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Health impact assessment, the concept, science, and application in China

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Health impact assessment, the concept, science, and application in China

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Health Impact Assessment, the concept, science, and application in China

by

Junteng Zhao

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(URBAN PLANNING AND DEVELOPMENT)

May 2023

Copyright 2023 Junteng Zhao

ii

Acknowledgments
Finishing the journey of a doctoral study is challenging. I would not have succeeded without
the help of many people. Here, I would like to express my sincere appreciation to those who guided
me. I would thank my family members as the start. Then I’d like to thank Prof David Sloane,
LaV onna Lewis, and Bryce Lowery. David is a knowledgeable chair to help me navigate the
academic journey. LaV onna is my advisor, who provided much invaluable advice. Bryce is
thoughtful in helping me through the qualifying exams and the defense. Also, I could not get it
done without Prof Emma Aguila and Laura Ferguson’s support in the exams.
Next, I will fully appreciate Qinbo Liu, Yuquan Zhou, and Yining Lei. You’re the smartest co-
authors I have worked with. I cannot forget Prof Julie Cederbaum’s lectures on qualitative methods,
which are essential to this dissertation. I cannot omit the professors who passed the knowledge to
me in the four years, including Prof Tridib Banerjee, Dowell Myers, Katherine Aguilar Perez,
Frank V . Zerunyan, T.J. McCarthy, Lisa Schweitzer, Jeffery Jenkins, Kathleen Wilber, Nicolas
Duquette, Thomas Valente, Tessy Tzoytzoyrakos, and Reka Clausen. It’s time to be in memory of
Robert Sweeney, a very kind instructor of my teaching seminar. Prof Marlon Boarnet, Geoff
Boeing, and Amanda Burkhardt provided valuable advice on a paper accepted by APHA’s 2021
Annual. Besides, I learned a lot about teaching skills and communication with others from Prof
Todd Gish when I was his TA.
I am grateful to the professors, experts, and officials who offered interviews or help to the
chapters. Many senior Ph.D. students from or out of USC, including Yimin Ge, Jiawen Fang,
Shengjia Xu, Yingying Zhu, Yougeng Lu, Linna Zhu, Quan Yuan, and Shengxiao Li, shared their
valuable experiences with me, which I appreciate. I want to thank all the administrative members
for all their assistance in the past four years.

iii

I could not enter USC without help from professors in my previous studies, including Malo
Hutson, Maxine Griffith, Pengjun Zhao, Jingjing Shan, Weiping Wu, Bin Lu, and Richard B.
Freeman. I have to mark the help from my old friends, Shuhan He, Xiuxian Li, Hai Zhou, and
Tyler Haupert, who assisted me in overcoming difficulties.
Lastly, the navigation of Buddhism is indispensable for me to overcome all the difficulties.
The City of Ten Thousand Buddhas and Gold Wheel Monastery is a spiritual pillar when I am in
Los Angeles.

iv
Table of Contents

Acknowledgements ........................................................................................................................ ii
List of Tables ............................................................................................................................... vi
List of Figures .............................................................................................................................. vii
Abbreviations .............................................................................................................................. viii
Abstract ......................................................................................................................................... ix
Introduction .................................................................................................................................. 1
The big picture of my dissertation ............................................................................... 1
A brief history of HIA around the world ..................................................................... 5
Introducing Health Impact Assessment in China ........................................................ 6
A comparison of the political framework of China and other countries on HIA ........ 6
Some Chinese basic contexts........................................................................................ 13
The structure of this dissertation................................................................................... 17
Chapter 1: Health Impact Assessments: Planning Lessons from China ...................................... 25
Abstract ........................................................................................................................ 25
Introduction .................................................................................................................. 25
Methods and Data ........................................................................................................ 29
Results .......................................................................................................................... 32
Conclusion ................................................................................................................... 54
Chapter 2: The strengths and weaknesses of Chinese Health Impact Assessments (HIAs) —
evidence from pilot HIA policies ............................................................................................... 64
Abstract ....................................................................................................................... 64
Introduction ................................................................................................................. 65
Method and Data ......................................................................................................... 72
Results ......................................................................................................................... 75
Discussion ................................................................................................................... 88
Conclusion .................................................................................................................. 92
Chapter 3: Why is the development of Health Impact Assessments in China slow? The
implication from multidisciplinary perspectives on healthy cities ............................................ 101
Abstract .......................................................................................................................101
Introduction .................................................................................................................102
Method and Data .........................................................................................................103
Results ........................................................................................................................ 107
Discussion .................................................................................................................. 121

