Health impact assessment on urban development projects in France: finding pathways to fit practice to context

Abstract

In France, there is increasing interest in health impact assessments (HIAs) and most are performed on urban projects. The field of expertise is still under development and mostly established within the public health sector. To date, in France, all HIAs conducted in urban planning are stand-alone HIAs disconnected from the required environmental impact assessment (EIA). The paper opens with an introduction of the close and complex relationship between health and urban planning, HIA and a description of key elements needed for understanding the French context. Then, the paper analyses the context and the implementation process for four HIAs in progress in order to understand the specific characteristics of urban development, identify the key stages for introducing a health perspective into urban projects, and extract avenues to be explored when adapting HIAs applied to urban planning in France. Using a qualitative multiple case study design, an analysis framework was built to compare several aspects of the four HIAs and made it possible to highlight three pathways for adapting HIA to the urban planning sector: the schedule, links between the EIA and HIA, and the complementarity of the initiatives to involve residents. Legal measures enable a point of contact that brings health institutions and cities closer together. HIA is yet another tool that public authorities now have at their fingertips to work together in strengthening democracy and in reducing social, geographical and environmental health inequalities. More research must be undertaken to develop an understanding of the practice-related context; to judge HIA’s capacity to draw on existing approaches in different fields; and to explore the different avenues leading to increased health, wellbeing and equity.

Keywords

health impact assessment healthy urban planning health promotion determinants of health environmental health pollution ecosystem approach

Introduction

Health and urban planning: a close and complex relationship

Health and urban planning are historically linked (1). The development of towns and cities demonstrates the close and complex links existing between urban planning and health. Earlier forms of town planning may have been effective in fighting plague and cholera epidemics in the nineteenth century and tuberculosis at the start of the twentieth century; however, paradoxically, they have also contributed to many of today’s health problems. Nowadays, in developed countries, obesity, asthma, health inequalities, mental health problems, social isolation and exposure to different types of pollution are inherent to the challenges faced by public health. These are impacted, in turn, by the quality of our living environments, which are themselves a product of the urban planning and development policies implemented by municipalities. Today, numerous studies provide evidence of the impact of these policy choices on a wide range of determinants of health (1,2). However, due to the complex relationship between the multidimensional aspects of human health, environment and urban planning, moving from knowledge to action is a real challenge.

Over the last few decades, decision-makers have steadily become more aware of the impact their urban policies have on the health and wellbeing of populations. This is primarily due both to the work of the WHO Healthy Cities Network – established in 1987 to implement a health strategy for all at a local level – and, more recently, to the Adelaide Declaration on integrating health in all areas of policy. Health impact assessment (HIA), a practice promoted for over 20 years, is considered to be a promising way to include health issues in decisions made outside the health sector that otherwise would not have taken health into account; HIA is a systematic approach to predicting the health impacts of proposed policies, plans or projects by applying a set of quantitative, qualitative and participatory techniques. By using an evidence framework in a democratic, equitable, sustainable and ethical way, the aim is to produce a set of health-based recommendations (3,4).This evidence-based practice is frequently used in urban settings at policy and project level and has increasingly become recognised as a promising way to explicitly incorporate health concerns into planning processes (5 –8). Nevertheless, the issue is complex as several other forms of impact assessment listed at an international level, such as environmental impact assessment (EIA) or social impact assessment (SIA), are expected to perform many of the same functions as HIAs (9,10).

The French context

In France, the interest shown for HIAs is relatively recent (11). The field of expertise is still under development and mostly established within the public health sector. To date, all HIAs conducted in urban planning are stand-alone HIAs disconnected from the required EIA.

The aim of this paper is to analyse the practice of HIA implemented in urban settings in France in order to find ways of adapting them to the specific context of urban project development. To begin, we introduce key elements needed for understanding.

