Health Impact Assessment in Latin America and the Caribbean: An

underutilized methodology for advancing sustainable development and health equity

Dr. Jonathan Drewry, Regional Health Impact Assessment Advisor, Sustainable Development and Health Equity (SDE)

3rd of October, 2013

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Outline I. Trends and relationship between regional mandates

and HIA II. Sector relationship to health and sustainable

development III. Past HIA efforts and practitioner views on current

application IV. Opportunities and recommendations

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I. Trends and Relationship Between Regional Mandates and Health Impact Assessment

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Demographics • 582 million inhabitants • 45 million indigenous • 79% of population urban • 93% literacy but with marked

differences in rural areas and low resource countries

• 52% Brazil and Mexico • 40% of population living in

poverty • High levels of social inequality

Sources: World Bank, 2013; Agenda de Salud para las Americas 2008-2017;

Sources: UNDESA2010; PEAR LAC; 2013 4

Inequality • Most pressing challenge

facing the Region • LAC average gini coefficient

of .52 • High inequality in education

levels • Limited income

redistribution through taxes and transfers

Source: D. Cardona , 2006

00.20.40.60.8

CubaArgentina

UruguayChile

Mexico

Brasil

Costa Rica

PanamaColombia

PeruParaguay

El SalvadorNicaragua

Ecuador

Rep Dominicana

Honduras

Venezuela

BoliviaGuatemala

Haiti

Source: Lopez and Perry, 2008

Inequality Index, LAC countries

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Alignment of Regional Mandates with Health Impact Assessment

• UN Development Agenda= inclusive social, environmental and economic development

• Rio Declaration on Social Determinants of Health= transparent and inclusive decision-making processes

• Rio+20 the Future we Want= evidence based and transparent assessments

• 8th Global Conference on Health Promotion and HiAP= scale up application of HIA as tool and means for intersectoral approach to health

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Determinants of Health, HiAP and HIA

Tools, the legal basis, and accepted and applied best practices

Development of health policies in other sectors Narrowing the gap between evidence and policy making for health

Reduce health inequities

Equity, Social and Environmental Justice & Sustainable Development

Determinants of Health

• Income and socioeconomic conditions

• Education/literacy • Employment and

working conditions • Social environment • Physical

environment • Access to health

services • Gender, diversity,

culture • Peace and Security

HIA and HiAP Health Outcomes

Risks

Determinants

Policies

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Relationship Between HIA and HiAP Health in All Policies: Overarching

conceptual framework for systematic engagement with other sectors

HIA and HiAP similarities: government approach to place health and reduction of inequalities high on local/national agendas, raising awareness of decision maker role

with determinants, and systematic approach to addressing determinants

Health equity as political priority

Capacity of MoH to engage sectors

Evidence for SDH

and equity

response

Community involvement

Trust between govt.& public Public

safeguards &

protection

HIA: one of most structured

approaches for HiAP

Targ

ets

Tool

Evid

ence

Part

icip

atio

n

Polic

y A

sses

smen

t

Add

ress

es

SDH

/Equ

ity

Means for HiAP as best practice or legal requirement

Tool, methodology or practice for achieving HiAP

at different societal levels

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II. Sector Relationship to Health and Sustainable Development

Source: World Bank and Noticias RTV

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Food and Agriculture • Health oriented food and agricultural systems (e.g. Bellagio Report) • Marketing and publicity for unhealthy food targeting youth • Agricultural risks to workers (e.g. pesticides and kidney failure) • Inappropriate farming, processing or storage (e.g.2009 Mexico H1N1

outbreak)

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Extractive Industry

• In 2011 mining investments highest in the world representing 28% of total investment

• Long history of environmental and social justice issues

• 223 cases of social unrest in Peru alone

• Potential to improve community health

Source: MEG 11

Urban Planning and Megacities

• Most urbanized Region of the world (80%)