v
Conclusion ................................................................................................................. 128
Conclusion.................................................................................................................................. 137
References ..................................................................................................................................149
Appendices .................................................................................................................................150

vi

List of Tables
Table i. Abbreviations
Table 1. Documents and events for Health in All Policies (Liang, 2020)
Table 2. A comparison of the political framework on HIAs in China and other countries. (adapted
from Liang, 2020)
Table 3. Sorting the cases reviewed in this study
Table 4. Online Available HIA Policies and Their Overlapping Rates
Table 5. A Comparison between Yichang and Hangzhou’s policy texts on HIA targets

vii

List of Figures
Figure 1. Locations of Chinese HIA cases
Figure 2. The standard process of HIA (WHO, 2022; adapted from ECHP, 1999)
Figure 3. The whole procedures of Chinese HIAs (CHEC, 2020)
Figure 4. The Governmental Organizational Map of HIA in Hangzhou (CHEC, 2022; Hangzhou
Municipal Health Commission, 2020a,b; and personal communications with experts)

viii

Abbreviations

Table i. Abbreviations
Abbr. Full name Abbr. Full name Abbr. Full name Abbr. Full name
Agr
CM
EH
Gov
M&S
SJ
SM
HIA

DALY

Agriculture
Construction Management
Environmental health
Governance
Math & statistics
Social justice
Social Medicine
Health Impact
Assessment
Disability-adjusted life
years

Arch
Earth
Eng
HC
OECD

EIA

YLL
UNDP
Architecture
Earth Sciences
Energy
Healthy City
Organization for
Economic Cooperation
and Development
Environmental Impact
Assessment
years of life lost
United Nations
Development Program
Atmo
Eco
Env
HP
PA
Soc
SIA

GBD

CHEC
Atmospheric
Ecology
Environment/Environmenta
l Health Promotion
Public administration
Sociology
Social Impact
Assessment
Global Burden of
Disease
Chinese Health
Education Center
CC
Econ
Geo
IS
PH
UP

ECHP

Climate Cha
Economics
Geography
s
Public healh
Urban
Planning
European
Center for
Health Policy

ix

Abstract
China started developing Health Impact Assessments (HIAs) in 2016. However, most current
studies focusing on Chinese HIAs center on the introduction of the practice from western countries
or the implementation of pilot case studies in local places. Few studies exist to systematically
review Chinese practices and policies. This study builds on the work of existing Chinese HIA case
studies and pilot policies to try to uncover the state of the science in China and identify the pros
cannot be applied. This study also tries to identify the structural barriers halting the development
of HIA and suggest a few feasible recommendations to promote the tool.
In Chapter 1, this study summarizes the findings regarding locations of Chinese HIA cases,
lead agencies, procedures, screening, scoping, health impacts and health economic impacts,
stakeholders, appraisal, and reporting and monitoring. It further implies some takeaways for urban
planning, including the significant role of urban planners, the value of Health in All Policies, the
need to the respect community voices, the merits of Chinese innovations, and the prosperity of a
growing HIA consulting enterprise.
Chapter 2 finds there is significant homogeneity based on text analysis of the regulatory files.
Strengths include taking advantage of the pilot status, building a powerful governmental working
network, creating multiple channels for public participation, utilizing information and
communication technology, and establishing a motivation system. The weaknesses include no
regulation on private projects, emphasis on fastness over thoroughness, and weak measures to
protect sustainability.
Chapter 3 examines the structural barriers of HIAs. Interviews revealed four structural barriers,
including the functional inconsistency between EIAs and HIAs, the scientific uncertainties of the

x

process between environmental pollutants and human health, insufficient operability of current
laws, and challenges for multidisciplinary collaboration. The authors recommend four actions,
including emphasizing the HIA’s role of decision-making instead of scientific values, starting the
specific legislation or regulation on HIA and relevant matching policies, developing an
authoritative technical guideline, and employing more multidisciplinary staff in the governmental
sectors.
This study concludes HIAs are a significant tool to promote the combination of public health
and urban planning in China. Urban planners’ engagement is one of the most crucial factors to the
success in the HIA field. Urban planners need to keep Health in All Policies in mind for better
planning, yet such a task has a few challenges. The public engagement is non-existent in academic
HIAs, but in a real decision-making process, stakeholders are important. Chinese insights for the
global HIA community, include the fast development of application of Internet communication
and technology, the initial screening, and the organizational innovation. To serve private business,
it is expected the professionals working in this field will grow and a HIA consulting enterprise will
thrive. Yet, to achieve the healthy development of HIAs in China, urban planners, policy and law
makers, and other professionals should work closely and collaboratively to develop practical
technical guidelines, proper regulations on the delivery of HIAs, and expand the applications to all
kinds of scenarios.

