🔦 🔍💡 EIS and public policies: why your health impact assessment efforts struggle to change decision-making — and what political science says about it. 🧩 Administrative silos have their own logic, not a dysfunction to correct.
📌 This article addresses a recurring frustration in the field: producing a rigorous health impact assessment, only to find that it does not influence decision-making. It provides a solid theoretical framework to understand that this blockage is not an individual failure but a structural characteristic of siloed decision-making systems. Useful for arguing with funders impatient for immediate results and for building a realistic long-term influence strategy. Reads like an antidote to burnout in the face of efforts perceived as futile.
📜🔗LINK to the source
1. ANALYTICAL SUMMARY
Context and issues — a persistent gap between rhetoric and practice. Governments display massive support for the principle of "Health in All Policies" (HiAP) and for the EIS intended to implement it, but few demonstrate a real transformation of decision-making practices (p. 46). The EIS are mainly multiplying at the local level on urban planning and transport projects, with a rare and poorly documented direct impact (p. 47-48). The obstacles — the image of "health imperialism", bureaucratic burden, lack of legal mandate, opposition from powerful interests — are not unique to health but common to all cross-cutting "mainstreaming" (p. 48-49).
Operational contributions — set realistic expectations. The chapter mobilises three theoretical frameworks (rare paradigm shift, limited rationality, siloed complexity) to explain why the EIS does not produce a rapid shift (p. 48-52). It draws practical implications: aim for indirect and cumulative influence, transform participatory approaches into a lever for political legitimacy, invest in long-term EIS partnerships rather than one-off interventions (p. 52-54).
2. KEY POINTS OF THE DOCUMENT
- The gap between rhetorical support and actual implementation of HiAP is consistently documented, including in exemplary contexts such as Norway and South Australia (p. 46-47).
- The EIS have professionalised (training, networks, methodological standards) but their direct effect on public decision-making remains "patchy" and poorly documented (p. 47).
- Three structural factors explain the ambition/results gap: lack of clarity at the time of trade-offs, incongruence with governments' short-term logics, high political cost of redistributive reforms (p. 51-52).
- The authors propose to reformulate the objective of the HIA: not a visible decision-making "output", but an "input" to the political process — diffuse influence on the framing and composition of decision-making tables (p. 53).
- The HIA in iterative mode, with continuous investment in relationships and resource sharing, produces more promising results than the HIA designed as an isolated one-off intervention (p. 53-54).
3. ACTION TRACKS FOR LOCAL ACTORS
- Reframe the objectives of an HIA approach with partners from the outset: present the expected influence as diffuse and cumulative rather than as an immediate decision-making result (p. 52-53).
- Prioritise iterative and sustainable HIA mechanisms, with a trust-based relationship built over time, rather than easily marginalised "one-off" HIAs (p. 53-54).
- Use participatory approaches of the HIA as a lever for political legitimacy and ownership by non-health actors, not just as a means of collecting complementary evidence (p. 52-53).
- Anticipate the resistance of administrative silos (sectoral rules, closed networks, established beliefs) as normal characteristics of the system to be navigated rather than "fixed" (p. 50-51).
- Document and highlight the indirect effects of conducted HIAs (agenda shifting, broadening of debate) to justify the continuation of the mechanism, in the absence of measurable immediate decision-making impact (p. 47, 52-53).
Unmet need: no transferable tool or methodological framework is provided in this chapter — to be supplemented with a methodological chapter from the same Handbook (e.g. "A walk through the steps of Health Impact Assessment").
4. ADDITIONAL REFERENCES
🔍➕ For more information, see the articles referenced by "Health Practices" on the topic - Health Impact Assessment https://www.pratiquesensante.com/blog/tag/evaluation-d-impact-sur-la-sante-152
- Lamprecht N. et al., "Prospects and Perspectives of Health Impact Assessment: A Systematic Review of the Peer-Reviewed Literature From June 2007 to January 2023", Public Health Reviews, April 2024.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11059091/ - "A systematic review of whether Health Impact Assessment frameworks support best practice principles", Public Health (ScienceDirect), June 2024.
https://www.sciencedirect.com/science/article/pii/S0033350624001951 - "Designing the Public Health of Tomorrow", report, vie-publique.fr, 2025.
https://www.vie-publique.fr/rapport/284241-dessiner-la-sante-publique-de-demain
5. FREQUENTLY ASKED QUESTIONS (FAQ)
- What distinguishes HiAP from EIA? HiAP is the overall strategic direction, EIA is the technical tool intended to implement it in each project (p. 44-45).
