UvA-DARE (Digital Academic Repository) Health impact assessment legislation in developing countries: A path to sustainable development?

The sixth Global Environment Outlook argues that the planet is becoming seriously polluted, with huge consequences for the health and wellbeing of people. Legal instru-ments for assessing and reporting environmental impacts of projects have focused on environment impact assessments (EIAs). However, increasingly health impact assessment (HIA) is being used to emphasize the health dimensions of the environment and sustainable development. This article addresses the question: How can HIA legislation help developing countries to achieve the Sustainable Development Goals (SDGs)? A key aspect of the SDGs is to minimize trade-offs and enhance synergies. This could be to some extent operationalized by HIAs through enhancing synergies on health and reducing trade-offs on health. The article first sketches the relationship between EIAs and HIAs and provides an overview of the global distribution of HIA legislation. Second, it discusses the benefits and challenges of HIA legislation oriented towards sustainable development agendas by gathering lessons learned across the globe and highlighting those relevant to developing countries. The article concludes by sketching how HIA policy can be catalysed and operationalized to achieve the SDGs.

deaths 7 and 90 percent of traffic-related deaths, 8 most of which affect the urban poor.
Hence, it is urgent to address environmental exposures leading to adverse effects in countries suffering unequal health burdens. For this, health arguments could be used to support environmental protection. 9 International environmental law supporting the link between health and the environment can be traced back to the 1972 United Nations (UN) Declaration on the Human Environment, which recognized the health dimension of environmental issues. 10 The International Court of Justice also recognized that 'the environment is not an abstraction but represents the living space, the quality of life and the very health of human beings, including generations unborn '. 11 In the developing world, however, the domestic implementation of environmental treaties has failed to reinforce the synergies between health and environmental objectives. 12 Traditional legal approaches to air pollution, for instance, fail to respond to health threats because of data scarcity and weak mechanisms for ensuring compliance with international norms. 13 International law has also been unable to address the cumulative ecological challenges from the local to the global level, or address those who cause transboundary harm and provide reparation to those who suffer from such harm. 14 Health impact assessments (HIAs) are increasingly being used as a tool to quantify and assess the impact of ecological damage on human health. 15 HIAs provide a framework to estimate and mitigate health risks through effective measures. 16 Despite the promising potential of HIA, 17 the coverage of HIA legislation across the world remains scarce and scattered. 18 Furthermore, inadequate research on HIAs in developing countries is a barrier to the advancement of policy and practice. 19 Moreover, the role HIA legislation can play in solving environmental health complexities and its influence on sustainable development, more specifically on the Sustainable Development Goals (SDGs), 20 remains largely unexplored. Therefore, this article addresses the following question: How can HIA legislation help developing countries to achieve the SDGs?
To this end, the article sketches the relationship between environment impact assessments (EIAs) and health; provides an overview of the global distribution of HIA legislation in the world; discusses how legislation can advance HIA practice especially in developing countries; and argues how HIA policy can be catalysed and operationalized to achieve the SDGs.

| HIA AND THE SUS TAINAB LE DE VELOPMENT GOAL S
There is increasing interest in how HIA could support the 2030 Agenda for Sustainable Development. 21 This global agenda includes 17 SDGs and 169 targets to be achieved by 2030. SDG3 addresses health: 'Ensure healthy lives and promote well-being for all at all ages.' 22 Health is a cross-cutting concern across 10 out of the remaining 16 goals with 28 health-related targets and 47 health-related indicators. 23 A key aspect of the SDGs is to minimize trade-offs and enhance synergies between economic, social and environmental challenges.