1
Introduction
The big picture of my dissertation
Combining urban planning with public health is crucial in the current urban management
(Corburn, 2004) because health is a fundamental element of urban residents’ well-being. Corburn
(2017) argues that urban planning includes “political processes, institutions, and discourses that
generate policies, rules, and physical plans that shape where we live, learn, work, and play in cities
and towns.” The elements of urban planning highly influence “the distribution of social, physical,
and economic ‘goods and bads’ that influence human health and explain persistent urban health
inequities” (Ibid). Such an impact can be reflected by but not limited to infectious diseases, fire,
housing, fresh water, and sanitation (Greenberg & Schneider, 2017). A few examples illustrate how
the connection works--(1) poor housing is a negative factor for children’s asthma, (2) increased
automobiles use causes air pollution, and air pollution contribute to many lung diseases (3) the
Great Chicago Fire caused significant life and wealth losses, (4) inadequate facilities provide
unsafe water to drink, and (5) rapid urbanization becomes a stress in people’s life and may cause
mental problems. Due to the significant influences of urban planning on public health, planning
has been widely recognized as a physical determinant of health and a social determinant of health
(Friel et al., 2011).
However, human understanding of the relationship between urban planning and public health
is not linear. History has given lectures on how inadequate urban planning was a disaster for public
health. For the booming cities in the late 19
th
century, the for-profit fire departments, were poorly
equipped “and could not handle even small fires that broke out in the shoddily erected wooden
structures that went up like matchsticks.” (Schneider & Greenberg, 2018).

2
Before the coming of the 20
th
century the causes of diseases were hypothesized as miasma in
the air (Tulchinsky & Varavikova, 2014). Hence, the methods to control infectious diseases were
to remove the filth and isolate sick people (Walston & Johnson, 2021). Congestion was blamed for
the concentration of the miasma (Sloane, 2006), so multiple urban planning approaches were
applied to control congestion, usher in building codes, improve infrastructure, and remove
environmental filth, which helped quench the disease but not all the time (Corburn, 2017).
The germ theory, developing in the late 19th century, explained that microorganisms were the
principal causes of infectious diseases (Tulchinsky & Varavikova, 2014). The germ theory was
widely accepted around the 1890s, significantly changing public health practices. Physicians and
laboratory technicians became dominant health professionals, while urban planners gradually were
marginalized. Health professionals' focus largely diverted from improving the environment to
killing the microbes. The urban planning profession also changed a new track to center on
efficiency and urban aesthetics (Corburn, 2017; Sloane, 2006). From the 1890s to 1940s, urban
planning and public health increasingly drew away, with a marginalized effort to work together on
some subfields. In the 1940s and 1950s, health was recognized as a great merit by American
middle-class whites, but health was also used to discriminate against people of color by
demolishing their “blighted” neighborhoods with the excuse of urban renewal. A series of
American housing policies deprived people of color of the benefits of homeownership, better
schooling for children, capital accumulation, and participation in the growing suburban economy
of people of color (Corburn, 2017).
In the 1960s, a series of social movements and shifts dramatically changed American culture,
including the civil rights movement, environmentalism, increasing life expectancy, and the
recognition of the negative health consequences of suburbanization (Frumkin et al., 2004). In the

3
next decades, chronic diseases gradually replaced infectious diseases as a more significant threat
to human health. The germ theory was refined by a biomedical model adding individual health
factors such as lifestyles, behaviors, habits, and genetics to become the dominant health philosophy
(Tulchinsky & Varavikova, 2014). Because of the impact of urban planning on people’s behaviors,
planners and health professionals started a faltering reconnection to work together for human
health and well-being.
World Health Organization (WHO) has been an indispensable participant and a game-changer
in reconnecting these two fields since the 1970s. WHO organized numerous meetings and
published a series of documents that dramatically shaped the ideology, principles, and paradigm
of health. One of the critical philosophies is Health in All Policies (HiAP). Liang (2020)
summarized the milestones of the invention of HiAP, which were primarily based on WHO’s works
(Table 1).

