Health Impact Assessment (HIA): analyses and challenges to Brazilian Health Surveillance

Missifany Silveira André Luiz Dutra Fenner About the authors

Resumo

O presente artigo tem como objetivo discutir sobre a Avaliação de Impacto à Saúde (AIS), apontando as principais iniciativas do setor saúde, desafios e perspectivas para a sua aplicação no Brasil. A AIS é uma metodologia preconizada pela OMS já bastante difundida em diversos países, mas com poucas iniciativas no Brasil. As questões de saúde no âmbito dos grandes empreendimentos no país são comumente realizadas de forma pontual nos processos de licenciamento ambiental, diferentemente da AIS que traz uma abordagem integrada, com a participação dos atores sociais no território desde o início do projeto. Trata-se de uma pesquisa de natureza analítica e exploratória. Para tanto, realizou-se uma revisão sistemática sobre o tema, bem como o levantamento de documentos governamentais das principais iniciativas já realizadas pelo Ministério da Saúde, no âmbito da Vigilância em Saúde Ambiental, nos processos de licenciamento de empreendimentos. Buscou-se analisar os principais marcos conceituais, apontando possibilidades para sua aplicação no Brasil, assim como novas perspectivas para atuação do campo da Vigilância em Saúde nessa temática, permitindo que a variável saúde seja avaliada durante as diferentes intervenções de uma política, programa ou projeto.

Avaliação de impacto à saúde; Licenciamento ambiental; Grandes empreendimentos; Determinantes sociais

Abstract

This study aims to discuss the Health Impact Assessment (HIA), pointing out the main initiatives of the health sector, challenges and perspectives for its implementation in Brazil. HIA is a methodology recommended by the WHO and is widely used in several countries, but with few initiatives in Brazil. Health issues in the context of large projects are commonly conducted on a timely basis within the environmental licensing processes, unlike HIA, which proposes an integrated approach, with the involvement of social stakeholders in the territory since the beginning of the project. This is an analytical and exploratory research and, thus, a systematic review on the subject was carried out, as well as a survey of government documents on the main initiatives already conducted by the Ministry of Health within Environmental Health Surveillance in the environmental licensing processes of large projects. We sought to analyze the main conceptual frameworks, pointing out possibilities for their implementation in Brazil, as well as new perspectives for Health Surveillance in this area, allowing the health variable to be evaluated during several interventions of a policy, program or project.

Health impact assessment; Environmental licensing; Large projects; Social determinants

Introduction

Since the 1970s, there has been a lack of health-related aspects during environmental assessments of major development projects in the global context. In this context, following intensive campaigns by the World Health Organization (WHO) through programs such as “Health for All in the 21st Century” and, most recently, the “Healthy Cities Network” strategy, the Health Impact Assessment (HIA) has gained greater visibility as an intersectoral action tool to promote health and reduce inequalities, and is apprehended by several countries11. Bacigalupe A, Esnaola S, Calderón C, Zuazagoitia J, Aldasoro E. La evaluacion del impacto sobre la salud: una herramienta para incorporar la salud en las intervenciones no sanitarias. Gaceta Saniaria 2009; 23(1):..

Proposed by the WHO, HIA is an effective methodology to identify the positive and negative impacts of an intervention in the territory, whether policy, plan, program or project22. World Health Organization. (WHO). European Centre for Health Policy. Health Impact Assessment: mains concepts and suggested approach. Gothenburg Consensus paper. Geneva: WHO; 1999.,33. Abrahams D, Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, Metcalfe O, Pennington A, Scott-Samuel A. Policy Health Impact Assessment for the European Union: Final Project Repost. Aug/2004. [acessado 2012 abr 4]. Disponível em: http://www.ihia.org.uk/ephia/reports/finalprojectreport.pdg
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. Not overlapping with other evaluations, HIA facilitates the assessment of the health variable during the different interventions, providing a new evaluation perspective that was not previously taken into account by decision-makers.

While adopted almost two decades ago – since the Gothenburg Consensus in 1999 – HIA continues to cause a stir among different public and private sectors, as well as academics and civil society organizations. A research conducted by Balby44. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012. pointed out a significant number of publications – scientific papers, manuals, guides, books – and international conferences on the issue. It is also worth mentioning that, in 2011, the Society of Practitioners of Health Impact Assessment (SOPHIA) was established to gather the professionals involved in the practice of HIA44. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012..