Initiated in France in 1976, EIA has become ever more thorough with the transcription of European Union directives and, since 1996, has given increasing consideration to the health dimension, particularly biophysical determinants of health. The 2010 ‘Grenelle de l’Environnement’ Law led to the further development of EIA. This in turn gave impetus to professionals and academics from the health, urban planning and environment sectors – within a working group – to conduct in-depth research at a national level on health challenges in the field of urban planning. This work resulted in the publication of a guide aimed at all actors involved in the urban planning decision process (12), which has now become a national reference document. Among the key findings of this project, three main concrete outputs caught our attention: a reference framework established for healthy urban planning (HUP) (see Box 1 online); an all-encompassing tool developed for analysing urban planning projects ‘with a broad health lens’; and an operational tool aimed at regional health agencies (RHA) to help them formulate their health recommendations required by the environmental authority in the EIA processes. The use of this last tool by all RHA was supported by a note published by the French Ministry of Health in 2015.

The first French HIA project, concerning a day-care centre for young children, was undertaken in 2008 in Rennes. In 2010, a national HIA seminar supported by the Ministry of Health was organised. Progressively, work was undertaken, training was established and meetings were organised to encourage the sharing of experiences. In 2015, the French National Institute for Prevention and Health Education issued a call for proposals with the aim of promoting this approach. Today, ten or so experiments are in progress – most of them concerning urban development projects. HIA is now a fast-growing practice, driven by the shared desire of cities and RHA to work together in contributing to better health and a reduction in social health inequalities.

Description of the implementation process for urban development

In France, implementing the main guidelines of an urban planning policy happens at a local level. These guidelines are set out in urban master plan documents, which guide the different development projects.

A development project involves a large number of actors (see Box 2 online) and is part of an approach aiming to supervise the project from its conception through to its implementation (13). This approach has five main stages: initiation (Φ1), conception (Φ2), set up (Φ3), execution (Φ4) and closure (Φ5). Each stage meets a series of specific requirements and actions (see Figure 1). Here, we need to highlight two major requirements: one that concerns the EIA regulatory procedure and the other, initiating consultation. Depending on the specificities of the development project (nature, scale, land ownership, degree of public authority involvement, etc.), the project owner decides whether to establish their project within the framework of a specific planning procedure. We offer to give a short description of the planning procedure concerning three of the studied projects: the French zone d’aménagement concertée or ZAC. Defined by French urban planning legislation, a ZAC is a complex procedure enabling large-scale projects to be managed over a long time-period. Initiated by public authorities only, it is established by a local authority and enables a development project to be launched prior to gaining ownership of the land at the project site. It also enables specific town planning financing to be sought. Since 2010, the EIA procedure has been applied to an increasing number of urban projects. The EIA report is submitted for approval from the environmental authority. The opinion emitted by the environmental authority conditions whether the implementation process continues or not (see Figure 1). Since the publication of the HUP guide (12), health advice given by RHAs, at the Ae’s request, is increasingly based on examining more than just the biophysical determinants of health.

Figure 1.

Stages of an urban project development.

Consultation is defined by urban planning legislation and is present right from first stages of the project (Φ1) even before the project is properly defined as such. Even if it is legally required until the end of the conception phase (Φ2), the methods for implementing it can be defined by the local authority initiating the project. These methods can be disclosed during the project launch meeting (end of Φ1) or later. Aside from this, other measures have also been taken to ensure civic participation in local decision-making. In fact, since the seventies, the role of inhabitants in the decision-making process has been strengthened. As of 2002, the notion of ‘grassroots democracy’ developed, especially through the creation of ‘neighbourhood councils’ bringing together councillors, technicians and inhabitants. The latter could be consulted by the mayor for any action impacting the neighbourhood in a spirit of dialogue. As a result, certain cities conduct proactive policies in this respect. They establish charters that define everyone’s roles and commitments, create committees consisting of representatives of civil society and organise different modes of consultation to build bridges between technical and user expertise.