Table 1
Documents and events for Health in All Policies (Liang, 2020)
Time Name Location Content
1978 Declaration of Alma-Ata Alma Ata,
Kazakhstan, The
Soviet Union
Primary care for everyone in
2000
1986 The Ottawa Charter Ottawa, Canada Health promotion
1988 The Adelaide
Recommendation on Healthy
Public policy
Adelaide, South
Australia
All policies need to consider
health and equity and be
responsible for health.
Healthy public policies are to
create a supportive
environment for health.
1991 Sundsvall Statement on
Supportive Environments for
Health
Sundsvall,
Sweden
Supportive environments for
health
1999 The Gothenburg Consensus
Paper on Health Impact
Assessment
Gothenburg,
Sweden
Health Impact Assessment is
a tool to support assessments
on public policies, programs,
and projects

4
2006 Health in All Policies Finland Finland raised the concept of
HiAP for its EU Presidency.
2007 The Declaration on Health in
All Policies.
Rome, Italy EU member states’ health
ministers met to underline
multisectoral collaboration
and incorporate health
assessments into public
policies.
2008 Closing the gap in a
generation: Health equity
through action on
the social determinants of
health
WHO
Commission on
Social
Determinants of
Health
The root cause of the
pervasive health inequity is
the disparity of social
determinants of health
within and across nations.
2010 The Adelaide Statement on
Health in All Policies
Adelaide, South
Australi
Only when the government
and all sectors make health
and well-being key points in
policymaking can they
achieve the best outcomes of
the governmental goals.
2011 Rio Political Declaration on
Social Determinants of Health
Rio de Janeiro,
Brazil
Health in All Policies to
collaborate to work on social
determinants of health and
promote health equity and
social inclusiveness.
2013 Helsinki Statement
Framework for Country
Action
Helsinki, Finland Define HiAP; Appeal to
countries to emphasize
social determinants of
health; provide technical and
organizational supports
2016 Shanghai Declaration on
promoting health in the 2030
Agenda for Sustainable
Development
Shanghai, China Commit to good governance
for health
2018 Preventing disease through
healthy environments
A global assessment of the
burden of disease from
environmental risks
Geneva,
Switzerland
An updated GBD study with
environmental factors
affecting people’s health
2019 Healthy environments for
healthier populations: Why do
they matter, and what can we
do?
Geneva,
Switzerland
The environmental factors
that people can act to control
diseases and promote a
healthier life
2022 Regulations and Laws
promoting health and well-
being goals (SDG3) in WHO
South-East Asian countries
South-East Asia National legal frameworks
help to attain these health
goals, including universal
health coverage,

5
implementation of health
policies, and the application
of the International Health
Regulations.

Among these WHO efforts, Health Impact Assessment (HIA) is a flexible tool to achieve
HiAP that has attracted growing attention from urban planners (Forsyth et al., 2010). An HIA can
be used in many fields (Harris-Roxas et al., 2012), including predicting traffic crashes and
infectious and chronic diseases. Concurrently, urban planning can also work in these fields. For
crashes, urban planning is crucial to design safer streets for drivers, riders, and pedestrians to
commute. Urban planning has a prominent role in influencing human health for infectious diseases.
For example, lockdown ordinances to prevent people from contracting SARS-CoV-2. For chronic
conditions, urban planning is influential on four themes, including environmental quality,
socioeconomic impacts, management and governance, transportation and urban design (Sharifi &
Khavarian-Garmsir, 2020; Śleszyński et al., 2022; Mouratidis & Yiannakou, 2022). Hence, the
overlaps of the goals of an HIA with urban planning make the assessment a good tool for planners
to refine their work.
A brief history of HIA around the world
HIA is a tool to evaluate the health impacts and consequences of "the overall effects, direct or
indirect, of a policy, a program, or a project on the health of a population." (ECHP,1999). The first
HIAs were done in the 1980s in Canada and Central and Eastern Europe. Those early HIA practices
were for significant infrastructure or an appraisal of political science and other social sciences
(Kemm et al., 2004; Forsyth et al., 2010). HIAs expanded to many European countries in the 1990s,
such as the UK, the Netherlands, British Columbia, etc. As Table 1 mentioned, the European Center
for Health Policies of WHO published its famous Gothenburg Consensus Paper in 1999, which