• Rapid expansion of peri-urban zones without adequate planning

• More urban inequities through dual, divided, segregated cities

• Many associated health determinants -water quality, housing, human security and violence

Source: UN Habitat, 2012

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Transportation • In LAC highest cause of mortality

between 5-29 years of age • Traffic safety laws and

enforcement • Relationship between

transportation and health remains understudied in LAC

• Limited active or non-motorized means of transportation

Year # of accidents # of deaths # of injuries 1998 81115 3321 26417

1999 79605 3214 31578

2000 76665 3118 29945

2001 76545 3200 27747

2002 74221 2929 29887

2003 74612 2856 32670

2004 74401 3103 34752

2005 74870 3481 39559

2006 77840 3481 46882

2007 79972 3510 49057

2008 85337 3489 50059 Source: Sagastegui, 2010

Table: Traffic Accidents in Peru, 1998-2008

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Water and Sanitation • In LAC 2 million hectares of produce

irrigated with inadequately treated wastewater

• Wastewater is oftentimes released without treatment into rivers, lakes, and oceans

• Water resource development and vectors

• Monitoring and linkages between health and nutrition related to improved systems

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III. Past HIA Efforts and Practitioner Views on Current Application

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Examples of HIA Projects and Training in Mexico, Central America and Caribbean

HIA Manual- Ministry of Health, 2012

HIA Air Quality Mexico City, 2008

PEEM training, 1996

CISALUD El Salvador, 2013

Manual and education in EHIA , 2004

HIA manual investment projects, 2012

Caribbean Env. Health Inst.- EHIAs, 2000

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Examples of HIA Projects and Training in South America

HIA network and MoH engagement , 2012

Private sector HIA gold/bauxite mining, 2012

PAHO health impact of wastewater reuse, 2013

UMAZ, IRDC EHIA and Mining 1999

WHO-PAHO, health and environment HIA agreement, 2000

PAHO HIA trainings, 2000 & 2011

EHIA legislation, 2009

EHIA Law, 2009

Interest in HIA for the mining sector, 2013

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Regional Practitioner Feedback Literature review, key informant interviews and surveys with HIA and EHIA practitioners in the following countries: • Brazil – HIA consultants and Ministry of Health • Caribbean– Environmental Health Practitioners • Canada- WHO Collaborating Centers and consultants • Cuba- Universities • Ecuador- Univerisities, Consultants • El Salvador- Pan American Health Organization • Jamaica- Pan American Health Organization, Universities • Mexico- Universities, Ministry of Health • Peru- Private Sector Environmental Consultants

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Regional practitioner feedback: Views on advances in practice 1994-2014

• Nonexistent in most countries • Some integration into mining and water resource management • Limited advances including health in EIAs • Limited number of examples that respect HIA guidelines (e.g. ex

ante, participation, international minimum requirements) • Only multinationals in extractive industries developing internal

guidelines for their companies • Case of Brazil increasing participation of Ministry of Health in

large EIA projects

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Regional practitioner feedback: View on limited application in LAC

Integration with EIA • Legislated and dominates assessment activities • Practitioners relucant to incorporate HIA • Extractive industries reluctant to add level of approval • Integration with EIA = limited advances • Disconnect between environment and public health

applications Administrative and financial resources • Huge administrative commitment • Fear of creating additional barriers and delays • Long road to institutionalization as few trained professionals

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Regional practitioner feedback: View on limited application in LAC (cont.)

