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This interest in costs and benefits has extended to Health Impact Assessment (HIA). Costs
must be explicit and proportional to the decision at hand. It would not be reasonable to
Environmental Impact Assessment Review 25 (2005) 791798
www.elsevier.com/locate/eiarDeveloping a framework to assess costs and benefits
of Health Impact Assessment
Phillip Atkinson a,*, Anthea Cooke b
aPublic Health Specialist, Southwark PCT, United KingdombIndependent HIA Consultant, United Kingdom
Abstract
This paper presents some early thinking as to how the costs and benefits of HIA might be
assessed. After considering previous work it uses a comprehensive HIA in Dulwich, SE London as a
case study to highlight the possibilities and difficulties of collecting necessary data on costs and
benefits. It then sets a context for developing a costbenefit framework for analysis. The framework
is viewed alongside the major types of economic evaluation. The paper concludes with a review of
outstanding issues and considers how evidence on cost and benefit might make a difference in the
application of HIA.
D 2005 Elsevier Inc. All rights reserved.
Keywords: Health Impact Assessment; Cost; Healthy Living Centre
1. Introduction
There is a growing national and local interest in the costs and benefits of public health
activities. A recent report on the future cost of healthcare in England (Wanless, 2004)
concluded dthere is generally little evidence about the cost-effectiveness of public health.TWith the need to meet targets and pressures on funding, local decision makers are
increasingly asking what difference an intervention will make and how much it will cost.0195-9255/$ -
doi:10.1016/j.
* Correspon
E-mail addding author.see front matter D 2005 Elsevier Inc. All rights reserved.
eiar.2005.07.011
ress: phil.atkinson@southwarkpct.nhs.uk (P. Atkinson).
spend o10,000 on an HIA to influence the use of o20,000 whereas it would be worthinvesting this sum to influence a decision that would affect many millions of pounds. The
since the HIA is attempting to estimate the impact, though effective scoping should
P. Atkinson, A. Cooke / Environmental Impact Assessment Review 25 (2005) 791798792provide a rough idea of the proposed effects. It has been argued that 10% of the cost of
health care interventions should be spent on evaluation and this figure might be applied to
HIA. The Finningley Airport HIA cost less than a tenth of the planning costs for this
1benefits of HIA are often implicit and rarely quantified. Evaluation has been identified as
the dweakest pointT of HIA and the need for information on costs and benefits of HIA isincreasingly recognised (Kemm and Parry, 2004b).
2. Cost and Benefits
The cost of undertaking an HIA should, in theory, be relatively easy to measure. Many
studies record attendees and the time devoted to meetings, community events and so on,
and it is usually possible to estimate the time taken to write the reports. Other costs, such
as external consultant time and catering, are known. With these figures together with the
cost of staff time it should be simple to calculate a total cost for the HIA. However in
practice the required information is often not available. Day rates and the time spent
(especially outside meetings) may be inadequately recorded and allocation of overheads
uncertain. External costs can be dlostT in other budgets (Kemm and Parry, 2004b). Forthese reasons the total cost of an HIA can be difficult to determine.
A small number of studies have attempted to evaluate HIA in the UK. These include
Alconbury Airport HIA (Close, 2001), Finningley Airport HIA (Abdel Aziz, 2003), the
review of four Mayoral strategies (London Health Commission, 2003). Other papers in
this edition add further examples (Elliott and Francis, 2005; Bekker et al., 2005). Very few
of these studies attempted to quantify the cost of each study and in many instances cost
was not even mentioned. The Alconbury evaluation (Close, 2001) estimated the time
devoted to the project, a total of 684 hours, but did not convert this into a monetary value,
and worked out that the dadditional expensesT (printing, conferences, expenses) wereo6000. The Finningley Airport evaluation (Abdel Aziz et al., 2004) took 348 person-days,equivalent to o52,20069,600 assuming an average cost of o150200 per day (includingoverheads). They spent o14,846 on outside consultants and around o2500 printing reportsso the total cost of the HIA was between o69,20086,600. Fleeman (1998) costed threeprojects within the Merseyside HIA programme some years ago at an average at o12,650each, and Ardern (2004) calculated the costs of a local transport plan HIA study as
o11,000, in addition to dcurrent work objectivesT.Little information is available to help practitioners estimate the cost of a proposed HIA
and until more published HIAs show their full costs it will remain difficult to quote costs for
those wishing to commission an HIA.1 It has been suggested that costs should be
proportionate to the size of the predicted impact. However this leads to a circular argumentThe London Health Observatory have recently developed a tool to estimate the cost of HIA. See
www.lho.org.uk.
project and a tiny fraction of the total cost of developing the new airport (Abdel Aziz et al.,
2004).