6
started a new era of HIA (ECHP, 1999). After public awareness of the role of HIAs, European
countries decided to practice such a tool extensively. They prioritized HIAs as a core of Phase IV
of the European Healthy Cities Network (Ison, 2012), which tested the applicability of such a tool
in over 30 countries and across varied socioeconomic backgrounds (Simos, 2017). The United
States had its first HIA in 1999 (Bhatia & Katz, 2001), while developing countries such as Thailand
sped up legislation on HIAs in the 2000s (Suwanteep et al., 2016; Liang, 2020).
Introducing Health Impact Assessment in China
Here I briefly introduce the fundamental policies that shape today’s HIA landscape in China.
A more detailed description is in Chapter 1. Compared to those pioneering countries, China began
using HIAs late. President Xi Jinping announced that China would establish the institution of HIA
at the National Health and Sanitation Conference in August 2016. The upcoming Health China
2030 (October 2016), a high-level national initiative, included a political commitment from the
President. Later, the Basic Medical Care, Sanitation, and Health Promotion Act (2019) and The
Outline of the People's Republic of China 14th Five-Year Plan for National Economic and Social
Development and Long-Range Objectives for 2035 (2021) continued to include establishing the
institution of HIA as a legislative and governmental goal. China started to pilot HIAs in 2017, and
it expanded the scope of pilots in July 2021. Right now, the institution of HIA is still being
formalized.
A comparison of the political framework of China and other countries
on HIA
The Chinese primary legislative framework of HIA has been described in the former section.

7
This section will compare the relevant Chinese political framework on HIA with other countries.
The supportive table is referenced from Liang (2020), but the author checked the correctness of
her initial table and made a few adjustments based on each country’s legislative framework.
Thailand is a unique country which wrote the HIA into its Constitution. Few countries put HIA
in the Constitution, while many developed countries introduced a piece of the federal or the
national level public health portray. For China, the Basic Medical Care, Sanitation, and Health
Promotion Act is a fundamental law in the public health field. This law defines the institution of
HIA, but it does not portrait the details. The problem of the lack of details and operability will be
discussed in Chapter 3.
Two relevant Chinese laws, Environmental Protection Act and Environmental Impact
Assessment Act, influence but do not determine the practice of HIA. The Section 39 of
Environmental Protection Law requires the nation to establish and improve the system of
monitoring, investigation and risk assessments on environment and health. Plus, the nation
encourages the research of the environmental impacts on public health and adopt measures to
prevent and control diseases related to environmental pollution. Although the Section 39 lays out
the potential for an HIA, the lack of supportive research has hindered development. Another law,
Environmental Impact Assessment Act, is a specific piece of legislation focusing on making the
EIAs. This law does not contain any requirements on health, but since many local jurisdictions are
considering integrating EIAs and HIAs together, the framework of this law will significantly
influence the practice of HIA via making an EIA and related coordination and integration.
The legislative pattern of China can be concluded as a public health law defines the HIA from
two perspectives, including a health public policy and a low environmental health risk for projects.
The environmental laws include two parts—one regulates the potential for health considerations

8
in environmental affairs, and the other just regulates EIAs but can be integrated into an EHIA. We
compare China to international practices and find that some countries have similar laws to realize
the same functions. For the function of the public health law, Thailand has a comparable legislation.
However, most western countries do not have a national or federal public health law to regulate it.
For Canada, Impact Assessment Act of 2019 incorporated HIAs into all the impact assessments,
which is a federal legislation to legitimate the practice (National Collaborating Centre for
Environmental Health, 2021). For the Netherlands, the Public Health Act requires that
municipalities examine the health consequences of local policies. This law potentially outlines the
usage of HIAs to meet this requirement, but it doesn’t give further guidance and clarification. The
City and Environment Act rules under what conditions infrastructural planning in environmentally
vulnerable sites will be approved with an assessment of population health, so an HIA has a
necessity (den Broeder & Staatsen, 2012). However, most countries, such as the US, Australia, and
Germany do not have a federal level legislation to legitimate HIAs. For these countries, the practice
of HIAs was usually thriving in some states or provinces. For the United States, only Vermont,
Massachusetts, and Washington State (Health Impact Project, 2015) succeeded in adding HIAs
into its legislation. For Canada, Québec and British Columbia were pioneers, but the development
of HIAs was disrupted in British Columbia because of political elections (Kemm et al., 2004b).
For Australia, the practice of HIAs is in a hot debate in lawmakers because of the effectiveness of
HIAs, so it never succeeded in becoming a national law (Harris-Roxas et al., 2012a). Germany
does not have a federal legislation regulating HIAs, but a resolution passed by the Conference of
Ministers of Health to promote the agenda. The North Rhine-Westphalian Public Health Service
Act calls for HIA in local planning (Fehr & Mekel, 2012).
All these countries realize the importance of environmental policies and utilize EIAs to