Researchers and scholars, also known as HIA “practitioners”, maintain that, due to its predictive, multidisciplinary, intersectoral and participatory nature, with a focus on social inequalities, this methodology aids decision-making, and aims to maximize health gains through an intervention33. Abrahams D, Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, Metcalfe O, Pennington A, Scott-Samuel A. Policy Health Impact Assessment for the European Union: Final Project Repost. Aug/2004. [acessado 2012 abr 4]. Disponível em: http://www.ihia.org.uk/ephia/reports/finalprojectreport.pdg
http://www.ihia.org.uk/ephia/reports/fin...
,55. Bhatia R, Wernham A. Integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice. Review 2009; 14(4):1159-1175.,66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011.. It is therefore assumed that the HIA is capable of optimizing the conditions and quality of life of a given population that will undergo some type of intervention in its territory, improving the health situation in local communities and thus ensuring the sustainability of a project55. Bhatia R, Wernham A. Integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice. Review 2009; 14(4):1159-1175.,66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011..

Thus, HIA encompasses the identification, prediction and evaluation of the expected changes in health risks – which may be either negative or positive, individual or collective – caused by a policy, plan, program or development project that affects a population22. World Health Organization. (WHO). European Centre for Health Policy. Health Impact Assessment: mains concepts and suggested approach. Gothenburg Consensus paper. Geneva: WHO; 1999..

In Brazil, the adopted Environmental Impact Assessment (EIA) model is not sufficient to reflect the health impacts of a given population during the implementation of projects77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.. At the same time, identifying the socio-environmental and health impacts of large enterprises is complex and is a major challenge.

Thus, this analytical and exploratory study aims to discuss the Health Impact Assessment (HIA), pointing out possibilities for its application in Brazil, and in the future allow the health variable to be evaluated during the several interventions of a policy, program or project. Therefore, we sought to analyze the main conceptual frameworks, as well as the initiatives of the Brazilian health sector, the challenges faced and new perspectives for action in the field of health surveillance in this area.

Health Impact Assessment (HIA) in the international context and its interface with other assessment methodologies

For the first time, WHO defined HIA as a “combination of procedures, methods and tools to assess a proposed policy, plan or program regarding its potential health impacts and the occurrence of these impacts on the population”22. World Health Organization. (WHO). European Centre for Health Policy. Health Impact Assessment: mains concepts and suggested approach. Gothenburg Consensus paper. Geneva: WHO; 1999.. This definition was a milestone for HIA, when it was launched by WHO in 1999 in the Gothenburg Consensus document, during the seminar “Health impact assessment: from theory to practice” prepared by the European Centre for Health Policy (ECHP) in Gothenburg, Sweden22. World Health Organization. (WHO). European Centre for Health Policy. Health Impact Assessment: mains concepts and suggested approach. Gothenburg Consensus paper. Geneva: WHO; 1999..

The International Association for Impact Assessment (IAIA)99. International Association for Impact Assessment (IAIA). Avaliação de Impactos na Saúde: princípios internacionais da melhor prática. São Paulo: IAIA; 2006. Edições Especiais nº 5. says that HIA guiding principles are based on the Gothenburg Consensus, which values democracy, equity, sustainable development, ethical use of evidence and a global approach to health. It is also relevant to reinforce the need for HIA to assess the effects on the social determinants of health99. International Association for Impact Assessment (IAIA). Avaliação de Impactos na Saúde: princípios internacionais da melhor prática. São Paulo: IAIA; 2006. Edições Especiais nº 5..

Based on commitments made by the European Union (EU), the HIA methodology was applied in the development of public policies of EU countries, originally called European Policy Health Impact Assessment Methodology or EPHIA methodology. It aimed to inform and influence the process of elaborating a policy, program or project, taking into account its implications on health inequities33. Abrahams D, Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, Metcalfe O, Pennington A, Scott-Samuel A. Policy Health Impact Assessment for the European Union: Final Project Repost. Aug/2004. [acessado 2012 abr 4]. Disponível em: http://www.ihia.org.uk/ephia/reports/finalprojectreport.pdg
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.

