Health impact assessment in international development assistance: the World Bank experience



Jean-Roger Mercier1

Lead Specialist, Quality Assurance and Compliance Unit, Environmentally and Socially Sustainable Development, World Bank, 1818 H Street NW, Washington, DC 20433, USA (email:



The World Bank Group is an intergovernmental organization of more than 180 member countries that provides financial assistance to borrower governments in accordance with its goal of fighting poverty. It has embraced the United Nations Millennium Development Goals and has developed a strategy for achieving them, based on two main pillars: building the climate for investment, jobs and sustainable growth; and investing in poor people and empowering them to participate in development. The Bank undertakes poverty reduction at both the country and global levels through financial assistance provided by the International Bank for Reconstruction and Development (IBRD) and the International Development Agency (IDA) and through partnerships with other organizations.

The spectrum of countries eligible for World Bank financial assistance ranges from Ethiopia with a GDP of US$ 100 per capita per annum to Slovenia with a GDP of US$ 9780 per capita per annum. During the period 1 July 2001 to 30 June 2002, IBRD lent US$ 11.5 billion for 96 new operations in 40 countries and IDA lent US$ 8.1 billion for 133 new operations in 62 countries.

The World Bank expects its borrowers to use environmental impact assessment (EIA) and other environmental and social analyses to integrate selected environmental and social aspects into the identification, planning, appraisal and implementation of the investment projects that it supports. Such assessments constitute the safeguards incorporated into ten environmental, social and legal policies issued by the Bank in the late 1980s and the early 1990s.a

In an increasing number of borrowing countries, EIA is required by national laws; its scope often includes matters of human health. To date, measurement of health-related impact assessment requirements has been relatively scarce, but existing data on EIA requirements provide a basis to identify opportunities for bringing health impact assessment (HIA) into the mainstream of activities. As of 2002, in a sample of 92 low- and middle-income countries worldwide, 85 had enacted EIA, most of which (75%) had adopted EIA before 1997.

Under World Bank policy, the borrowing governments are responsible for the preparation of the environmental assessments (EA) of the Bank-financed investments and associated components, even those components not financed by the Bank. Each project's preparation includes the environmental and social screening of the investment projects and categorization as follows: A for those with potential for significant environmental impact; B for those whose impact is not considered to be as significant; FI for projects involving Financial Intermediaries; and C for projects presenting no or very few environmental hazards. For the first three categories, an EA report needs to be prepared and disclosed in the country and worldwide, through the World Bank's InfoShop: reports for more than 1000 projects are available at the InfoShop's web site (

As part of the EA process, identifying, avoiding, mitigating and compensating for negative impacts on human health is performed routinely. Examples of such integration in the EA preparation process include the Ouagadougou Water Supply project in Burkina Faso and the Chad–Cameroon Petroleum Development and Pipeline project. The Ouagadougou Water Supply project involved the construction of a dam, 60 km away from the capital city. The environmental management plan of the EA for this project contains a comprehensive public health component, focusing on preventing the transmission of waterborne diseases, and this component is being implemented now that the dam has been built. In the Chad–Cameroon Pipeline project, health-related risks were assessed and mitigated, both for the working population and for the population living in the oil field areas and along the pipeline. An Indigenous People's Plan was also developed for the Bakola populations (the report of the Environmental Compliance and Monitoring Group of this project, which contains the latest information on its actual impacts, can be found at: Once potential negative impacts on human health are integrated into the EA of a Bank-funded project, the preventive measures are built into the project through the technical and legal provisions of the loan and are implemented throughout the project cycle (usually 5–8 years). Public participation in identifying health hazards is critical and, though it has not been systematically documented, its inclusion has been a practice in several Bank-funded activities.

Impacts of development activities on human health have been avoided or mitigated and human health hazards have been monitored in projects funded by the World Bank since the late 1980s. In the Lower Kihansi Hydroelectric project in the United Republic of Tanzania, the implementation of a public health component of the environmental management plan helped to decrease prevalence of HIV by 50% in the targeted group versus the non-targeted group after eight years of implementation. In the Sélingué Dam Environmental Audit in Mali, a public health management plan was designed and implemented to treat the population suffering from malaria — an epidemic that followed the construction of the dam (not funded by the Bank) in the 1950s.

The World Bank has also produced abundant reviews and guidance on HIA, with particular emphasis on infrastructure-related projects. Guidance on the integration of health aspects in EA has been published in an Environmental assessment sourcebook update (Birley M, World Bank, 1997) and is available from the Bank's web site ( The World Bank has helped to develop a methodological approach regarding HIV/AIDS transmission, which is becoming one of the most critical restraints on growth in sub-Saharan Africa (see Box 1).



Large infrastructure construction and rehabilitation works are the obvious priorities for integrating HIA into the EA process, because of the specific risks generated by the sudden surge in human presence from migratory workers and because of the intrinsic health and safety hazards associated with construction. However, other sectors may also generate serious health hazards, for example, tourism development, an activity which is typically funded by the World Bank's sister organization the International Finance Corporation (IFC).

Development studies have demonstrated the importance of having the proper institutions and policies in place at the macroeconomic level and of empowering local communities to improve service delivery to the poor. As a consequence, Bank loans at the macro level (development policy support) as well as at the micro level (community-driven development) require the full integration of public health concerns into existing safeguards, including EA. It is becoming imperative to simplify and streamline Bank processes, while achieving monitorable objectives on the ground. In addition, during the World Bank's assistance to countries in developing strategic EA for increased incorporation of environmental concerns into decision-making in policies, plans and programmes, the integration of public health — as a key linchpin between environmental management and poverty reduction — will also become critical.

In order to respond to this new set of health-based demands, the next steps for the World Bank include training of staff in borrowing countries and agencies, increasing cooperation between staff of the health sector and staff working on environmentally and socially sustainable development, and harmonizing EA and its content and process with borrowing countries. The World Bank also welcomes the development of partnerships in the international community to move forward the agenda of integrating HIA into EA. The integration of health, environmental and other social concerns into World Bank and borrower procurement practices is also being actively explored.

Conflicts of interest: none declared.



1 The opinions expressed in this article are those of the author and do not necessarily reflect those of the World Bank.
a The safeguard policies are: Environmental Assessment (OP 4.01), Natural Habitats (OP 4.04), Forests (OP 4.36), Safety of Dams (OP 4.37), Pest Management (OP 4.09), Indigenous Peoples (OD 4.20), Involuntary Resettlement (OP 4.12), Cultural Property (OPN 11.03), International Waterways (OP 7.50), and Projects in Disputed Areas (OP 7.60) (available from:

World Health Organization Genebra - Genebra - Switzerland