Focus and objectives of this article

The success of HIA, in terms of supporting projects that foster fairness, wellbeing and health, depends on its capacity to influence decision-making processes as well as to increase awareness among stakeholders of the role other public health policies have to play. Far from being the result of a rational, linear process, a decision is generally associated with an iterative and incremental approach, resulting from a compromise between the constraints of decision-makers (14), and not necessarily supported by evidence (15). The use of knowledge depends on a variety of factors. These factors consist not only of produced knowledge, but also of the socio-political and institutional context in which this knowledge is used; the characteristics of the decision-makers; and the existence of interaction between knowledge producers and users (16,17). For knowledge to be incorporated into decision-making, researchers and HIA practitioners must understand the decision-making context; identify the types of use and the potential users; ensure that there is space for dialogue; and adapt their design to the situation (14,18).

In terms of urban development, projects are subject to specific technical, administrative and regulatory procedures. These consist of pre-implementation studies, documents to be produced and consultation processes to be organised. The decision-making process is made up of several discrete decisions taken at different stages of the urban development project, in keeping with the incremental model. In this way, inasmuch as urban development projects are conducted over a long period of time, HIA contributions can be made at different moments and the process of influence affects different actors involved at these key moments. It is therefore essential to understand when and how HIA contributions can make the project progress, and who is involved.

Furthermore, over the last 15 or so years, a health system reform process has been underway to plan and implement a health policy adapted to specific areas, with shared governance alongside other public policy sectors and local authorities. The creation of RHAs in 2009 was an important step. The corresponding legal measures create both a point of contact and contractualisation tools, bringing health institutions and cities closer together. Ultimately, HIA is yet another tool that public authorities now have at their fingertips to work together in strengthening democracy and in reducing social, geographical and environmental health inequalities.

The aim of this article is to analyse the context and the implementation process for four HIAs in progress in order to understand the specific characteristics of urban development; identify the key stages for introducing a health perspective into urban projects; and extract avenues to be explored when adapting HIAs applied to urban planning in France.

Methods

Four HIAs applied to urban development projects in France were studied (see Table 1). They were at different stages of progress and not advanced enough for conclusions to be drawn on their effectiveness in terms of their recommendations being addressed and increasing developers’ and decision-makers’ awareness of the health consequences of their decisions. Nevertheless, they were based on the same urban planning procedures and embedded in a similar context with regards to the evolution of health policies and the current national impetus to promote HUP. We analysed the context to identify: a) the characteristics and key stages of urban planning as windows of opportunity to integrate HIA contributions during project review b) the possible links between the types of consultation within development procedures; c) the way health policy instruments are used to adopt dialogue-based policies that are more beneficial to health. We built an analysis framework to compare several aspects of the four HIAs (see Box 3).

Table 1

Presentation of the cases.

Project	Site A	Site B	Site C	Site D
Site	Greenfield and formerly developed district	Brownfield	Station and neighbouring district	Brownfield Port site
Project management	Régie	SPL	Régie	SPL
Urban location	Peripheral	Interface	Interface	Peripheral
Sub-projects	Housing Roads Landscaping Sport and leisure facilities	Housing Roads, transports, cultural facilities Retail services	Platforms, station Roads Green site landscaping	Housing Roads Cultural facilities Tramway
Stakes	Urban links Environmental Neighbourhood dynamics	Urban continuity Social diversity	Accessibility Urban continuity Humanisation of the site	Urban links Environmental Social
HIA
Time scale	Φ 4 (Tr3)	End Φ 2	Φ 2/3	StartΦ 3
Initiator	City and metropolitan area	City and metropolitan area	City and metropolitan area	Metropolitan area
Governance	Metropolitan area and ARS	City	City and metropolitan area	Metropolitan area and ARS
Stages	E1/2	E3/4	E5	E1/2
Urban policies
Geographic location a priority?	No	Yes	No	Yes
Inclusion of LHC?	No	Yes	Yes	Yes

Box 3:

Study methodology

Sample: Four HIAs
Selection criteria
- urban development projects that are in progress
- diversity of conditions (project scale, carrying institutions, partnerships)
- availability of information (documents, contact persons)
- involvement of the authors in the HIA work
Data collection
- documents: milestone documents during the preparation of the development project; health planning documents; concertation meeting, steering committee and training session reports
- review literature to collect evidence on relevant topics
- observation : committees, working groups, training sessions
Data analysis
- characteristics of development projects: stakes, scale, development procedure framework, nature of sub-projects
- characteristics of HIAs : motivation, expectations, addressed issues (especially equity), scope, governance
- comparison between the stages of the two approaches (urban programming and HIA)
- identification of the pivotal actors and their room for manoeuvre
- links between the different types of consultation (urban policies and HIA)
- embedding HIA in health policy frameworks (local health contracts, city health workshops, health programs, etc.)