According to Abrahams et al33. Abrahams D, Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, Metcalfe O, Pennington A, Scott-Samuel A. Policy Health Impact Assessment for the European Union: Final Project Repost. Aug/2004. [acessado 2012 abr 4]. Disponível em: http://www.ihia.org.uk/ephia/reports/finalprojectreport.pdg
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, this method adopts the basic reference of the “social health model”, which extrapolates the lack of disease and addresses the physical, mental, social and spiritual well-being of people. To this end, it recognizes that health and well-being are affected by complex interactions between social and economic factors, physical development and individual behavior, as well as hereditary factors. The analysis of health inequities is one of the key principles of this methodology, in which the existence of individuals and groups of people with better or worse conditions of health is pointed out, emphasizing current inequalities. This factor reflects the differentiated exposure to health risks associated with factors such as socioeconomic, ethnic and gender conditions, over the lifetime of individuals33. Abrahams D, Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, Metcalfe O, Pennington A, Scott-Samuel A. Policy Health Impact Assessment for the European Union: Final Project Repost. Aug/2004. [acessado 2012 abr 4]. Disponível em: http://www.ihia.org.uk/ephia/reports/finalprojectreport.pdg
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.

According to Winkler66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011., while it is one of HIA’s advantages, the Social Determinants of Health (SDH) approach is a complex task because it involves individual, social, environmental, economic and institutional factors66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011.. As shown in the figure below, when HIA is carried out, such as increased disease burden in developing countries, health determinants can have a decisive influence on the effect of a policy, program or project evaluation.

Thus, the commitment to integrate the different bodies and institutions responsible for policies, programs and projects is fundamental, in order to select the main determinants, through the most relevant and accessible data and information for analyzing health inequalities and, consequently, reduced inequities66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011..

In this regard, the discussion paper for the World Conference on Social Determinants of Health (WCSDH)1010. Organização Mundial da Saúde (OMS). Diminuindo diferenças: a prática das políticas sobre determinantes sociais da saúde: documento de discussão. Brasília: OMS; 2011., held in Brazil in 2011, corroborates this argument because it considered that most of the burden of disease occurs due to the conditions under which people are born, live, grow, work and age. Therefore, this set of conditions called “social determinants of health”, in which the environmental, cultural, economic, political and social determinants of health are summarized is of paramount importance to evaluate the conditions related to this aspect in a given population1010. Organização Mundial da Saúde (OMS). Diminuindo diferenças: a prática das políticas sobre determinantes sociais da saúde: documento de discussão. Brasília: OMS; 2011..

It is worth mentioning that, in 2013, Helsinki hosted the 8th World Conference on Health Promotion, which indicated, among its main objectives, the implementation of the “Health in All Policies”1111. Leppo K, Ollila E, Sebatián P, Wismar M, Cook S. Health in All Policies: Seizing opportunities, implementing policies. Helsinki: Ministry of Social Affairs and Health; 2013.. This intersectoral approach aims to integrate health in all policies across all sectors so that health and health systems are systematically incorporated into decision-making. Its main characteristics build on human rights and social justice as a focus on the formulation, implementation and evaluation of policies1111. Leppo K, Ollila E, Sebatián P, Wismar M, Cook S. Health in All Policies: Seizing opportunities, implementing policies. Helsinki: Ministry of Social Affairs and Health; 2013..

In this context, HIA is also cited as one of the components of this strategy, in order to achieve better health outcomes by reducing inequalities identified in this area. Such an approach, which includes health in the context of other social policies – such as transportation, housing, education, the environment, agriculture – is a significant influence on health determinants1212. Gulis G, Mekel O, Ádam B, Cori L. Assessment of Population Health Risks of Policies. New York: Springer; 2014..

According to studies submitted by the York Health Economics Consortium (YHEC)1313. York Health Economics Consortium (YHEC). Cost Benefit Analysis of Health Impact Assessment. Final Report. York: University of York, Department of Health; 2006., HIA can be integrated with other forms of impact assessment to determine, based on evidence, the impact on health determinants likely to be affected by a policy, plan or program. Such integration would be beneficial in providing information and guidance to professionals who are unaware of the health impacts caused by potentially polluting enterprises1313. York Health Economics Consortium (YHEC). Cost Benefit Analysis of Health Impact Assessment. Final Report. York: University of York, Department of Health; 2006..

