Resource Manual to Support Application of the Protocol on SEA
ANNEX/CHAPTER A7: HEALTH
The authors: this document was prepared by Nick Bonvoisin (United Nations Economic Commission for Europe), Jiri Dusik and Ausra Jurkeviciute (Regional Environmental Center for Central and Eastern Europe) and Marco Martuzzi and Matt Soeberg (World Health Organization), with substantial advice from a small editorial group established by the Meeting of the Signatories to the Protocol and comprising: Ursula Platzer-Schneider (Austria), Mari van Dreumel (Netherlands), Roger Gebbels (initially United Kingdom, later European Commission), Roger Smithson (United Kingdom), David Aspinwall (initially European Commission) and Henrieta Martonakova (United Nations Development Programme). Further advice was provided by Tanya Burdett (United Kingdom), Alan Bond (University of East Anglia,
United Kingdom), Ben Cave, Barry Sadler , Martin Smutny, Martin Birley, Martina Froben (Germany), Tristan Aoustin (Centre International de droit comparé de l’environnement, France) and others.
The Meeting of the Signatories is expected to decide whether this is an annex to or a chapter of the Resource Manual.
A7.1 INTRODUCTION TO THE CHAPTER
1. This Chapter provides guidance on the consideration of human health as part of SEA, as required by the Protocol. Section A7.2 discusses why health matters and
the provisions of
the Protocol with regard to health. Section A7.3 goes on to look at possible practical arrangements.
2. This Chapter is intended to be useful both to SEA practitioners wishing to understand the potential effects on human health of plans and programme, and to environmental and health authorities from whom information and advice may be sought (e.g. as ‘statutory consultees’) or which wish to ensure that health issues are fully addressed.
Like the Manual as a whole, however, it does not constitute formal legal or other professional advice, or serve as interpretative guidance for the Protocol.
3. Parties might use the ideas in this Chapter to explore how health can be considered in their national setting, undertaking pilot studies, developing procedures to satisfy the requirements of the Protocol and drafting guidance meeting their own institutional needs and context.
A7.2 WHY HEALTH MATTERS
4. As the European Environment and Health Action Plan 2004-2010 notes,  “Good health is something which everyone wants – for themselves, their children and for the wider economic and social benefits it brings to our society. It plays a major role in long-term economic growth and sustainable development – there is increasing evidence showing that it is not so much the cost of health that is high, but rather the cost of ill-health (in terms of healthcare, medicines, sick leave, lower productivity, invalidity and early retirement).”
5. Evident links between the state of the environment and the state of health led to the launching of the intergovernmental “Environment and Health” process. The 1999 London Declaration on Environment and Health provided a major stimulus to the development of the Protocol on SEA, and the follow-up declaration in Budapest in 2004 confirmed the commitment to take health into account in the assessment of strategic proposals under the Protocol.
6. As a result, the Protocol provides for the consideration of health as an integral part of the SEA of plans and programmes.
A7.3 POSSIBLE PRACTICAL CONSIDERATIONS
7. This section examines interpretative and methodological challenges, as well as practical approaches to the consideration of health as part of SEA, focusing on:
- The determination of significant health effects (subsection A7.3.1)
- Consulting environmental and health authorities (subsection A7.3.2)
- Assessing the expected impacts on health, including both qualitative and quantitative assessment of health effects (subsection A7.3.3)
- Scoping and preparation of the environmental report (subsection A7.3.4)
A7.3.1 Determination of significant health effects
8. The Protocol does not provide a definition of health. Instead, it requires that relevant health issues or factors that need to be considered within an SEA are identified for each plan or programme, taking into account the results of consultation of relevant environmental and health authorities.
9. During such determination, relevant authorities may find it useful to consider the framework of determinants of health outlined in Figure A7.1 below. It will be important to identify which determinants of or factors influencing health may be significantly affected by the implementation of a plan or programme. It may then be useful to consider how the plan or programme may, for example, protect and promote health in line with relevant environmental, including health, objectives.