| HIA: A brief description
An HIA is defined as an assessment process combining mixed methods to judge the potential health effects a proposed policy,  Switzerland and the United States, were also practising HIA within formal frameworks.
Second, the advocacy of HIA in developing countries was driven by private industrial corporations and major financial institutions and influenced by the scramble for access to natural resources. Indeed, most HIAs conducted in developing countries focus on large development projects led by the private sector rather than on public initiatives led by local governments. 60 However, HIA has been institutionalized in the Thai constitution 61 and is being incorporated in the Vietnamese Health Action Plan. 62 No standalone HIA policy exists in Laos, Cambodia and Malaysia, but HIA legislation forms part of their EIA processes. 63 In Latin America, only Mexico and Brazil have published national-level guidelines on HIA, 64 but no country in Africa actively promotes or regulates HIAs. 65 HIA activity has been identified in Middle Eastern countries 66 but HIA policy has only been reported in Iran, which has expressed an interest in integrating HIA into its Fifth Economic, Social and Cultural Development Plan. 67 Third, it is possible that the tension between private and public approaches to HIAs has blurred the leadership components needed for governments to decide on how to introduce HIA via public policies and environmental legislation and how to make companies accountable.

| HIA legislation in the world
The global distribution of HIA is uneven. In several countries, HIAs are now required by law, either as stand-alone processes, or as part of the EIA process (see Table 1). Some countries considered as pioneers in the field of HIA do not have formal HIA legislation but have published national guidelines and frameworks to facilitate the practice of HIA. Table 1 shows that while many high-income countries have adopted some form of HIA legislation (17 countries), very few LMICs have done so (eight countries). The table is adapted from previous studies. 68 There has been some reasoning on the contextual and administrative factors that may hinder the introduction of legal provisions for HIA. Some of them include the lack of knowledge and low training capacity in HIA practitioners, limited technical guides and frameworks for best practice, lack of operational tools, data limitations, and blurriness on HIA utility and use. 69 As mentioned in Section 2.1, although the WHO has suggested a five-step process for a basic HIA, referred to as common HIA standards, there is still variation in the modalities to conduct a HIA. This inconsistency in practice is commonly reported in EIAs, but unlike HIAs, the lack of uniformity in EIA practice is not complemented by weak policy coverage. The core issue for HIAs hence remains that developing countries, claiming the highest fraction of death and disease avoidable by environmental improvement 70 -that is, countries who are most in need of HIAs -are not conducting them.

| The implications of the HIA policy vacuum in developing countries
The lack of HIA legislation in developing countries is a major barrier to the advancement of the field. About 94 percent of all HIAs are conducted in high-income countries. 71 In an increasingly globalized Further, HIAs enable the assessment of health effects across different sectors and policies. 75 Therefore, the establishment of legislation can allow for HIAs to be integrated in key processes that inform both public policies and private projects. There is growing evidence that developing countries are in need of anticipating and proactively managing project-related health impacts, particularly in the extractive sector. 76 Without HIA legislation, developing countries will continue to conduct large private projects without the regulatory capacity to tackle a broad range of adverse health effects, such as high incidence rates of sexually transmitted infections, pollution of drinking water or elevated transmission of vector-borne diseases.
Last but not least, HIAs legislation can support developing countries in achieving health across different population groups (health equity) and within larger operational frameworks such as the 'Health in All Policies' (HiAP) approach. 77 HiAP is one of the most widely recognized approaches in public health. The WHO defines HiAP as an approach to increase accountability of policymakers for health impacts at all levels of policymaking. It underlines that public policies have consequences on health systems and on determinants of health; HiAP also contributes to sustainable development. 78 At the international level, the adoption of the HiAP approach 79 underlined a general consensus that policymakers, project leaders, stakeholders, practitioners and regulators should consider all risks and benefits of interventions likely to affect health and its determinants. 80 It facilitates synergies across nonhealth sectors in order to improve population health and health equity. 81 In Switzerland, 82 for instance, HiAP was recognized as a paradigm that could help advance the productive feedback loop between HiAP and HIA applications. 83 Similarly, HiAP approaches operationalized by HIA can ensure far-reaching effects of environmental protection in developing countries.