Noble and Bronson1414. Noble BF, Bronson JE. Integrating Human Health into Environmental Impact Assessment: Case Studies of Canada’s Northern Mining Resource Sector. Arctic 2005; 58(4):395-405. argue that the inclusion of health impacts in the Environmental Impact Assessment (EIA) of projects has received greater attention from health professionals and institutions, including WHO and Health Canada, in recognition of the need and benefits of an approach to health in the Environmental Impact Assessment (EIA)1414. Noble BF, Bronson JE. Integrating Human Health into Environmental Impact Assessment: Case Studies of Canada’s Northern Mining Resource Sector. Arctic 2005; 58(4):395-405..

A Canadian experience in mining projects has allowed us to conclude how the processes that assess the impacts of the respective projects have not given proper importance to the issue of human health. The study identified learning opportunities to move towards a more inclusive approach to health in EIA, as highlighted by Noble and Bronson1414. Noble BF, Bronson JE. Integrating Human Health into Environmental Impact Assessment: Case Studies of Canada’s Northern Mining Resource Sector. Arctic 2005; 58(4):395-405.. Authors say that integrating health into environmental impact assessments requires a number of considerations, such as assessing the effects of projects on health, based on the recognition that human health, well-being and the environment are inseparable. In this aspect, social and health repercussions should be considered with the same scientific rigor that is given to the biophysical factors during the evaluation of environmental impacts1414. Noble BF, Bronson JE. Integrating Human Health into Environmental Impact Assessment: Case Studies of Canada’s Northern Mining Resource Sector. Arctic 2005; 58(4):395-405..

From this perspective, some authors dialogue towards the integration of HIA and EIA, enabling a new category of analysis, aimed at promoting better living and health conditions to the population in the area covered by a project55. Bhatia R, Wernham A. Integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice. Review 2009; 14(4):1159-1175.. However, Bhatia and Wernham55. Bhatia R, Wernham A. Integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice. Review 2009; 14(4):1159-1175. affirm that this integration relies on some requirements:

  • A project proponent who recognizes the EIA as a regulatory strategy available to public health;

  • A responsive agency that conducts EIA;

  • Involvement of public health institutions;

  • The complementary objectives between community stakeholders and health professionals; and

  • Collaboration between institutions responsible for EIA, affected public health institutions and stakeholders, as well as guidelines, resources and training for the integrated HIA-EIA practice.

In a lecture delivered at the National School of Public Health (ENSP), according to Professor Mirko Winkler1515. Escola Nacional de Saúde Pública Sérgio Arouca (ENSP). Informe ENSP. Avaliação de Impacto à saúde em grandes empreendimentos em Países Tropicais. Palestra proferida pelo Professor Winkler, M. Fiocruz, 2015. [acessado 2016 maio 6]. Disponível em: http://www.ensp.fiocruz.br/portal-ensp/informe/site/materia/detalhe/37558.
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, HIA proposes, in its design, the systematization of information, incorporating scientific evidence, with an eye toward identified problems and the expected health impacts. Therefore, it is a technical and political tool that supports decision-makers. It is worth mentioning that one of the most important aspects of this methodology is its integrated approach, with the participation of social stakeholders in the territory since the beginning of the project around problems that may arise with the new development 1515. Escola Nacional de Saúde Pública Sérgio Arouca (ENSP). Informe ENSP. Avaliação de Impacto à saúde em grandes empreendimentos em Países Tropicais. Palestra proferida pelo Professor Winkler, M. Fiocruz, 2015. [acessado 2016 maio 6]. Disponível em: http://www.ensp.fiocruz.br/portal-ensp/informe/site/materia/detalhe/37558.
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.

Health Impact Assessment (HIA) in Brazil: advances and challenges

The HIA model became the object of study in Brazil, based on the experiences reported by other countries, through “HIA practitioners”33. Abrahams D, Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, Metcalfe O, Pennington A, Scott-Samuel A. Policy Health Impact Assessment for the European Union: Final Project Repost. Aug/2004. [acessado 2012 abr 4]. Disponível em: http://www.ihia.org.uk/ephia/reports/finalprojectreport.pdg
http://www.ihia.org.uk/ephia/reports/fin...

4. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012.

