual projects identified by the EIA directive (Council of the European
Union 1985) or public plans or programs identified by the strategic environ-
mental assessment (SEA) directive (EP/Council 2001). “The common principle
of both directives is to ensure that plans, programs, and projects that are likely to
have significant effects on the environment are made subject to an environ-
mental assessment prior to their approval or authorization” (EC 2011c). Consul-
tation with the public is a key feature of environmental-assessment procedures.
Member states are free to supplement the assessment processes, and they
must incorporate them into their national consent regimes (that is, the frame-
work by which projects are given permission). For that reason, there is some
variation in processes between member states. The Directorate-General for the
Environment ensures that each member state implements the EIA and SEA
directives, and the European Court of Justice is the final arbiter if assessments
are disputed. As both directives are procedural, the courts tend to be concerned
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138 Improving Health in the U.S.: The Role of Health Impact Assessment
with how the assessments have been conducted rather than with their accuracy.
Issues of quality are typically left to the organizations overseeing the consenting
process, although that can be problematic; for example, health authorities are not
always asked to comment on the health components of environmental assess-
ments.
Environmental Impact Assessment
The EIA directive applies to public and private projects (Council of the
European Union 1985).5 Annex I of the directive stipulates projects for which it
is mandatory to conduct an EIA, such as railways, roads, waste-disposal installa-
tion, and waste-water treatment plants. Member states have discretion over
whether to conduct an EIA on projects listed in Annex II, such as some types of
agricultural or extractive-industry projects, urban-development projects, and
flood-relief projects.
Although the rationale for the EIA directive states that “the effects of a
project on the environment must be assessed in order to take account of con-
cerns to protect human health” (Council of the European Union 1985), human
health is not explicitly included in the list of direct and indirect effects of a pro-
ject that must be identified, described, and assessed.6 Although environmental
assessment considers health protection (for example, calculations of safe expo-
sures are included in the derivation of environmental limits for air emissions and
water quality), EIAs do not look in detail at the populations likely to be exposed,
and compliance with the environmental limits does not mean that there will be
no health effects (even small increases in air emissions can have effects on
health).
National governments have interpreted the EIA directive differently, and
their interpretations determine the extent to which health is explicitly considered
in EIA (Bond 2004). For example, the English ministry responsible for planning
has resisted including health explicitly in EIA; in contrast, Germany has sought
to address health in EIA and passed a resolution in 1992 on HIA in the context
of EIA (Fehr et al. 2004). The boundaries are set by bureaucrats in government
ministries whose interests often lie in avoiding placement of extra duties on their
minister or on businesses. Frequently, the approach taken is to meet legal com-
pliance with minimum expense, and this can result in poor coverage of health. A
review of 39 environmental impact statements in the United Kingdom found that
72% did not list human health in the table of contents, 49% provided no analysis
of possible human-health effects, and 67% did not include sufficient data to es-
5
The EIA directive has been amended three times (EP/Council 2001, 2003, 2009) to
bring it into line with United Nations Economic Commission for Europe Conventions
(UNECE 1991, 1998) and to update the list of projects that come under the EIA directive
to include those related to transport, capture, and storage of carbon dioxide.
6
The effects include those on human beings, fauna and flora, soil, water, air, climate
and landscape, interaction between them, material assets, and cultural heritage.
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139
Appendix A
timate the number of people potentially affected by the project or activity being
considered (British Medical Association 1998 cited in Bond 2004).
A study of the application of the EIA directive concluded that when possi-
ble human health effects of a project should be assessed in an EIA rather than by
a separate HIA (Hilding-Rydevik et al. 2005). The authors acknowledged that
best practice for including health in EIA remains undefined and depends on a
number of factors, such as how health is defined (that is, whether it is based on
environmental impacts or on a wider array of human health determinants)
(Hilding-Rydevik et al. 2005).