Findings

General presentation of the four HIAs

The four sites (A, B, C, D) shared similar characteristics that nonetheless varied from one site to another: A and B were located on unused land; B and D were adjacent to very deprived districts with serious environmental and social issues; B and C were located between the city centre and the outskirts; and A and D were remote with bad links to the city centre.

The development projects were of varying scale. Projects A, B and D were subject to a specific regulatory procedure and included a range of sub-projects. Project C concerned the development of a train station. Finally, these projects all shared common challenges linked to urban continuity, coherence between districts, mobility and social diversity.

The decision to undertake a HIA is always motivated by a willingness to ‘experiment’ with the approach and here, was taken by the city (B, C, D) or the RHA (B), with the strong support of a councillor (C, D). The HIA was conducted as a partnership between the city and the RHA. The governance of the HIA included a more (A, D) or less (C) extended group of stakeholders.

These HIAs were at different progress stages: scoping stage (A, D); assessment/reporting stage (B); and monitoring stage (C).

The HIAs from the four urban development projects

We analysed the HIAs through the lens of three essential development procedure aspects: project phasing; EIA procedure; and consultation.

Case A

The HIA was launched very late in the implementation process (Φ4) and concerned the execution of the 3rd project stage (Tr.3). Capacity for the HIA to influence was restrained with possible action limited to a micro-local level (type of green spaces, garden use, etc.). The EIA was conducted before the introduction of new rules and RHA’s. Physical determinants of health were barely considered. In addition to official public meetings, the project also undertook specific work on the needs and challenges in terms of use for the populations concerned. The HIA was an opportunity to sustain this approach especially for the project’s social aspects. Despite this, the inhabitants were still not included in the governance of the HIA.

Case B

The HIA was introduced at the end of the conception phase (Φ2), after the urban project manager had been chosen and a landscape scheme defined. Contact with the developer was regular and recommendations were given concerning the draft projects (location of facilities, distribution of footpaths, cycle paths or roads, surface area allotted to green spaces, etc.) via technical sheets—the format most adapted to developer practices. The EIA report is based on the HUP guide and the analysis takes a wide range of determinants of health into account. The local authority had developed actions encouraging inhabitants to participate at a local level over several years. A two-tier organisational method was adopted for the development project to encourage consultation that on the one hand, gathered inhabitants into theme-based working groups managed by the city, and on the other hand, conferred the organising of public meetings to the developer. Consultation was seen as an ongoing process and continued in keeping with a model developed by the project management team. To avoid any confusion for the inhabitants, it was decided that they should not be included in the governance of the HIA, as there was likely to be overlap with local initiatives already in place. Furthermore, contacting both the public officials and practitioners required a prior agreement in principle from all the councillors.

Case C

The HIA was introduced at the conception phase (Φ2). Recommendations were integrated in the draft projects (road planning, layout of green spaces, types of services and facilities) and were more easily implemented due to the presence of a HIA team member responsible for liaising with the sub-project manager. The environmental authority did not deem it necessary to undertake an EIA. Meetings were organised with neighbourhood councils from adjoining sectors to discuss the project where HIA was presented. A questionnaire was distributed to the attendees but the result was inconclusive.

Case D

The HIA was introduced at the start of the setting up phase (Φ3), and the opportunities to contribute were plentiful. The EIA-based health advice revolved around physical environmental determinants of health. Discussion groups and participatory workshops were organised concerning the development project. Still at an early stage, the HIA planned to include the inhabitants, via their representatives, in the governance of the HIA and work closely with the inhabitants, going above and beyond regulatory framework recommendations.