The benefits of an HIA are even more difficult to identify and to quantify. There are a
large number and wide range of benefits that need to be considered. Process benefits result
from undertaking the HIA and include wider appreciation of the determinants of health,
and enhancing individual skills. Impact benefits are evident very soon after completion of
the HIA. Of these, the most obvious and arguably the most important is the effect on
decision makers, but other impact benefits could include increased interagency working
and greater community involvement. Outcome benefits are delayed and are the
improvements in determinants of health or health itself that result from implementing
the recommendations.
Assessing and quantifying these benefits is challenging. The process benefits are the
easiest to assess whereas the impact benefits are more difficult. Assessing the effect of an
HIA on decision making is notoriously difficult. Questionnaires, interviews, focus groups
can all be used, but they rely on eliciting respondents views to (often narrow) questions and
shed little light on how people behave in practice (McDaid et al., 2002). Finally, assessment
of outcome benefits is more difficult still and so is often ignored in HIA evaluation. The
accuracy of the predicted effect on health is also rarely assessed (Parry and Stevens, 2001).
Different benefits will be evident at different stages. Process benefits become apparent
soon after the HIA, whereas impact benefits may only become assessable after months or
years and outcome benefits may only be realised after many years. Contamination is an
issue at each stage, as it becomes difficult to determine whether any benefits were due to
the HIA itself, or to other factors operating at the same time.
Those responsible for identifying and quantifying benefits will never be entirely
independent and objective, as all evaluation has a political component (Seedhouse,
1997). However, steps should be taken to reduce bias and ensure the use of measures
that are sensitive to each benefit. Assessing benefit can be a time consuming resource
intensive task and the use of this time and resource must be justified. Difficulties of
identifying and quantifying benefits are common to evaluation in general (Naidoo and
Wills, 2004).
A number of studies have attempted to assess the benefits of HIA (Jackson et al., 2005;
Elliot and Francis, 2005). Some interviewed stakeholders to identified perceived benefits.
Common themes included building knowledge and skills, among both participants and
authors; bringing clarity and presenting the whole picture as part of the decision making
process; putting health and public health onto the agenda of a wider range of agencies and
encouraging multi-disciplinary and interagency working. No study has attempted to
quantify these benefits.
Assessing cost and benefits is a complicated task requiring time and energy that are
often in short supply. Adding a substantial component to the already daunting task of
doing an HIA may be challenging. If health impact assessment is merged with other
impact assessments in integrated impact assessments it will become even more difficult to
distinguish costs and untangle benefits. Will evidence on cost and benefit of HIA make
any difference? It is difficult to tell. Unfortunately, evidence that information on costs and
P. Atkinson, A. Cooke / Environmental Impact Assessment Review 25 (2005) 791798 793benefits really influence decisions remains limited (Drummond, 1994; Sloan et al., 1997;
Hoffman and Graf von der Schulenburg, 2000).
3. The Healthy Living Centre in Dulwich
An HIA of a Healthy Living Centre will be used as an example to illustrate how
account can be taken of costs and benefits. A Healthy Living Centre (a centre providing an
integrated range of medical and other community services) was being proposed as part of
the plan to re-develop Dulwich Community Hospital, in South-East London. The multi-
agency steering group asked the local public health department to lead on a comprehensive
HIA to help development of the proposal. Scoping with the steering group supported by
P. Atkinson, A. Cooke / Environmental Impact Assessment Review 25 (2005) 791798794outside consultants started in July 2003, followed by a community profile, literature
review, stakeholder analysis focusing on older people, and substantial community
consultation. The final report was delivered in December that year. The recommendations
were accepted by the strategic planning group and are now being taken forward through
the business planning processes.
Initially it was assumed that assessing the cost of the HIA would present no real
problem, as detailed records were kept regarding expenditure and staff time devoted to the
different stages of the HIA but the task proved more difficult than expected. A decision
was taken to include the cost of all staff time, irrespective of the organisation they worked
for, to give a btotalQ cost rather than cost to the health service. This was the cost that shouldbe used to make comparisons with other public health interventions. However, for some
partner organisations staff salaries were not known and the individuals were not willing to
share this information. In these cases salary had to be estimated. Staff overheads were not
considered in these estimates, but in retrospect, should have been included. Total staff
costs were then calculated from the time that individual had devoted to the HIA and their
estimated hourly rate.