5. Bhatia R, Wernham A. Integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice. Review 2009; 14(4):1159-1175.
-66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011.. From this perspective, the search for new tools and methodologies that can assess health impacts is evidenced as a prerogative of the health sector, reinforcing its role in social policies in order to ensure more effective institutional arrangements and response capacity.

In Brazil, few studies show the health variable in prior evaluations (ex ante) of the impacts related to a policy, plan or project. Participation in retrospective (ex post) studies, that is, in evaluations during or after the implementation of a project44. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012. is more common. This corroborates the analysis of large enterprises, in which the evaluation of the health variable is used especially in specific projects or programs – as is the case of malaria-related disease – during environmental impact assessments77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838..

In this regard, during environmental impact assessments, under the jurisdiction of a sector with a strong institutional role, socio-environmental and human health-related aspects are not always considered in the environmental licensing processes of projects88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.,1616. Silveira M, Padilha JD, Schneider M, Amaral PST, Carmo TFM, Netto GF, Rohlfs DB. Perspectiva da avaliação de impacto à saúde nos projetos de desenvolvimento no Brasil: importância estratégica para a sustentabilidade. Caderno de Saúde Coletiva 2012; 20(1):57-63.. This fact demonstrates the gap arising from the lack of articulation between sectoral public policies in the face of the socio-environmental impacts generated by large projects88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838..

Environmental studies as a requirement for the implementation of potentially polluting projects have in fact been inefficient in pointing out the impacts and the lack of health risks inherent to these projects and were limited primarily to biophysical aspects. Research on this topic points out that the poor insertion of health aspects during the EIA stems from the lack of coordination between the different sectors and specific legislation or tools77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,1717. Barbosa EM, Barata MML, Hacon SS. A saúde no licenciamento ambiental: uma proposta metodológica para a avaliação dos impactos da indústria de petróleo e gás. Cien Saude Colet 2012; 17(2):299-310..

Despite the lack of institutional, technical and political mechanisms, several instances of the health sector concentrate efforts to introduce the proper aspects of this area in the environmental licensing processes of large projects77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.. From this perspective, environmental health has fulfilled its role of systematically monitoring processes related to large projects, proposing tools and methodologies to evaluate health impacts that may contribute to the establishment of territories with adequate environmental and social sustainability1818. Tambellini AT, Câmara VM. A temática saúde e ambiente no processo de desenvolvimento do campo da saúde coletiva: aspectos históricos, conceituais e metodológicos. Cien Saude Colet 1998; 3(2):47-59..

Aiming at defining the guidelines that strengthen the participation of the health sector in these processes, and at the same time proposing to carry out studies to implement the HIA methodology in Brazil, the Ministry of Health, through the Environmental Health and Worker Health Department (DSAST) of the Secretariat of Health Surveillance (SVS) has been carrying out some initiatives, as highlighted in the table below (Chart 1).

Chart 1
Initiatives of the health sector in the environmental licensing processes of large projects and actions for the strengthening of HIA in Brazil.

In addition to contributing to environmental health in the country, these initiatives collaborated to bring professionals from both sectors closer in the environmental licensing of large projects, integrating government agendas for the inclusion of health in plans and projects, and at the same time setting HIA within the scope of the Brazilian health sector77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016..

Based on international experiences and the various actions, the discussion on the HIA methodology acquired a broader scope within the SUS, with the elaboration of the document: “Health Impact Assessment - HIA: Methodology adapted for application in Brazil26”. This is the most current reference nowadays, published by the Ministry of Health with the purpose of inducing the development of specific activities for the adaptation and development of HIA in the country. This publication aimed to contribute to the improvement of the health and environmental policy and to act as a guide for the ongoing environmental policy, since it is configured as a proposal document that “will address the health sector’s performance in environmental licensing processes”2626. Brasil. CGAVAM/SVS/MS. 1ª. Oficina de Trabalho sobre Avaliação de Empreendimentos pelo Sistema Único de Saúde – SUS. Brasília, 6 a 8 de julho de 2005. 2005 (Arquivo CGVAM)..

It is also worth noting that this document’s importance is recognized as the first report in the country that advocates the relevance of health impacts, mainly due to the construction and implementation of large projects77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.. Thus, the causal interrelationships between environmental impacts and the possible effects on human health are undergoing a reorientation to include health in the Environmental Impact Assessment (EIA), aiming at strengthening actions that instigate companies to mitigate and compensate for impacts on the health of the population.