Three pathways for adapting HIA to the urban planning sector

The schedule

The case studies differed in terms of timescale (see Figure 2). The moment at which the HIA was introduced into the unfolding development project, along with the type of procedure used and the actors concerned, were key elements for the HIA practitioner in establishing his/her own schedule, and in identifying the available information required to make the right proposals at the right time. The aim was to ensure these proposals would be effective at the execution stage of the project (Φ4). Although, it was important to have relatively precise information in evaluating the impact of development choices, the HIA had to be introduced early enough to enable draft projects and specifications to evolve, thus ensuring that recommendations were actually implemented in the development project. The main users of this work were not only the developers, but also the constructors and the managers.

Figure 2.

The HIA stages within the development process of the four projects.

Links between the EIA and HIA

The scale of an HIA depended on whether an EIA existed, when the HIA was conducted and the range of determinants studied. The most recent EIA tended to comply with the HUP reference guide which means that human health should be more explicitly considered. As a result, the HIA was either in addition to an EIA and covered mainly social determinants, or a comprehensive evaluation with an in-depth focus on all determinants of health using a socio-ecological model.

The complementarity of the initiatives to involve inhabitants

In the development projects, consultation initiatives were implemented in keeping with either specific regulations or a grassroots democracy. It depended on the local authorities’ position on this subject. The implementation of a HIA added another layer to the process of involving the inhabitants with its inherently democratic principle: everyone has a right to participate in developing, implementing and evaluating policies. Participation is defined as ‘the active involvement of all interested parties’ (19).

In all four situations, the cities showed a willingness to go further than just straightforward consultation by taking a ‘co-construction’ approach with inhabitants, ideal for incorporating a HIA. The dialogue with inhabitants depended both on the consultations organised by the cities and the public representatives’ understanding of the HIA approach and what it contributed, or not, to the debate. While the advantages of the HIA in this respect were not clear for some representatives, and even seen as a threat inasmuch as the dialogue would be out of their control, for others, HIA was a means of gaining more knowledge and legitimacy because the dialogue was conducted by a third party.

Institutionalised bridges between health and urban planning policies

As mentioned before, the progress made over the last few years shows a move towards more collaboration between regional health institutions and their partners – local authorities, especially cities. The latter sit on governing bodies and have a say in regional policy-making. Regional policy-making is based on a group of programmes and local health contracts. These are agreements between cities and RHAs on how to meet health needs of a geographic area by acting on determinants of health, with the aim of harmonising regional health policy and local policies. In proposing that embedding HIA within planning tools was an opportunity for connecting health and urban planning policies, we tried to locate where these insertions occurred and gauge the outcomes.

Even today, there are very few explicit references to HIA in regional policy documents considering that these documents were drawn up in 2010, when HIA was barely starting to gather momentum. However, HIA was included in the health and environment programme (C) and was actually included via a ‘sustainable city’ action in (B). HIA was promoted via the more recently established local health contracts (B, C, D). Generally conducted together by RHA representatives and cities, local health contracts promote knowledge sharing to better understand what does and does not generate health and identify institution-specific levers of action. An HIA inserted into a local health contract is an opportunity to explain HIAs, as most factors impacting health and quality of life can be found in urban development; to promote their use; and seek financing from numerous partners. Finally, specific instruments have been in place for the most vulnerable urban areas for many years now – an ideal base for local health contracts. This interlinking brings together actors from different sectors and institutions to work on the urban planning, environmental, social cohesion and health challenges faced by an area. Consequently, actors situated at the interface of different professional worlds and planning tools, be they leaders or representatives of the institutions involved in the different bodies, play a major role in disseminating innovations. The notion of intersectorality promoted over many years but over-hyped by the reform of RHAs finally becomes a tangible reality with HIA, having more operational success than the standalone tools used to coordinate institutions. As acknowledged by Wernham and Teutsch (20), HIA is ‘a concrete way to move from an aspirational goal to building a strong, practical foundation to support health in all policies’.