| HIA LEG IS L ATI ON: AN OPP ORTUNIT Y FOR DE VELOPING COUNTRIE S TO ACHIE VE THE SUS TAINAB LE DE VELOPMENT GOAL S?
Literature supports HIA as an effective tool to help achieve SDGs. In

| Benefits of HIA legislation for developing countries in the context of SDG achievement
There are various benefits of HIA legislation for developing countries. actions. 89 HIAs can also be applied at different levels (project, local, national and regional) and in various policy sectors. 90 In China, HIA has been recommended to address the inadequacies of weak health protection and promotion in the face of the escalating emergence of environmental pollutants (SDG11) and health inequality (SDG10). 91 In India, HIA has been promoted to decrease negative impacts of urban transportation on health, 92 but also to increase the impacts of community health practices. 93 In different countries in Africa, HIAs have been used for addressing the health and socio-economic effects of the e-waste crisis 94  HIAs (see Table 1). 96  Chinese cities. 104 Increasingly, HIAs of urban planning and transport (SDG11) are mandated by cities and governments in developing countries. 105 One study reports that the economic development of transport will cause an additional 51,000 extra hospital admissions and more than 850,000 restricted activity days in India. 106 These studies show that by attributing economic values to health effects, HIAs are practical and helpful to estimate advances made in different indicators relevant to sustainable development.

| Design issues in HIA legislation
When considering the future of HIA legislation in developing coun- In Thailand, HIA legislation was incorporated in the National Health Act, 114 one of the few Thai laws resulting from a large citizen participation process (more than 400,000 people joining general and specific public hearings and provincial assemblies). 115 In the draft law submitted to the National Health System Reform committee, HIA was addressed as follows: 'guidelines and measures to establish the healthy public policy and the process of HIA from the public policy, aimed at joint learning of all sectors in the society, through the sufficient academic utilization, with the transparent and accountable mechanism'. 116 The draft also asserts that 'the right of Thai people to participate in accessing the information, suggesting, performing, using the assessment outputs and making decision on the approval and permission of the policy implementation and crucial projects The Thai HIA legislation affords the opportunity to discuss contested issues and implications for HIA policy and practice in different developing countries. The first issue relates to health impact thresholds that would make a HIA mandatory under all circumstances. The emergence of transboundary threats to health such as climate change and air pollution requires that countries adopt environmental policies addressing health risks within, but also beyond their territories. HIAs provide not only the tool but also the platform to address risks such as air pollution that can no longer be perceived as a purely local or regional issue. 120 The globalizing nature of health risks will only grow as distant sources from different continents contribute to local deaths and disease.
The 2020 COVID-19 outbreak is an illustrative example of the complexities and far-reaching impacts of health at national and global levels.
The second issue is related to HIA costs. Even if adequate HIA legislation is in place, who will pay for the HIA? So far, most HIAs in developing countries have been undertaken by experts that have found the necessary resources through their own organization.
Legislation can extend the practice to public bodies, but this would mean that they would need to commission their own HIA and use their own staff to conduct them. To make HIA practice sustainable, it would be favourable that proposers of commercial or development projects pay for their own assessment, as it is currently done in EIA, but this funding mechanism would need to be clarified for statutory HIAs.
The final non-addressed issue lies in the question of monitoring HIA outcomes. So far, no concrete steps have been taken to monitor the advancement of HIA across nations. It may be effective to introduce an SDG-related indicator on whether countries legislate and use HIA so as to best monitor and evaluate the local, regional and international benefits of HIA. Establishing an SDG indicator would not make HIA mandatory for all nations, but could formalize national and international intentions towards safeguarding the health of people and the planet.

| CON CLUS ION
The crossroads between health and environmental law presents a valuable opportunity to address the limitations of environmental policies. As global urbanization progresses, countries without HIA legislative frameworks face an acute risk of morbidity and mortality while getting locked into unsustainable systems.
Countries show important variation in the coverage, timing and form characterizing HIA policy. This article exposes the urgent need for HIA legislation in developing countries, and displays how the process can be catalysed and operationalized in order to achieve the SDGs.
SDG-driven HIA legislation in developing countries can mitigate trade-offs between health and environmental change and enhance synergies between different goals and sectors.
HIAs provide opportunities to make economic savings while also using existing frameworks such as EIAs to advance public