To the Editor:

Health impact assessment (HIA) is promoted by the World Health Organization in order to identify and address health co-benefits and risks, as well as measures to improve health and reduce health inequities. At a European level, health issues have been featured in European treaties since the formation of the European Union and governments are expected to promote health equity. Essential values underlying HIA (e.g. equity, democracy, transparency) which are required to be believed in their relevance by practitioners and decision makers must be taken into account.¹Currently, HIA is not a legal requirement in the European Union and implementation and institutionalization are incomplete in all concerned countries.²Despite the growing policy concerning and activity aimed at institutionalizing HIA, the majority of HIAs are done voluntarily, outside legislative or regulatory requirements.³In Spain, the National Public Health Act 2011 incorporated HIA to the Spanish legal system 8 years ago.

The incorporation of HIA to the Spanish legal system was deemed positive in technical and scientific environments. However, Spain is a decentralized state and most policies (e.g. health governance) are based in the gradual development of federal arrangements through its regional governments, also known as Autonomous Communities.⁴Despite multijurisdictional countries are supposed to facilitate better matching of citizen preferences, sometimes, there is a lack of basic common rules at a national level. On a regional level, HIA has been institutionalized in only one out of 17 autonomous communities (as is the case of Andalusia). On the other hand, HIA is also mentioned in regional Public Health Laws in the Autonomous Communities of Catalonia, Valencia, the Balearic Islands, Aragon and Galicia (Fig. 1). However, there has not been further regulatory development of HIA in these last Autonomous Communities, where only some pilot HIAs have been conducted, mostly in urban planning, as well as within the Basque country. In short, Andalusia is leading the implementation of HIA in Spain, and more than 700 HIAs have been conducted in different activity sectors between the years 2015 and 2018 in Andalusia.

Figure 1. Institutionalization of health impact assessment in Spain. 

Despite the limited development of HIA in Spain, it has already been documented that some stakeholders perceive it as a competitive limitation and a possible disadvantage in economic development between Autonomous Communitie.⁵This approach is a serious threat that may conduct HIA towards a bureaucratic drift and the trivialization of the process could generate more rejection than its expected positive results.⁶

In this context, implementation of HIA faces many difficulties and barriers at different levels, including poor governance and lack of political support,³which can cause a lack of equity in health and its determinants. Thus HIA practice should be based on a legal obligation within European Union, in order to avoid inequities in health and its determinants between groups of people within regions and between regions. In this sense, a general consensus exists today that the European Union treaty provides grounds for upgrading the status of HIA.³