Since it is a tool that allows estimating the impacts caused by a health policy, plan or programs, and especially estimating social inequities, the HIA methodology in Brazil is currently conceived from its integration with the EIA2626. Brasil. CGAVAM/SVS/MS. 1ª. Oficina de Trabalho sobre Avaliação de Empreendimentos pelo Sistema Único de Saúde – SUS. Brasília, 6 a 8 de julho de 2005. 2005 (Arquivo CGVAM)..

It should also be noted that current regulations for development projects anchored only in the EIA might be insufficient for more comprehensive assessments such as HIA77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.. This peculiarity turns out to be a weakness because, in most cases, strategic decisions have already been made, with little scope for alternatives with lower health risks44. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012.. Furthermore, it is considered that it is difficult to proceed with the evaluation or monitoring of health recommendations in the environmental impact assessments following the conclusion of the licensing process. Hence, HIA is a fragile methodological tool to “minimize negative impacts and maximize positive impacts in different social, economic and geographical contexts”, as explained in the document published by the Ministry of Health2626. Brasil. CGAVAM/SVS/MS. 1ª. Oficina de Trabalho sobre Avaliação de Empreendimentos pelo Sistema Único de Saúde – SUS. Brasília, 6 a 8 de julho de 2005. 2005 (Arquivo CGVAM)..

The document Health Impact Assessment - HIA: Methodology adapted for application in Brazil2626. Brasil. CGAVAM/SVS/MS. 1ª. Oficina de Trabalho sobre Avaliação de Empreendimentos pelo Sistema Único de Saúde – SUS. Brasília, 6 a 8 de julho de 2005. 2005 (Arquivo CGVAM).could introduce in its conception, according to our understanding, in addition to the EIA, the Strategic Environmental Assessment (SEA). The latter is a tool that enables “analytical and participatory approaches that integrate environmental considerations into plans, policies and programs, assessing interconnections with economic and social considerations”2727. Brasil. Ministério da Saúde (MS). Seminário sobre Saúde Ambiental e Saúde do Trabalhador e suas interfaces com o Programa de Aceleração do Crescimento (PAC). Brasília: MS; 2007.. Predictive impact assessments are essential to support the policy formulation phase and, in the case of Strategic Environmental Assessment (SEA), are shown as a decision-supporting tool. They apply to policies, plans or programs in the design phase, rather than in the evaluation during the implementation phase, as is the case with EIA2828. Brasil. Portaria Interministerial nº 822, de 30 de abril de 2008. Disciplina o regime unificado de pagamento de tributos, de contribuições e dos demais encargos do empregador doméstico (Simples Doméstico) e dá outras providências. Diário Oficial da União 2008; 2 maio..

According to the Organization for Economic Cooperation and Development (OECD)2727. Brasil. Ministério da Saúde (MS). Seminário sobre Saúde Ambiental e Saúde do Trabalhador e suas interfaces com o Programa de Aceleração do Crescimento (PAC). Brasília: MS; 2007., while being at the highest level of decision-making, policies tend to have more flexible propositions than projects, since they generally have well-defined specifications and standards. This statement is evident in the EIA, through the Environmental Impact Study (EIS), which is mandatory in the environmental licensing processes of specific projects. In this regard, a broader discussion is required, which will direct the methodological approach towards integrating HIA into other assessments, such as EIA and SEA, including as a strategy for strengthening sectoral policies, especially in the implementation phase of a given project.

However, HIA should not be seen as a tool to replace the EIA in the licensing processes, but it could be configured as a complementary tool. However, the environmental sector, which is responsible for analyzing health issues in these processes, is not manned with technical staff capable of doing the task, which hinders the analyses that are sometimes challenged by the control bodies due to the lack of effective response of the project’s conditionants77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.. Thus, until new methodologies are built and institutionally accepted within the scope of public policies, the few opportunities for inclusion of the health-related elements in the environmental licensing processes of large projects should continue.

