Assessing and monitoring health impacts of infrastructure development projects in sub-Saharan Africa

Background: Health impact assessment (HIA) has developed over the past 20 years as a discipline to support decision-making for projects, programmes and policies with the aim to maximise health benefits and minimise negative health impacts. While much focus has been placed on promoting the use of HIA, including new methods and tools for early steps in the HIA process, only little progress has been made in the crucial evaluation of the effectiveness of HIA. Hence, information whether HIA has supported decision-making and stakeholder participation and mitigated health impacts, is sparse in the peer-reviewed literature. The gap of monitoring and evaluation (M&E) evidence is especially large in a developing country context.

Objectives: The objectives of this PhD thesis were to present case studies implemented in three large-scale extractive industry projects in the DRC, Côte d'Ivoire, and Zambia and a renewable energy project in Sierra Leone. The case studies show (i) the implementation and outcomes of HIA of infrastructure development projects in sub-Saharan Africa and (ii) M&E of health outcomes and health-related indicators in communities affected by these projects.

Methods: M&E in HIA was achieved through repeated cross-sectional health surveys in semi-purposively selected sentinel sites in the area of influence of a project and in non-impacted comparison communities. The selection of health or health-related indicators depended on factors such as health data gaps found during the HIA scoping step, perceived future impacts, experience from similar contexts and time and financial considerations.

Conclusions: The baseline and follow-up health data collection within the HIA framework covering a broad range of biomedical, behavioural, contextual and environmental indicators allowed projects and health authorities to better understand pressuring health needs in the communities and take actions for health promotion. The approach of cross-sectional health surveys used for M&E of health impacts is promising in detecting changing patterns of community health and designing locally adapted health interventions. However, periodic M&E in 3-4 year intervals is not sufficient as certain indicators warrant shorter intervals between measurements. A combination of continuous and cross-sectional monitoring is recommended to the benefit of the individual projects, HIA practice in SSA and most importantly, the affected communities to protect and improve their health. The case studies presented in this PhD thesis, emphasising on the need of a robust M&E component in HIA, support the evaluation and advancement of HIA practice.

Keyword: health impact assessment


Astrid Knoblauch

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