There were questions as to what contributions should be included. For example, should
the cost of the time of someone who simply attended one 2-h meeting be added to the
total? Should the costs of community participants be included? Over 200 people attended a
number of rapid HIA workshops, and were given no payment. Some might consider that
the value of their time should be included in the total cost of the project. This was not
done, but it should be considered in future HIAs. Besides staff other costs were largely
fees paid to external HIA consultants and a small amount to support meetings and publish
the various reports. These were relatively easy to quantify.
The costs for all the main components of the HIA, and the total cost, are shown in Table
1. The cost of meetings is largely made up of staff and consultant time but there is a small
element for room hire and catering. The rapid workshop with the steering group proved
Table 1
Main costs of the HIA of Dulwich Healthy Living Centre
Steering group and other meetings o2154Rapid workshop with steering group o2964Community profile o3800Literature review o4537Stakeholder consultation o2800Community consultation o5209Recommendations o3188
Total cost o25,000 approx
relatively expensive but this included preparation for all the other workshops used in the
community consultation later on. The community profile was compiled by a postgraduate
student under the supervision of a public health specialist, and the stakeholder consultation
by one of the external consultants. The literature review, identifying characteristics of
dsuccessfulT Healthy Living Centres and examining the effectiveness of proposed projectsin the centre itself was conducted partly by the external consultants and partly by a public
health staff member. The community consultation was the most expensive part of the
project. It involved 10 events held over 3 weeks attended by over 200 people, and required
substantial organisation, facilitation, and time to write up the results. Finally, the cost of
the recommendations includes agreeing them with the steering group, writing the final
report, and a small amount for publication of the report. The total cost of the HIA came to
approximately o25,000, including all staff costs both internal and external.A review of the potential benefits of the HIA produced six categories:
! Influence decision makers;! Improved interdisciplinary/interagency working;! Promoting health;! Enhance individual skills, knowledge and experience;! Encourage community involvement;! Informing and assisting future HIAs.
P. Atkinson, A. Cooke / Environmental Impact Assessment Review 25 (2005) 791798 795Table 2 summarises how these benefits could be measured and their cost. Influencing
decision makers is probably the most important benefit, but one of the most difficult to
Table 2
Categories of benefit, methods of measuring them and cost
Benefit category Measurement of benefit Cost
Influence decision makers Post-HIA questionnaire asking what difference
it made, shadow decision makers, monitor
further request from decision makers
Total cost of HIA
Interdisciplinary/interagency
working
Attendance at steering group meetings, look
through minutes, evidence of effective joint
working during and after HIA
Cost of timea of
people attending
meeting
Promoting health (better understanding
of health and its determinants, putting
public health on wider agenda)
Pre- and post-HIA questionnaire to members
of steering group exploring understanding
and practice
Part of cost of
timea devoted to
the HIA
Enhance individual skills,
knowledge and experience
Questionnaires and interviews to assess skills
before and after HIA, explore how skills were
used and what difference this made
Part of cost of
timea devoted to
the HIA
Encourage community involvement
(sense of value/inclusion, enhanced
control, social networks, involvement
of hard to reach groups)
Post-HIA workshop questionnaire, numbers
coming to later workshops (Cost must also
include time costa of workshop organisers,
room hire, refreshments, etc.
Cost of timea of
participants)
coming to
workshops
Wider benefit Numbers asking for information or
copies of HIA
Cost of printing
and distributing
reportsa Cost of time is sum of (hours spenthourly rate) for each person involved.
assess. Questionnaires or interviews have been suggested, but they will only provide a
partial picture, as described earlier. Pre- and post-HIA questionnaires might help to elicit
the difference that the HIA made. Observation of decision makers working (McDonald,
2002) is an approach that might be adopted for some future HIAs. It is too early to assess
the impact of the Dulwich HIA on decision making, but the early signs are promising.
Improved interdisciplinary and interagency working have been cited as important
benefits of HIA. These may simply happen during the HIA, or continue after the HIA
is completed. This could be assessed by studies focusing on what has changed as a
result of involvement in the HIA. Evidence of ongoing interdisciplinary working would
provide a more robust objective measure of the impact of the HIA. Organisations
represented at the steering group meetings included voluntary sector, council, private
finance initiative company, Primary Care trust (health authority) and local residents
brought together through the Dulwich HIA. These continued to meet together to lobby
for the proposed centre, to raise funds, and to work with the architects.
Promoting health through dimproving understanding of how health is affected bydifferent factors and by putting public health on the wider agendaT is another importantbenefit. This may occur in a professional or community setting. Housing professionals
may for example realise the importance of their work for health, and members of the
community may start to understand how their health is more than simply not feeling ill.