In a 2009 survey of the application of the EIA directive, all new member
states reported that human health aspects are assessed as part of the EIA reports
(COWI 2009). Common elements include the identification of human health
effects during the scoping stage of EIA, consultations with health authorities or
experts in the field on human health, and assessment of human health effects as
a part of the environmental documentation submitted by a developer. Few new
member states, however, have produced specific guidance documents for those
activities (COWI 2009). Most new member states that were surveyed define
health in environmental terms and involve public-health authorities mainly on
environmental-health matters. For example, in Hungary, human health issues are
examined in the EIA procedures for transport projects (focusing on noise),
transmission lines (focusing on nonionizing radiation), hazardous-waste man-
agement facilities (focusing on complex effects on environmental health), and
strip mines and cement factories (focusing on air pollution). Malta is the only
member state that mentions well-being and states that, when relevant, health and
well-being are studied with reference to socioeconomic impacts (COWI 2009).
Strategic Environmental Assessment
The SEA directive (EP/Council 2001) refers to public plans and programs
but not to policies. The idea is to identify issues at a strategic level so that they
do not arise at a project level; in practice, however, the link between strategic
assessment and project assessment has proved problematic. Although SEAs are
used to evaluate plans in various sectors, they are conducted primarily for land-
use planning (EP/Council 2001).7 If the environmental effects of plans or pro-
grams are deemed likely to cross national boundaries, the member state in
whose territory the plan or program is being prepared must consult the other
member states (EC 2011d). The SEA directive, unlike the EIA directive, explic-
itly requires the consideration of “the likely significant effects on the environ-
ment, including on issues such as … human health” (EP/Council 2001). The
debate on how to include health in SEA is evolving in Europe.
7
SEA is mandatory for plans or programs that are prepared for a prescribed range of
sectors and set the framework for granting consent for the future development of projects
listed in the EIA directive (EC 2011d).
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140 Improving Health in the U.S.: The Role of Health Impact Assessment
The SEA directive requires that numerous aspects be examined, including
human health, but it does not provide detailed definitions of those aspects. Thus,
health is addressed in SEA practice in various ways and in ways that do not sys-
tematically require the input of public health or even formal sign-off from health
authorities. In Denmark, health is a formal component in the assessment of spa-
tial plans; noise, drinking water, air pollution, recreation and outdoor life, and
traffic safety are considered with regard to health (Kørnøv 2009). A review of
eight SEAs in England and Germany found that all considered aspects of physi-
cal and natural effects (such as noise, emissions, and pollution) on health, and
four considered social and behavioral aspects (Fischer 2010). Ensuring that im-
portant health effects are satisfactorily identified and considered is challenging,
and the SEA directive has not yet led to widespread involvement of public-
health experts in the assessment process or in planning. One difficulty is that the
health sector tends to be outside the plan-making process, and most HIA experi-
ence tends to be at the project level (Cave et al. 2007).
In 2010, the SEA protocol on EIA, which has been adopted by at least 35
member countries, will enter into force (UNECE 2003). It goes much further
than the SEA directive in referring explicitly throughout to impacts on environ-
ment and health, in indicating that all health impacts should be considered (not
only those associated with environmental factors), and in indicating that health
authorities should be consulted at the different stages of the process.
Examples of Advancing Health Impact Assessment
Independently of Environmental Impact Assessment
and Strategic Environmental Assessment
Member countries have taken different approaches to advancing HIA out-
side the environmental-assessment process. Since the late 1990s, Sweden has
used HIA as a mechanism for addressing the determinants of health in policy-
making (Berensson 2004). Although no legislation requires HIA, agencies,
counties, and municipalities continue to learn about and use it. Local politicians
across Sweden were actively involved in developing the country’s initial guid-
ance documents for HIA and recommended that health be an early part of all
policy discussions (SFCC 1998). The decision to screen all political proposals to
determine which should be further evaluated led to many policies being recom-
mended for HIA (Nilunger et al. 2003).
Sweden’s Health Policy Act of 2003 based its national objectives on
health determinants rather than diseases or health problems and linked achieve-
ment of the objectives to a monitoring system and annual evaluations. In 2005-
2008, 11 central agencies and all of Sweden’s county administrative boards were
required to implement HIA and were supported by the National Institute of Pub-
lic Health in doing so (Knutsson and Linell 2010). Although the requirement has
heightened interest in and political support for issues related to public health and
particularly HIA, there is no legal requirement for HIA, and there are no specific
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167
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