10. The World Health Organization (WHO) broad concept of health – well-being, not merely the absence of disease – in itself suggests that plans and programmes may influence health in many ways. Some of their effects are direct and self-evident, and many are already well recognized in practice. But others are indirect and difficult to predict. As with many types of environmental effect, the pathways between factors in the physical environment and health outcomes can be complex and take place over long timescales. It is also important to be aware that the effects of plans and programmes on health will often be synergistic, with different types of impact combining to bring about both beneficial and adverse effects.
11. In addition, there are significant issues in relation to the relevance to SEA of available data on health, which are collected for different purposes and are often at too high a level of generality to be useful in SEA. Statistics on rates of illness and death do not necessarily provide illuminating baseline data or a sound basis for monitoring the effects of implementing a plan or programme.
12. Though there is uncertainty about the relative importance of various determinants and their complex interactions, the determinants presented in Figure A7.1 are recognized as being the main factors that influence health. As such, they can be used as a starting point for assessment of the likely significant health effects of a plan or programme.
13. For example, plans and programmes may influence transport, housing, employment, education and social services and so promote social cohesion, ease access to community facilities, encourage exercise and reduce the need to drive. So a transport plan may affect the following health determinants: individual lifestyle (e.g. through encouraging or discouraging levels of physical activity); social and community networks and influences (through altering community facilities or changes in fragmentation of communities); living and working conditions (e.g. through changes in
the number of
road traffic accidents); and environmental conditions (e.g. through air pollution and noise). A further, practical, example is provided in Box A7.1 below.
Figure A7.1: The main determinants of health 
|Box A7.1: Assessment of health effects within the SEA of the Czech Operational Programme for 2007-2013 for “Enterprise and Innovation”
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14. Examples of health determinants that may be affected by a plan or programme include:
- Factors affecting healthy lifestyle such as facilitation of walking and cycling, availability of healthy products, availability of public spaces for exercise, provision of public transport and discouraging private car use
- Factors related to social or community influences or networks, such as community cohesion, community severance or fragmentation, social support or isolation, accessibility of community services (including medical services, social support, shopping), accessibility of local transport and communication networks, land use and urban design, safety and levels of crime
- Factors related to living and working conditions, such as the availability and quality of housing, access to safe drinking water and adequate sanitation, indoor air quality and exposure to hazards (i.e. risk of accidents, including work-place and transport hazards)
- General socio-economic factors (e.g. education, employment and income), cultural factors (e.g. effects on traditional lifestyle values, religious values, or sites of cultural and spiritual significance), and environmental factors (air, water and soil pollution, noise, disease vector breeding places , etc.)
15. Some of the above-mentioned factors are inter-linked or cannot easily be clustered into one category of determinant and might indeed appear in more than category. However, this framework of health determinants is not meant as a complete checklist or rigid template for categorizing or clustering health factors. It is presented as a framework for possible use in the initial identification of various health factors that may be affected by a particular plan or programme.
16. The focus of SEA under the Protocol is on the physical environment. However, as practice with applying the Protocol develops it is anticipated that more complex interactions between the physical, social and behavioural environments might be assessed in some countries.
17. Though environmental factors are important in determining health, socio-economic ones are probably more so, with income and education being strongly correlated with health (see Box A7.2). However, it may be difficult to assess the influence of many types of plans and programmes (for example, land-use plans) on these health determinants.
|Box A7.2: Measures of socio-economic status that are important determinants of health
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18. The Protocol requires assessment of only those environmental, including health, issues that are deemed likely and significant. Environmental and health authorities may therefore find it useful to gradually reduce any long list of possible health factors that may be affected by a particular plan or programme to only those on which the plan or programme may have likely significant effects. Some guidance on such a process is contained in annex III to the Protocol.
A7.3.2 Consulting environmental and health authorities
19. Consultation of environmental and health authorities is at the core of the consideration of health within SEA. In many countries, however, it is easier to identify relevant authorities with environmental responsibilities than to identify their health counterparts. Typically there are many organizations with differing responsibilities:
- National authorities are often the lead agencies on health policy development and implementation issues.
- Regional and local authorities may have a more specific role in operational matters relating to local populations.
- Municipal authorities may have a role in protecting and promoting health . This can include both traditional health management such as sanitation and water supplies as well as issues such as health promotion activities and primary health care services.