Discussion

Today the climate is favourable for deploying HIAs. Consequently, it is also ideal for incorporating health into other policies (16). The HIAs in progress are undertaken by Healthy Cities with a ripple effect brought on not only by being a member of this network (21), but also due to national momentum. The enthusiasm for this method has prompted an analysis of experiences in progress to adapt the method to the French urban development context and also to ensure the effectiveness and quality of this approach. The analysis of these four cases backed up by other experiences outside of this study, invites us to think about the challenges involved in developing HIA today.

HIA: at the crossroads between project guidance and impact assessment

The timescale for an urban development project is restrictive for the normally much shorter-lived HIA. That being said, the ability of HIAs to adapt to this given is proof of its effectiveness but also reveals potential two methodological traps it could fall into. The first relates to the sequencing of the assessment into phases linked to the project’s progress. Certain project components (public spaces, housing, roads and facilities) are implemented before others. The decision-makers expect the HIA to provide operational proposals for developers or subcontractors as the project progresses. This leads to a segmentation of work. Specific attention is paid to certain determinants to provide adaptable recommendations right up until the final report. The risk is an altered overall view of the project. The second relates to a fine line between providing urban project guidance to make it as health-oriented as possible, and conducting an impact assessment. Indeed, the operationalisation of health in all policies can be conducted in two ways: ‘health lens analysis’ and ‘HIA’. These use the same framework but are initiated at different points (4).

Currently, municipalities are committing to urban redevelopment projects in vulnerable areas as part of a widespread national programme and applying for HIAs which, in this case, actually come closer to guidance than assessment. There is continuity between project planning or design guidance, conducting an HIA and implementing recommendations, but the actors responsible for activities within different phases must be clearly identified to avoid confusion between these different activities (22).

EIA and HIA: a like-minded couple

Whether HIA should stand alone or be incorporated into other impact assessments is still an open debate (23). Since the 2000s, this question has been a feature of the International Association for Impact Assessment debates and more and more literature is available on this subject (24,25). Some think that impacts on health would be dealt with more efficiently in EIAs, whereas others are more in favour of a separate and distinct procedure (26), guaranteeing the proper management of health challenges. The question is complex and needs to be examined case-by-case according to project type and practices more or less in favour of HUP, as health institutions are not yet up to speed with this new approach.

In France, HIA and EIA processes are still disconnected. Each group of experts evolve in different spheres and there are no regulations or suggestions about how to work with EIA and HIA. Since the publication of the national guide on healthy urban planning, the urban and public health sectors have started to create links and seem to be becoming more aware of the benefits of a closer collaboration. Compared to the US, Australia, New Zealand and many others countries, French urban planners are not yet at the same stage of awareness and understanding of HIA and its opportunities, although improvements are in progress. Most consider HIA as a constraint, like EIA. More work on and practice with HIA is needed. Recommendations on best practice for giving more consideration to health will be a key issue for the new French community of experts.

Consultation and HIA participation: two interlocked but non-identical processes

The drive for more democracy is clear and civic participation is currently a prime topic in all public policy sectors in France. However, this ideal is not easily attained and comes in several indistinct forms, from straightforward consultation to more in-depth consultation. Integrating citizens into the decision making process is a delicate and complicated matter raising questions about the legitimacy, representativeness and exercise of democracy (27). Introducing an HIA into a framework that allows for multiple forms of information-sharing and negotiation adds even more complexity. The involvement of inhabitants may seem redundant or be regarded as undermining the local authority. However, it does not quite fulfil the same purpose. Of course, information from consultations needs to be reintegrated into the evidence base. This said, HIA still needs active civic participation to help define what will be analysed in depth, and to understand the links between the project and its impact on quality of life and equity. Furthermore, HIA is of special importance to projects within small towns that do not have access to all the structural resources needed to set up consultations.

Today, more research must be undertaken to develop an understanding of the practice-related context, to judge HIA’s capacity to draw on existing approaches in different fields and to explore the different avenues leading to more health, wellbeing and equity.

Footnotes

Acknowledgements

The authors would like to thank everyone involved in the four HIAs for their support in this work. This long list of members includes people from both public health and urban sectors. We are also grateful to Nina Lemaire for her valuable research assistance and Annick Paisley for the English translation.

Declaration of conflicting interests

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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