Collaboration between public health and other fields such as transportation and land use planning, agriculture, and education has emerged as a critically important way to ensure that investments outside the health sector contribute to improving health rather than creating unintended health risks. In this context, HIA has emerged as one of the most effective ways to build inter-agency partnerships, develop appropriate metrics to measure health outcomes, and capitalize on opportunities to improve health.

As HIA has gained momentum in the U.S., some agencies and organizations have begun to establish the systems, relationships, and funding mechanisms needed to implement a stable HIA program that endures beyond the completion of a specific grant-funded project. Some of these HIA programs have come about through formalized inter-agency cooperation and funding agreements, in which a public agency finances a stable HIA program through permit fees, internal budget restructuring or collaborative agreements with other agencies. Others are developing through regional HIA collaborative groups, where non-profit community organizations, public health institutes, and public agencies have created a stable network that collaborates on HIAs; shares resources and expertise; offers university courses; maintains group websites; and provides training and technical expertise.  Though few such laws have been enacted to date, legislation that mandates, creates incentives for or otherwise supports HIA may be another approach to implementing an enduring HIA practice.

The examples provided below illustrate a range of approaches that agencies and organizations are using to begin to make HIA a routine, sustainable part of their core work.  Ultimately, each organization or agency must develop a program that meets their 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 states and regions develop robust, sustainable, self-supporting HIA programs. 

 

State HIA Program: The Alaska Example

In 2005, the North Slope Borough (NSB) and Alaska Inter-Tribal Council (AITC) began to work on integrating HIA into the federal environmental impact statement (EIS) process for oil and gas and mining projects. After considerable discussion and negotiation between the tribes and federal agency representatives, the NSB and AITC conducted HIAs for three different oil- and gas-leasing decisions, through collaboration with the federal agencies leading the EISs. As an outgrowth of this work, a widening circle of state, federal, and tribal agencies became engaged in HIA. In 2008, a workshop on HIA was held in Anchorage and included experts from five federal regulatory agencies, the CDC, state and local governments, regional health corporations, the Alaska Native Tribal Health Consortium, and national and international HIA experts. Conference attendees 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 to 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 (DHSS) established an HIA Program in July 2010 and now participates as a member of the state’s multi-agency large project permit team. [ii] The program now conducts HIAs for all large natural resource development projects in the state. [iii]

 

How does the Alaska HIA Program work?

The National Environmental Policy Act (NEPA) requires an EIS for large projects that have a potential for significant environmental effects.  At or before the start of an EIS, the federal agency in charge of the study contacts DHSS for an opinion regarding the need for and appropriate scope of the HIA. DHSS responds with a recommendation, and the HIA is built into the work plan for the EIS.  DHSS works with a contractor to develop a “stand-alone” HIA. The federal agency or the contractor preparing the EIS then integrates relevant sections of the HIA into the EIS. In certain situations, 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. 

 

How is the HIA Program funded?

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 and 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 DHSS are built into the costs of the EIS.

 

HIA Legislation: The Massachusetts Example

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.  To our knowledge, this is the only state-level law that requires the routine use of HIA, although several have been proposed. The inter-agency 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 that strives to achieve positive health outcomes and strengthens cross-sector commitment to forming transportation initiatives that support public health and active living.

How does the Healthy Transportation Compact work?

In Massachusetts, a working group containing members from each agency met regularly to plan the operations of the program and identify potential HIA targets.  The first question the working group discussed was how to define HIA, and whether there needed to be a Massachusetts-specific definition. 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 to guide the removal of a section of elevated freeway.

The Massachusetts Department of Health is using the McGrath Highway Corridor HIA to pilot the Healthy Transportation Compact HIA Program. Through conducting this HIA, the departments are developing the procedures, collaborative partnerships, data sources and metrics, and analytic approaches needed for a successful HIA partnership on future projects.  According to the Massachusetts Department of Health, the work on HIA to date has already contributed to building new partnerships and strengthening others.  These include partnerships between public health, transportation, energy and environmental regulators, as well as legislators, local health officials, and the general public.

How is the Healthy Transportation Compact funded?

The cost of HIAs will differ depending upon the questions to be answered, and the magnitude and complexity of the policy or project.  Small scale or “desk top” HIAs can be done with existing staff and several weeks of salary ($5,000-$10,000).  Larger HIAs requiring complex analyses on multiple issues can exceed $150,000. The Massachusetts Department of Health is using the HIA of the McGrath Highway Corridor as the test case to work out the details of the Healthy Transportation Compact HIA Program and the best funding mechanisms for ongoing HIA activity.