For most HIA “practitioners” in the international setting33. Abrahams D, Broeder L, Doyle C, Fehr R, Haigh F, Mekel O, Metcalfe O, Pennington A, Scott-Samuel A. Policy Health Impact Assessment for the European Union: Final Project Repost. Aug/2004. [acessado 2012 abr 4]. Disponível em: http://www.ihia.org.uk/ephia/reports/finalprojectreport.pdg
http://www.ihia.org.uk/ephia/reports/fin...
,55. Bhatia R, Wernham A. Integrating human health into environmental impact assessment: an unrealized opportunity for environmental health and justice. Review 2009; 14(4):1159-1175.,66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011., the HIA is applied to public policies as a planning tool, with the proposition of specific health actions with a view to improving the quality of life of the populations of the affected areas by predicting possible risks. However, one of the principles of the HIA conceptual model is the incorporation of social determinants, which gives greater scope for its evaluation.

In this regard, we point out the relevance of specifying the social determinants of health in the document published by the Ministry of Health. Thus, the tool would become more robust considering the complexity and interdependence of socioeconomic factors and conflicts arising from their interaction with the environment and, essentially, with the social determinants of health, as Winkler66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011. points out. According to this author, when the HIA is considered in the analysis of a policy, a program or a project, social determinants are the key points for identifying the impacts on vulnerable groups in a differentiated way, evidencing inequalities and inequities in health66. Winkler MS. Health impact assessment in complex eco-epidemiological settings in the humid tropics [thesis]. Basel: University of Basel; 2011..

Final considerations

While there are studies that point out ways to apply HIA in Brazil, research institutions should be interested in this methodology. In addition, it is important to sensitize health professionals toward proposing and disseminating the importance of the tool since there is no availability of HIA training in the country, and health institutions should propose a line of technical staff education and training to work in this field1515. Escola Nacional de Saúde Pública Sérgio Arouca (ENSP). Informe ENSP. Avaliação de Impacto à saúde em grandes empreendimentos em Países Tropicais. Palestra proferida pelo Professor Winkler, M. Fiocruz, 2015. [acessado 2016 maio 6]. Disponível em: http://www.ensp.fiocruz.br/portal-ensp/informe/site/materia/detalhe/37558.
http://www.ensp.fiocruz.br/portal-ensp/i...
.

According to research carried out on HIA, this methodology has advantages and limitations44. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012.. Therefore, it must meet certain prerequisites, such as: the main reasons for adopting HIA; the context of the proposal; type of institutions responsible for costs and decision-making; availability of trained evaluators; methods and tools used in the evaluation; participation of stakeholders; human and financial resources, among other factors44. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012..

The same research points out that one of the weaknesses of HIA in projects submitted to environmental licensing analysis in Brazil follows a predefined scope by the entrepreneur and the environmental agency and is to be negotiated between the parties. In this case, this does not meet one of HIA’s premises, that is, inclusion of the affected parties in the process. The research also indicates ways to overcome this limitation, towards greater involvement of health agencies in defining the scope of the Environmental Impact Assessment (EIA), in order to allow integration between health and environment from the onset of the process44. Balby CN. Avaliação de Impactos a Saúde: Desenvolvimento Internacional e Perspectivas no Brasil [dissertação]. São Paulo: Universidade de São Paulo; 2012..

Despite the initiative of the Ministry of Health, through the field of environmental health surveillance – which has a timely participation in these processes – the proposed new analysis methodology such as HIA appears shyly before the importance of the connection of development projects with public health and environmental policies77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.,1616. Silveira M, Padilha JD, Schneider M, Amaral PST, Carmo TFM, Netto GF, Rohlfs DB. Perspectiva da avaliação de impacto à saúde nos projetos de desenvolvimento no Brasil: importância estratégica para a sustentabilidade. Caderno de Saúde Coletiva 2012; 20(1):57-63.. Therefore, the advancement of this initiative in the scope of public policies in Brazil requires a methodological-scientific work with the support of research institutions and a political support so that the initiative of the Ministry of Health is implemented systematically in Brazil.

While there is mention in the normative reference about the importance of the participation of the health sector in the planning of development projects, there is still no specific legislation that regulates the systematic participation of the health sector in environmental licensing processes. The exception is found in procedures related to malaria endemic areas77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.,1616. Silveira M, Padilha JD, Schneider M, Amaral PST, Carmo TFM, Netto GF, Rohlfs DB. Perspectiva da avaliação de impacto à saúde nos projetos de desenvolvimento no Brasil: importância estratégica para a sustentabilidade. Caderno de Saúde Coletiva 2012; 20(1):57-63..