20. Health authorities are rarely involved in the plan- or programme-making process. In the WHO European Healthy Cities programme, health and planning agencies were found to cooperate regularly in only 25% of the cases studied. Health authorities may also lack the capacity to contribute effectively and they may need – at least initially – proper support or guidance. If necessary, appropriate
liaison arrangements and
procedures for soliciting their inputs (such as service agreements) could be put in place (see also section A4.4, which deals with consultation of relevant authorities).
21. Indeed, the determination of the health factors that are likely to be significantly affected by a particular type of a plan or programme, and the drawing of conclusions about positive and adverse impacts of a plan or programme on health, may not be easy tasks at first. In this regard, it could be useful if environmental and health authorities and those developing plans and programmes share information and gradually reach a common understanding on:
- Health determinants that are likely to be significantly affected by different types of plans and programmes
- Causal linkages between changes in health determinants and corresponding health effects
- Measures to prevent, reduce or mitigate any significant adverse effects on health
- Arrangements for monitoring actual health effects during implementation of various plans and programmes
A7.3.3 Assessing the expected impacts on health
22. The identification of the key health determinants that are likely to be significantly affected by a plan or programme can provide a basis for the assessment of the positive and negative effects of a plan or programme on health. Changes in these determinants may result in health effects that may be:
- Direct or secondary
- Short-, medium- or long-term
- Cumulative or synergistic
- Permanent or temporary
23. Table A7.1 provides a summary of physical environmental risk factors and possible related diseases and risks. Such a table, adapted to local conditions, may be useful to authorities in certain circumstances. It might also be adapted to different types of plan or programme.
24. In the light of the uncertainties and limitations discussed in section A7.3.1 above, it is not realistic to expect authorities carrying out SEA to make precise or detailed predictions about the potential effects, either beneficial or harmful, of their plans and programmes on health. Nor would it generally be practicable for them to carry out very detailed studies to predict these effects. It is essential that appropriate, simple and practical approaches be taken with more detailed studies being undertaken only in special cases, as adequately addressing health in SEA poses important methodological and procedural challenges.
25. In this regard, it is useful to note that the Protocol requires through its article 2, paragraph 7, provision only of information that may reasonably be required, taking into account:
- Current knowledge and methods of assessment;
- The contents and the level of detail of the plan or programme and its stage in the decision-making process;
- The interests of the public; and
- The information needs of the decision-making body.
26. In addition, annex IV, item 8, of the Protocol requires that the environmental report include information on difficulties encountered in providing the information to be included, such as technical deficiencies or lack of knowledge.
|Table A7.1: Examples of physical environmental risk factors and related diseases and risks (WHO, 2006; adapted to refer to the UNECE region )
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Qualitative assessment of health effects
27. In most instances, the assessment of health effects will be qualitative, not quantitative. However, qualitative assessment does not mean guessing: any judgement should be well reasoned and should whenever possible rely on existing research and knowledge. Annex A5.1 outlines some analytical tools that facilitate expert judgement; other tools may be derived from the medical profession. The London Health Observatory has produced A Guide for Reviewing Published Evidence for use in Health Impact Assessment, which details a number of steps for assessing quantitative and qualitative evidence that might be appropriate in SEA.
28. It should at least be possible to assess the positive and negative effects of a plan or programme on relevant health determinants and to draw overall conclusions on whether the plan or programme creates favourable conditions for a healthy population, with health being defined to include well-being, not merely the absence of disease.
29. Table A7.2 below gives examples of questions related to health that SEA practitioners might raise in connection with their proposals, together with notes on links which have been established between these issues and the health of individuals and social groups. The questions are broadly ranged in a sequence, from specific and direct effects to those which are subjective and linked to well-being and the quality of life:
Quantitative assessment of health effects
30. Most approaches to the quantitative assessment of health effects are likely to rely on elements of Health Impact Assessment (HIA). HIA has to a great extent developed separately from SEA, is based on different disciplines, and is far less focused on prediction of the effects of strategic proposals. However, careful use of its approaches and methods can provide decision-makers with valuable information on the implications for health of their plans and programmes. Box A7.3 gives an overview of the scope and methods of HIA.