 

Collaborative Networks: The Oregon Example

The collaborative HIA network in Oregon started in 2008 as an informal working group of public and private organizations that were interested in HIA. The original group included Multnomah County Health Department, Kaiser Permanente, Upstream Public Health, Oregon State Public Health Division, Oregon Public Health Institute, and the Coalition for a Livable Future.  The purpose of the working group was to learn about HIA. They read articles and engaged in learning calls with established HIA experts.  Dr. Rajiv Bhatia from the San Francisco Department of Health gave a lecture on HIA, which encouraged the group to volunteer their time to conduct their first HIA on plans to rebuild the I- 5 Columbia River Crossing highway. From there, the different partners started to look for and secure funding to complete additional HIAs. Upstream Public Health partnered with researchers at Oregon Health and Science University to conduct the Reducing Vehicle Miles Traveled HIA in 2009.

The Oregon Health Authority secured funding through the CDC and the Association of State and Territorial Health Officials (ASTHO) to develop capacity to conduct HIAs and to do local, regional, and state HIA trainings.  Oregon Health Authority and Upstream Public Health worked with Human Impact Partners and the Northwest Health Foundation to conduct training for local and state government and community leaders. Since then, nearly 15 HIAs have been completed in Oregon.

How does the Oregon HIA Network function?

The working group evolved into a network of organizations that meet quarterly throughout the year.  The Oregon HIA Network is a diverse group of over 250 professionals from government agencies, nonprofit and advocacy groups, health care organizations, and private sector companies. The Network meets four times a year to increase communication, encourage collaboration, and build collective capacity for HIA. A small steering committee meets monthly to outline and plan the agenda of the quarterly meetings. The role of the steering committee and the Network at large is to share information and advise ongoing HIA activities. The quarterly meetings are organized into three sections:

• New HIA Practitioner Orientation: The first half hour of every meeting is devoted to giving an overview of HIA to new practitioners. The short and focused time allotted is intended to bring new organizations up to speed and on the same page as the rest of the Network, so that the overall meeting is relevant and useful to the entire group.
• Updates on HIA Activity: The majority of time is dedicated to discussing updates on current HIAs and sharing information on funding opportunities from organizations participating in the Network.  Occasionally, new ideas for HIAs are discussed. The steering committee provides feedback on potential HIA topics screened by organizations within the Network and ensure that the HIAs are well designed.
• Learning Session: The remaining half hour is devoted to new learning. The time is spent discussing the different stages of HIA through case studies to support and identify best practices and ensure quality of HIA activity.  Example topics include stakeholder engagement or evaluation.

 

Organizations in the Network have collaborated on several HIAs.  In the Columbia River Crossing Draft Environmental Impact Statement (DEIS) HIA, the Multnomah County Health Department took primary responsibility for reviewing the scientific literature and documenting the findings, while the Oregon Health Department submitted a letter during the public comment period, and Workgroup members provided feedback, process guidance, and health expertise to the analysts. [iv]  The resulting report was used by HIA Workgroup partners, community members and other public health stakeholders in their own work.[v]

 

Other examples of collaborations include:

• The Oregon Public Health Institute worked with the Department of Transportation on the Lake Oswego HIA. 
• The Oregon Health Authority is teaming up with Metro and the Oregon Department of Transportation to assess the potential health impacts of Metro’s Climate Smart Communities greenhouse gas reduction scenario planning.
• The Oregon Public Health Institute, National Network of Public Health Institutes/Centers for Disease Control and Prevention (CDC), Northwest Health Foundation, and the Portland Bureau of Planning and Sustainability worked together on the SE 122^nd Ave HIA.

 

How is the Collaborative Network funded?

Different partners provide in-kind contributions, in terms of staff time and facility space, to sustain the activities of the Collaborative Network. Some organizations have received funding from foundations to conduct HIAs, including the Northwest Health Foundation, while others were completed with in-kind contributions from different organizations or a mix of both.

 

Other Approaches to Considering Health 

HIAs can contribute to developing new tools that streamline the integration of health into public policy decisions. For example, SFDPH used HIA to develop the Health Development Measurement Tool (HDMT), a checklist that incorporates data on a wide range of health determinants and can be applied to land use planning and urban development projects.  A number of cities have adapted the HDMT for their own use.  

The Nashville Area Metropolitan Planning Organization (MPO) has started to integrate health regularly into its transportation and planning activities.  The MPO changed the criteria used to score projects adopted in its 2035 Regional Transportation Plan. Most of the points on which transportation projects are scored are now based on positive outcomes for air quality, provision of active transportation facilities, injury reduction for all modes, and improvement to personal health and equity of transportation facilities in underserved areas. [viii] Although not a part of the official scoring criteria, the MPO also evaluated the submitted projects based on proximity to grocery stores, farmers markets and emergency food sources.[ix] As a result, 75 percent of the submitted projects included an active transportation element such as a bikeway, sidewalk or greenway and 70 percent of the adopted roadway projects have active transportation infrastructure.[x]