In Brazil, the Environmental Impact Assessment (EIA) is inadequate to cover the main health problems in the territory through the implementation of large enterprises, in which environmental licenses only have a purely registry-like role, proving fragile to cover more comprehensive actions from the viewpoint of social and environmental sustainability77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.. Thus, despite recognizing the positive and negative impacts in certain areas, the health impacts are measurable and cannot remain invisible in Brazilian legislation, even in the face of reformulations to the environmental licensing process in the country2929. Instituto Socioambiental (ISA). Notícias Socioambientais. ‘Nova legislação do licenciamento ambiental vai instaurar guerra fiscal ‘diz advogado do ISA, 16 de dezembro de 2016. [acessado 2017 jun 12]. Disponível em: https://www.socioambiental.org/pt-br/noticias-socioambientais/novo-legislacao-do-licenciamento-ambiental-vai-instaurar-guerra-fiscal-diz-advogado-do-isa.
https://www.socioambiental.org/pt-br/not...
.

Thus, the Health Impact Assessment (HIA) and its application in Brazil is a challenge. First, because it is a new object of study to be explored, and there is no significant number of research on the subject. Second, there is a contradiction between the interests involved in the country’s development and the impacts resulting from this process77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.,88. Silveira M, Araújo Neto MD. Licenciamento ambiental de grandes empreendimentos: conexão possível entre saúde e meio ambiente. Cien Saude Colet 2016; 19(9):3829-3838.,2929. Instituto Socioambiental (ISA). Notícias Socioambientais. ‘Nova legislação do licenciamento ambiental vai instaurar guerra fiscal ‘diz advogado do ISA, 16 de dezembro de 2016. [acessado 2017 jun 12]. Disponível em: https://www.socioambiental.org/pt-br/noticias-socioambientais/novo-legislacao-do-licenciamento-ambiental-vai-instaurar-guerra-fiscal-diz-advogado-do-isa.
https://www.socioambiental.org/pt-br/not...
. The project’s proponent, often the public authority, claims to have sufficient evaluation tools – such as licensing, for example – and any proposed new evaluation tools can be received as a “hindrance” to development.

Therefore, HIA should be considered as an important mechanism and of systematic use by decision-makers within the scope of public policies, in order to point out preventively ways to efficiently mitigate and compensate for socio-environmental and health impacts. However, there are difficulties in the introduction of new evaluation tools in the face of the impacts often identified in large projects, as was observed in the case of hydroelectric plants77. Silveira M. A implantação de hidrelétricas na Amazônia brasileira, impactos socioambientais e à saúde com as transformações no território: o caso da UHE de Belo Monte [tese]. Brasília : Universidade de Brasília; 2016.. The main hurdle is that government sectors still address HIA as yet another “bureaucratic tool” obstructing infrastructure projects in the country, rather than an essential measure of human health and environmental protection.

Considering that health inequalities stem not only from multiple economic, environmental and lifestyle factors, but also from the problems related to access to healthcare, “it is essential that reduced inequalities be considered as a fundamental priority at all levels of a political action, thus pursuing the ‘health in all policies’ strategy and conducting effective impact assessments that take into account the results in terms of equity in health”3030. Parlamento Europeu. Relatório: Reduzir as desigualdades no domínio da saúde na EU. Comissão do Ambiente, da Saúde Pública e da Segurança Alimentar. A7-0032/2011. (2009/2014). [acessado 2015 dez 12]. Disponível em: http://www.europarl.europa.eu/sides/getDoc.do?pubRef=-//EP//NONSGML+REPORT+A7-2011-0032+0+DOC+PDF+V0//PT.
http://www.europarl.europa.eu/sides/getD...
.

Finally, this analysis aims to contribute to mechanisms such as HIA that can subsidize the area of health surveillance in Brazil, given that the established development policies stem from diverse interests outside the region and, when implemented, de-structure the logic of local organization, increasing environmental and social conflicts in the area, reflecting on the health and quality of life of the various communities.

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Publication Dates

  • Publication in this collection
    Oct 2017

History

  • Received
    30 May 2017
  • Accepted
    26 June 2017
  • Reviewed
    19 July 2017
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