Community participation in health impact assessments: intuitively appealing but practically difficult.

Abstract

Health impact assessment (HIA)attemptsan extremely difficult task. It tries notonly to project the impacts of policies,programmes and developments on publichealth but to influence the politicaldecision-making process on the basis ofits findings. Given its high ambitions,it is not surprising that governments haveencountered difficulties in institutionaliz-ing HIA within the process of makingpolicy. Anticipating health impacts andinfluencing decision-making are difficultenough in their own right, withoutcombining the two in one process. Theambitions of HIA and the time andresource restrictions inherent in the policyprocess dynamic thus place seriousdemands on one another, and the politicaland institutional barriers confrontingHIA may necessitate sober compromiseswithinitsgeneralprocessandmethodology.One key methodological issue thatmay challenge the relationship betweenHIA and policy is the involvement of thecommunity in the HIA process. TheGothenburg consensus paper makes clearthe need for participation to underpinthe assessment process in order to main-tainvaluesofdemocracy,transparencyandequity (1). Indeed, community participa-tion is a central ideal found in almostall the contemporary major national andinternational declarations on health, butlittleempiricalworkhasexploredtheutilityof participation in attaining HIA’s objec-tives. For example, does broad-basedcommunity participation result in a moreaccurate prediction of impacts, improveddecision-making, increased transparency,local accountability, and increased com-munity empowerment and ownershipof policy?Whilst little work has been under-taken in the context of HIA, there is asubstantialbodyofliteraturethatdescribesthe impact of participation in other areasof health policy formulation and imple-mentation(2–4).Communityinvolvementmay have a positive impact on the successof project development and implementa-tion. Participation may also directly affectindividuals by changing attitudes andactions towards the causes of ill-health,promoting a sense of responsibility andincreasing personal confidence and self-esteem.Involvement inthepolicyprocessmay decrease alienation among sociallyexcluded groups and reorient powerrelationships with the ‘‘professional’’decision-makers.But other researchers have reportedconsiderable difficulties in conductingcommunity participation exercises (5–7).Participation is time-consuming andcommunities often questioned the valueof investing time and effort in a project.Local people are often too busy goingabout their daily business to becomeinvolvedinparticipatoryactivities,andthelegitimacy of those who chose to partici-pate with regard to representing the viewsof the wider community is unclear.Communities are not some homogenousbody — they are often fraught withdivisions, tensions and conflicts, andcertainvulnerablegroupsmaybeunwillingor even unable to participate.What can we learn for HIA fromthe participatory experiences of otherprevious policy programmes? Participa-tion is intuitively appealing but it is clearthat participatory approaches do notalways run smoothly. Working with com-munities is far from easy and participatorypartnerships take time to build if theyaretobetrulyparticipatory.Andhereinliesthe problem: HIA usually has to be donereasonably quickly, so as to operatewithinthepolicy-makingtimescale.Togetcommunity participation quickly necessi-tates the use of existing structures andpeople; it means compromising the extentof consultation with hard-to-reachgroups; and it means that assessmentsalmost certainly have to be predomi-nately ‘‘top-down’’ professionally-ledexercises. This type of HIA runs the riskof legitimizing a decision in which asubstantial proportion of the communityhave not been involved despite theassessment being conducted under thebanner of ‘‘participation’’.Sohowcanwecombineparticipationand HIA? Colleagues are developingtechniquesforrapidparticipatoryappraisaland these may go some way towardsovercoming some of the problemsdiscussed (8). But perhaps a more radicalsolution would be to suggest that in thecontext of HIA, limiting involvement toasmallgroupofexpertsmightbethemostappropriate and efficient means to gen-erate sufficient information to influencethe policy-making process (9). Supportfor such an approach comes not froma rejection of the validity of communityinvolvement but because if HIA is to getbeyond the field of purely academicinterest and gain credibility with policy-makers, it must fit policy-makers’ require-ments. And if it is to do this, communityparticipation may be difficult, if notimpossible, to achieve, given the time andresource constraints of the policy-makingdynamic. HIA should explicitly acknowl-edgethetensionbetweenthetimerequiredto deliver on the policy agenda and thetime required to build true participatorypartnerships with communities.Whilst ideal, participation may simplynot be possible for the majority ofHIAs. Those working on HIA should notapologize for this: if an assessment hasnot got the time or resources to bringabout meaningful community participa-tion, is it wise to attempt it at all?