Resumen de Ealth impact assessment of urban transport planning in low- and middle income countries
SUMMARY Urban transport contributes to the development of cities in Low-and-Middle Income Countries (LMICs) by generating economic growth, competitiveness and social progress. While rapid urbanization and mass motorization are often considered as measures for economic success, they are two key trends responsible for negative health impacts of transport. These impacts are likely to increase disproportionately in LMICs where 90% of 2.5 billion new urbanites will have migrated to to by 2050. Already, poor countries bear 80% of global non-communicable disease (NCD) deaths, 92 % of pollution-related deaths and 90% of traffic-related deaths in the world. Hence, new methods to assess how urban transport influences population health are urgently needed. Health Impact Assessments (HIAs) are known as evaluation tools to assess the overall burden of mortality and morbidity related to urban transport development in cities. HIAs can be used by policy makers to mitigate risks and increase benefits by estimating effects of transport policies on health and economic costs. Yet, only 6% of HIAs are conducted in LMICs. They cover limited areas and their purpose is restricted to approving privately led projects rather than integrating health into non-health sectors. Few LMICs regulate HIA with legislation and guidelines. No studies currently show how HIAs of urban transport planning can contribute to wider development policy agendas even if sustainability is stipulated as a ground value of HIA. Finally, few studies focus on participatory quantitative HIA (PQHIA) that combines stakeholder participation with quantitative HIA modelling and promotes evidence-based policy making. No peer-reviewed PQHIA of urban transport planning has been conducted in Africa.
This thesis examines and fills the practice, policy and theoretical gaps related to HIAs in LMICs. The overall aim of the thesis is to bring health into the agenda of urban transport by developing and testing a full chain PQHIA of urban transport planning policy applicable to LMICs. The main research question is: How can Health Impact Assessments of urban transport planning contribute to inclusive development in low- and middle- income countries? The research took place on the island of Mauritius located in sub-Saharan Africa, where the mismatch between urban population growth, exposure to environmental pollutants and limited resources are exacerbating urban health risks. The thesis is presented in 9 chapters. Chapters 1-3 present the general introduction, theoretical background and overall methods. Chapters 4-8 present five published/submitted papers and respective results used to respond to the main aim of the thesis. Chapter 9 discusses the main findings and implications for the advancement of HIA in LMICs.
This thesis applied a transdisciplinary approach and utilized qualitative and quantitative methods to conduct PQHIA. The theoretical framework of the thesis combines the DPSEEA model (Driver-Pressure-State-Exposure-Effect-Action) and the Inclusive Development theory (ID). The former traces the process by which a problem is caused and action is taken to address it. The latter looks at the degree to which the action taken accounts for social, ecological and relational inclusiveness. The theoretical framework accommodates the complex correlation between environmental indicators (e.g. air pollution) and health outcomes (e.g. death) while detailing the multistage and cumulative nature of health risks potentially generated by urban transport. It also frames the participatory dimension of the thesis which is used to examine how HIA outcomes can be further translated into policy decisions and actions. The framework validates this thesis as an adaptive learning process which examines and responds to environmental and life-style changes related to health and urban transport in LMICs The thesis started by investigating the state of art of HIA practice and policy in LMICs (chapter 4-5). In chapter 4, a systematic literature review was performed to identify the trends in HIA practice across 156 countries in the world. In total, 57 HIA case studies were identified in 26 countries. They varied significantly in purpose and methods. No study reported the time, money, and staff used to perform HIAs. Most HIAs were quantitative (72%), none of which were participatory (no PQHIAs). Barriers to HIA implementation included limited transparency in process, weak participation, and inconsistent delivery of recommendations. This paper was published in IJERPH journal. In chapter 5, a content analysis of policy was conducted to sketch the global HIA policy landscape and examine links with sustainable development. Currently, 25 LMICs have some form of policy, guideline or framework regulating HIA. Benefits of HIA policy include the use of integrative approaches, the promotion of regulatory processes, and the uptake of cost evaluation outcomes. Challenges for HIA policy include the lack of uniformity in HIA practice, the power dynamics around health integration, and the mismatch between policy frameworks and technical objectives. Adapted HIA legislation provides an opportunity for LMICs to achieve the Sustainable Development Goals (SDGs). This paper was published in RECIEL journal. Findings from chapter 4 and 5 provided a comprehensive overview of trends in HIA theory, practice and policy in LMICs. The thesis then proceeded to examine the urban transport planning context in Mauritius (chapter 6) before designing, testing and conducting a full chain PQHIA of urban transport in the capital city of Port Louis (chapter 7-8). Chapter 6 examined the alignment between urban transport policies and citizen needs. It also identified which population groups were most likely to be affected by possible misalignments. Policies in Mauritius emphasize an economic agenda focused on transport infrastructure rather than addressing public needs geared towards integrating urban transport planning in social life. There was an uneven distribution of urban transport needs across population groups (age, gender, socio-economic status). Policies catered for needs most likely to be expressed by the poor. Policies did not promote social and health agendas. Findings from chapter 6 were used to design and deploy the full chain PQHIA in Port Louis. Chapter 7 reported the process and results of the aforementioned PQHIA. It identified major risk exposures and estimated health impacts derived from urban transport planning policies. The PQHIA indicated that policies to reduce cars are not sufficient to increase physical activity, decrease traffic fatality and decrease air pollution exposure. Strong policies should aim to restrict all forms of motorization with particular measures to reduce motorcycle use and increase active travel (walking, cycling). Out of three scenarios, an ideal scenario can lead to 20% savings on the total government budget spent on road accidents and traffic congestion. Finally, chapter 8 integrated results from chapters 4-7 and proposed a final framework for conducting PQHIA in settings with scarce data, restricted budget and limited technical capacity. In summary, this thesis concludes that while several barriers to implementation of HIAs worldwide remain, there are opportunities to estimate health impacts of urban transport by applying PQHIAs in LMICs. PQHIAs can contribute to inclusive development by steering multilevel and multisectoral stakeholder engagement and by quantitatively assessing health impacts of transport in favour social and environmental goals. Participatory approaches in quantitative HIA are useful to contextualise quantitative modelling, engage stakeholders in HIA design and influence the uptake of outcomes after the HIA is conducted thereby providing opportunities for relational inclusiveness. For HIAs to provide health benefits in LMICs, they need to be properly integrated through transparent reporting processes, adapted legislation, good governance and strong evidence-based policy-making. Keywords Participatory Quantitative Health Impact Assessment (PQHIA), Inclusive Development, Urban transport planning policies, LMICs.
