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

Health impact assessment (HIA) attempts an extremely difficult task. It tries not only to project the impacts of policies, programmes and developments on public health but to influence the political decision-making process on the basis of its findings. Given its high ambitions, it is not surprising that governments have encountered difficulties in institutionalizing HIA within the process of making policy. Anticipating health impacts and influencing decision-making are difficult enough in their own right, without combining the two in one process. The ambitions of HIA and the time and resource restrictions inherent in the policy process dynamic thus place serious demands on one another, and the political and institutional barriers confronting HIA may necessitate sober compromises within its generalprocess andmethodology. One key methodological issue that may challenge the relationship between HIA and policy is the involvement of the community in the HIA process. The Gothenburg consensus paper makes clear the need for participation to underpin the assessment process in order to maintain values of democracy, transparency and equity (1). Indeed, community participation is a central ideal found in almost all the contemporary major national and international declarations on health, but little empirical work has explored the utility of participation in attaining HIA’s objectives. For example, does broad-based community participation result in a more accurate prediction of impacts, improved decision-making, increased transparency, local accountability, and increased community empowerment and ownership of policy? Whilst little work has been undertaken in the context of HIA, there is a substantial body of literature that describes the impact of participation in other areas of health policy formulation and implementation (2–4). Community involvement may have a positive impact on the success of project development and implementation. Participation may also directly affect individuals by changing attitudes and actions towards the causes of ill-health, promoting a sense of responsibility and increasing personal confidence and selfesteem. Involvement in the policy process may decrease alienation among socially excluded groups and reorient power relationships with the ‘‘professional’’ decision-makers. But other researchers have reported considerable difficulties in conducting community participation exercises (5–7). Participation is time-consuming and communities often questioned the value of investing time and effort in a project. Local people are often too busy going about their daily business to become involved in participatory activities, and the legitimacy of those who chose to participate with regard to representing the views of the wider community is unclear. Communities are not some homogenous body — they are often fraught with divisions, tensions and conflicts, and certain vulnerable groupsmay be unwilling or even unable to participate. What can we learn for HIA from the participatory experiences of other previous policy programmes? Participation is intuitively appealing but it is clear that participatory approaches do not always run smoothly. Working with communities is far from easy and participatory partnerships take time to build if they are to be truly participatory. And herein lies the problem: HIA usually has to be done reasonably quickly, so as to operate within the policy-making timescale. To get community participation quickly necessitates the use of existing structures and people; it means compromising the extent of consultation with hard-to-reach groups; and it means that assessments almost certainly have to be predominately ‘‘top-down’’ professionally-led exercises. This type of HIA runs the risk of legitimizing a decision in which a substantial proportion of the community have not been involved despite the assessment being conducted under the banner of ‘‘participation’’. So how can we combine participation and HIA? Colleagues are developing techniques for rapid participatory appraisal and these may go some way towards overcoming some of the problems discussed (8). But perhaps a more radical solution would be to suggest that in the context of HIA, limiting involvement to a small group of experts might be the most appropriate and efficient means to generate sufficient information to influence the policy-making process (9). Support for such an approach comes not from a rejection of the validity of community involvement but because if HIA is to get beyond the field of purely academic interest and gain credibility with policymakers, it must fit policy-makers’ requirements. And if it is to do this, community participation may be difficult, if not impossible, to achieve, given the time and resource constraints of the policy-making dynamic. HIA should explicitly acknowledge the tension between the time required to deliver on the policy agenda and the time required to build true participatory partnerships with communities. Whilst ideal, participation may simply not be possible for the majority of HIAs. Those working on HIA should not apologize for this: if an assessment has not got the time or resources to bring about meaningful community participation, is it wise to attempt it at all? n