Measurement of this benefit will depend on the context. Evaluation questionnaires are
often used at the end of community consultation events and perhaps these could be
developed, to reveal if understanding has changed. The community consultation was
particularly beneficial, in improving general understanding of health, especially among
dhard to reachT groups. The Dulwich HIA involved meetings with a black elderly group,an Asian elderly group, a visually impaired group, and two youth groups with a large
number of ethnically diverse young people. Many participants claimed their under-
standing of health had improved.
Previous studies have highlighted how involvement in HIA can enhance skills,
knowledge and experience. A skills audit is suggested as part of the scoping stage, of
HIA but is not often conducted. Perhaps more emphasis could be placed on
measurement of skills before and after the HIA to determine change.
Encouraging community involvement comprises promoting feelings of inclusion,
enhancing control, building social networks and social capital, accessing hard to reach
groups and addressing inequality. Benefits in this group are difficult to quantify and
methods for the measurement of social capital have been hotly debated. Nevertheless, it
should prove possible to adopt some simple measures that focus on process. A post-
workshop questionnaire could ask about the sense of inclusion and the number of
workshop participants that turn up at the recommendations event could be used as an
indication of engagement in the HIA.
Another benefit of each HIA is guiding and informing future HIAs. The number of
requests for information and reports from those not directly involved in the Dulwich
HIA is one indication of this wider influence. The literature review from the Dulwich
HIA was requested by several authorities proposing to develop Healthy Living Centres
P. Atkinson, A. Cooke / Environmental Impact Assessment Review 25 (2005) 791798796in other parts of London. Following the HIA, the Primary Care Trust (Health
Authority) Board requested a formal cost-effectiveness analysis for investing in the
start to quantify the benefits in particular areas. Many have been calling for evidence on
cost, benefit, impact and effectiveness of HIA, but little has actually been done. Now is the
In the current UK political climate with its focus on performance, targets, and valuefor money, evidence of cost and benefit is increasingly required for all activities
including HIA. Cost and benefit data will be needed to satisfy health managers, but other
justification for the use of HIA will also be required. There will still be a need to lobby to
ensure that HIA moves from being a mere dplay-thingT (Kemm, 2000) and becomes atool that is routinely used in public health practice to analyse policy and inform
decisions.
References
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in these areas. Methods to assess the influence of HIA on decision making are urgently
needed, as are tools to assess the effect of participating in an HIA in the local community.
Thought must be given to assessing the long-term benefits, such as improvements in health
over longer periods. Little attention to date has been given to negative impacts, but these
must also not be forgotten despite the obvious temptation to focus on the positive.
4. ConclusionHealthy Living Centre, which the London School of Economics have now been
commissioned to do.
The costbenefit framework works at a relatively simple level, comparing costs for
groups of benefits. The health economists would call this a cost-consequence analysis
(CCA) that looks at a range of outcomes, each with its own dimension. The different
outcomes are subjectively weighed and compared with costs. The final result is therefore
less tidy and more complicated than when using a single measure of utility (such as
QALYs) is used, but arguably closer to the real world scenario (Hale et al., 2003).
This paper has discussed the difficulty of assessing the costs and benefits of HIA, but
shown that it is possible to make a start. Relatively simple measures of benefit, such as
skills audits or post-workshop questionnaires could be easily incorporated into HIAs, and
P. Atkinson, A. Cooke / Environmental Impact Assessment Review 25 (2005) 791798 797Environ Impact Asses Rev 2005;25:74757 [this issue].
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assessment. Oxford7 Oxford University Press; 2004b.London Health Commission and Greater London Authority. Report on the qualitative evaluation of four health
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McDonald R. Using health economics in health services: rationing rationally? London7 Open University Press;2004.
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P. Atkinson, A. Cooke / Environmental Impact Assessment Review 25 (2005) 791798798Further reading
Kemm J, Parry J. What is HIA? Chapter 1. In: Kemm J, Parry J, Palmer S, editors. Health impact assessment.
Oxford7 Oxford University Press; 2004a.J 2001;323:117782.
Seedhouse D. Health promotion: philosophy, prejudice and practice. London7 Wiley; 1997.Sloan FA, Whetten-Goldstein K, Wilson A. Hospital pharmacy decisions, cost containment, and the use of cost
effectiveness analysis. Soc Sci Med 1997;45:52333.
Wanless D. Securing good health for the whole population HM Treasury. www.hm-treasury.gov.uk/consultation_
and_legislation/consult_wanless04_final.cfm.
Developing a framework to assess costs and benefits of Health Impact AssessmentIntroductionCost and BenefitsThe Healthy Living Centre in DulwichConclusionReferences