- Why do EIAs have little direct impact on decision-making? They fit into fragmented siloed systems, subject to limited rationality of decision-makers and rare and unpredictable change dynamics (p. 48-52).
- Does the lack of measurable impact make EIA useless? No — the authors identify real indirect effects: evolution of frameworks, maintaining visibility of health issues, broadening the actors around the table (p. 52-53).
- Is more scientific evidence needed to convince decision-makers? Not necessarily: the problem is a deficit of shared framing and political attention, not data — participation takes precedence over technical accumulation (p. 50, 52-53).
- Where are EIAs most used today? Mainly at the local and municipal level, on urban planning, transport and development projects (p. 47).
- What is the main operational recommendation? Invest in an iterative and relational HIA practice, built over time with sector partners (p. 53-54).
- Is the chapter pessimistic about the future of HIA? No — it advocates for strategic realism, comparing the approach to the fight against tobacco: slow and incremental progress, but with the potential for rapid change if circumstances allow (p. 54).
6. REWRITING IN PLAIN LANGUAGE
Why is it difficult to change policies through health?
Many governments say they want to put health into all policies.
This is the idea of "HiAP", Health in all policies.
To do this, they use a tool: HIA, Health Impact Assessment.
But in reality, it doesn't work well.
Decisions do not change much because of HIA.
It is not a problem of bad will.
It is a problem of power organisation.
The 3 main reasons
Administrations work in silos.
Each sector has its own rules.
Each sector has its own network of people.
It is difficult to get them to work together.
Decision-makers cannot analyse everything.
They have little time.
They make quick choices, not always logical.
Providing more scientific evidence is not enough to convince them.
Major changes are rare.
Most of the time, policies change gradually.
A true radical change rarely occurs.
It often takes a crisis for things to move quickly.
What the authors propose
Do not expect an immediate result from the EIS.
See the EIS as a tool for slow influence.
Build trust-based relationships over several years.
Involve residents and non-health stakeholders, not just produce reports.
7. CROSS-ANALYSIS — VALUES OF HEALTH PRACTICES
- Literacy : Not applicable — text intended for an informed audience of researchers and decision-makers, no public communication tool.
- Empowerment : The authors downplay the actual scope of citizen participation in the EIS, describing it as a rather "symbolic" than substantial objective (p. 53).
- Participation : Explicit recommendation to assimilate participatory techniques into the EIS, relying on the work of Hirono (2023) on citizen juries (p. 52-53).
- Community health : Central dimension — health is systematically treated as a collective issue related to social determinants (p. 46).
- Ethics : The text points out a critical bias — the accusation of "health imperialism" made against public health advocates (p. 47) — without a method to address it.
- Human rights : The HiAP literature posits health as a human right that should be shared equitably, not yet achieved (p. 46).
- Intersectorality : Central object of the chapter — urban planning, transport, education, taxation as concerned sectors (p. 44-45).
- Partnership : Recommended model of iterative EIS with shared investment in resources and long-term relationships (p. 53-54).
- Combating discrimination : Social health inequalities are central to HiAP, without specific treatment of identity discrimination (p. 46).
8. EVALUATION OF RESOURCE RELIABILITY
Scientific relevance : High — dense and recent bibliography (over 60 references, including several works from 2020-2023 by the authors themselves), recognised theories of public policy analysis (multiple streams, punctuated equilibrium, advocacy coalition framework), work directed by established figures in the EIS field, published in open access by Edward Elgar.
Operational relevance : Limited as it stands — theoretical essay without tools or frameworks directly transposable to the field. Strategic utility (understanding and anticipating blockages, adjusting discourse) rather than a manual.