Incorporation in political agenda • Inability to position HIA in the political agenda and large political commitment • Lack of procedural mechanisms in key ministries Marketing of Pratice • Not adequately “sold” to communities, politicians and countries • Lack of engagement in international networks • Lack of pilot projects Capacity of health authority • No governmental health involvement and standards for application • Government interest but little progress in development of regulations /guidelines • Lack of knowledge and technical assistance • Limited interest and resources to promote and institutionalize HIA

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IV. Opportunities and Recommendations

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Indication of HIA tipping point • Impetus from Helsinki and HiAP and other regional

mandates • Interest from Ministries of Health in community well-being

associated with mining • Sustainable development and tourism • International community and networks • Gradual shift from curative and catastrophic measures • Private sector engagement • PAHO/WHO and collaborating center interest and

involvement

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Examples of PAHO Activities • Spanish HIA Regional Manual • HIA PAHO Program Plan • HIA and mining workshops • Technical assistance for PAHO offices and Ministries of Health • WHO Collaborating Centers in training and pilot projects • HIA for water reuse in agriculture and planning tool for urban parks

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Recommendations: Determine current application and promote awareness and knowledge

• Need improved understanding of country specific existing legislation, laws, and policies

• Broaden evidence base through pilot projects • Establish national, regional and international networks • Promote key tenants-determinants, healthy public policies, and

equity • Develop training materials in Spanish and Portuguese • Agreement on universal Spanish definition • Establish regular trainings and resource centers

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Recommendations: Commitment and training of the health authority

• Training in HIA skills (e.g. screening procedures to prioritize projects or policies requiring an HIA)

• Foster interagency HIAs within non-health sectors and driven by inter-institutional health comittees (e.g. CISALUD)

• Develop the capacity of the health authority to commission, lead, respond to, make HIA recommendations and work effectively with non-health sectors (environment, mining, and tourism) and civil society.

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Recommendations: Create a favorable environment for policy development and practice

• Determine sectors with highest potential to influence health and guidance for integration

• Strengthen HIA civil society (universities, NGOs) practice and training

• Establish evidence base for HIA in the region highlighting strengths, barriers, and challenges

• Use international conferences (IAIA in Chile)to generate interest

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Conclusions • Application limited in spite of training and promotion • Limited success of EHIA without functional inter-ministerial relationship and

financing • Interest from health authority- sustainble development, health equity and

promotion • HiAP means for health authorities to incorporate HIA and strengthen healthy

public policies through regulatory frameworks • Further alignment with international community and WHO Collaborating Centers • Develop guidelines for institutionalization and best practices • Consolidated, sustained and multi-institutional approach in select countries • Healthy public policies in the extractive industry as an entry point

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References • UN Habitat, (2012) Estado de las cuidades de America Latina y el Caribe • Briceno-Leon R. (2005) Urban violence and public health in Latin America: a sociological explanatory framework Cad.

Saude Publica 21(6) • Cardona D. et al. (2013) Inequidades en salud entre paises de Latinoamerica y el Caribe (2005-2010) Gac Sanit. 27(4) • Carpio OV et al. (2011) Assessing the environmental impacts of urban growth using land use/land cover, water quality,

and health indicators: A case study in Arequipa, Peru. Journal of Environmental Sciences 7(2). • Heller J. et al. (2013) Promoting Equity through the Practice of HIA. • Kickbush I and Buckett K (2010) Implementing Health in All Policies, Adelaide 2010. Government of South Australia • Lopez JH and Perry G (2008) Inequality in Latin America: Determinants and consequences. World Bank Policy

Research Working Paper • Ollila E. (2011) Health in All Policies: From rhetoric to action. Scandanavian Journal of Public Health 39(6). • PAHO (2007) Agenda de Salud para las Americas, 2008-2017 • Preciado J and Paredes C (2011) Iniciativas de salud en Latinoamerica de la OPS a la iniciativa Mesoamericana.

Salud Publica de Mexico 53. • University of Princeton (20013) Project on Ethnicity and Race in Latin America. http://perla.princeton.edu/about/ • CEPAL http://noticiasrtv.com/inicio3/?p=79021 • Metals Economics Group http://www.metalseconomics.com/ • Sapag J and Kawachi I. (2007) Capital social y promocion de la salud en America Latina Rev Saude Publica 41 (1) • St-Pierre L. Governance tools and framework for health in all policies. National Collaborating Center for Healthy Public

Policy

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