31. This Manual emphasizes the integration of health into SEA and the avoidance of a separate HIA for a plan or programme subject to SEA under the Protocol. Nonetheless, HIAs have been undertaken that illustrate health and planning authorities working together, and that would also fit straightforwardly into an SEA methodology. One example of such an approach is that of the Cambridgeshire Health Authority in the United Kingdom.
32. To find out more about HIA, a good starting point is the WHO website at http://www.euro.who.int/en/what-we-do/health-topics/environmental-health/health-impact-assessment ; more information may be found at http://www.apho.org.uk/default.aspx?QN=P_HIA [and http://hiadatabase.nl/ - no longer available, but try via http://www.rivm.nl/en/aboutrivm/thematic_sites/ ]. See also the International Best Practice Principles for HIA published by the International Association for Impact Assessment (http://www.iaia.org/ ).
Table A7.2: Health in SEA: possible effects of plans and programmes on health
Examples of questions that can help to identify possible effects of plans and programmes on health, with notes on the ‘evidence base’ of known connections between these issues and health. (Questions are indicative only and might be used or adapted as relevant.)
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Box A7.3: SEA and Health Impact Assessment: similarities and differences
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A7.3.4 Scoping and preparation of the environmental report
33. Subsection A4.2.3 of the Manual describes steps in scoping and the preparation of the environmental report. This subsection provides some practical tips for addressing health issues within those steps, by presenting additional guidance on the contents of the report (further to Table A4.2). The suggestions in Table A7.3 below should not be treated as providing a complete and rigid framework. Those persons addressing health issues in the environmental report might adopt approaches based on the specific nature and context of the given plan or programme and on the comments obtained from health authorities during scoping.
Table A7.3: Possible approaches to addressing health in the Environmental Report
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 Commission of the European Communities, COM(2004) 416 final. Brussels, 9.6.2004. http://ec.europa.eu/governance/impact/ia_carried_out/docs/ia_2004/com_2004_0416_1_en.pdf .
 Declaration of the Third Ministerial Conference on Environment and Health (London, 1999) http://www.euro.who.int/en/home/conferences/fifth-ministerial-conference-on-environment-and-health/past-conferences/third-ministerial-conference-on-environment-and-health,-london,-united-kingdom,-1999/declaration.-third-ministerial-conference-on-environment-and-health and declaration of the Fourth Ministerial Conference (Budapest, 2004) http://www.euro.who.int/en/home/conferences/fifth-ministerial-conference-on-environment-and-health/past-conferences/fourth-ministerial-conference-on-environment-and-health,-budapest,-hungary,-2004/fourth-ministerial-conference-on-environment-and-health.-declaration .
 Adapted from Margaret Douglas, Martin Higgins and Sheila Beck. Strategic Environmental Assessment and health Briefing paper for the Scottish HIA Network, 2005. Available at http://www.healthscotland.com/documents/1250.aspx
 Hugh Barton and Marcus Grant (2006), drawing on Whitehead and Dahlgren (1991) and Barton (2005). Sources: (a) Barton H (2005) 'A Health Map for Urban Planners: towards a conceptual model for healthy, sustainable settlements' in Built Environment Vol 31, No 4, pp 339-355. (b) Barton H and Grant M (2006) 'A health map for the local human habitat' in Journal of the Royal Society for the Promotion of Health Vol 126, No 6. (c) Whitehead M and Dahlgren G (1991) 'What can be done about inequalities in health?' The Lancet 338 pp1059-1063
 Based on International Association for Impact Assessment. Health Impact Assessment: International Best Practice Principles. Special Publications Series No. 5 September 2006. Available at http://www.iaia.org/publicdocuments/special-publications/SP5.pdf .
 Hugh Barton, Claire Mitcham and Catherine Tsourou (eds.) 2003. Healthy urban planning in practice: experience of European cities. Report of the WHO City Action Group on Healthy Urban Planning. Available at http://www.euro.who.int/__data/assets/pdf_file/0003/98400/E82657.pdf .
 Available at http://www.apho.org.uk/resource/item.aspx?RID=44867 .
 Cambridgeshire Health Authority. 2002. Cambridgeshire & Peterborough Structure Plan Review: Health Impact Review. Prepared by Land Use Consultants in association with Anne Gordon Associates. March 2002, available at