9
evaluate whether projects have significant environmental projects. Such a function can be realized
in either one or two pieces of legislation. China and the Netherlands have two, while most countries
have only one with different titles of the legislation (see Table 2).
All these countries assign the responsibility to make an HIA to the public health administration.
Such a health administration can be the Ministry of Health, the CDC, or a public health office. In
China, the National Patriotic Sanitary Council is responsible to coordinate the provincial and local
pilots on HIAs, but most HIAs practices are local based and governed by local public health
administration. The cooperation of the national and local public health agencies is quite common
in HIAs, such as the US, Canada and the Netherlands.
Chinese Health Education Center is a significant intellectual supporter for operations. Other
countries, such as Thailand, Australia, and Germany also have professional public health institutes
involved. As for other sectors involved in HIAs, many governmental sectors, such as urban
planning and construction, transportation, environmental and ecological departments have a big
say in HIAs in China, echoed by a few western countries. The United States has many grassroots
and nonprofits involved in HIAS, which are quite different from Chinese practice.
All countries, including China, have a governmental funding source for HIAs. The California
Endowment, an organization who commits to the health of underserved communities in California,
is also a significant supporter of HIAs (The California Endowment, n.d.).
Each country has its own feature on HIAs. China emphasizes quickness over thoroughness.
Many Chinese HIAs are desk HIAs, and the completion working day are 60. Such a feature can
save time for decision making but may omit some long-term consequences. Thailand built a
specific administration to govern HIAs. The US is an early adopter of HIAs and developed a rich
legacy of tools, knowledge, and experience. Canada emphasizes the provincial HIA agendas, while

10
the federal government is a coordinator. Australia has a big interest in equity focused HIAs. The
Netherlands and Germany both emphasize quantitative HIAs rather than qualitative ones in
contrast to China. Germany went further and developed many sophisticated models by the
Bielefeld scholars. The Netherland focuses on evidence, which can learn from China. China shares
a feature with the Netherlands that both countries have two professional strands to develop HIAs,
including the Lalonde model HIAs and Environmental Health Impact Assessments that are
dominated by the environmental department.

11

Table 2.
A comparison of the political framework on HIAs in China and other countries. (adapted from Liang, 2020)
Country HIA
legislation
EIA legislation
with HIA
HIA
administration
Other involved
sectors
HIA funding features
China the Basic
Medical
Care,
Sanitation,
and Health
Promotion
Act
Environmental
Protection Act;
Environmental
Impact
Assessment
Act

Local health office The urban
planning sector,
the
environmental
sector, the
ecological sector
CHEC
Gov 1. Quant
2. Fast

Thailand The Thai
Constituti
on;
The
National
Health
Act
The National
Environmental
Quality Act
The National
Health Council;
The Natural
Resources and
Environment
Ministry
The Health
Ministry;
The Health
Institution;
National Health
Conference
Gov 1. Constitution;
2. Establish
the specific
admin

US Clean
Water Act
The Safe
Drinking
Water Act
The Clean
Air Act
NEPA CDC Grassroots,
nonprofits
Robert
Wood
Johnson
Foundation;
The Pew
Trusts;
California
Endowment;
Local gov
1. early
2. rich
tools
Canada The
federal
Impact
Assessme
nt Act
Québec
Public
Health
Act
Canadian
Environmental
Assessment
Act
The federal and
provincial health
administration
The
federal/provincial
environmental
and occupational
associations
Gov 1. provincial
2. fed coordi-
nate
3. QB & BC

12

(continue)

Australia VIC
Public
Health
and
Wellbeing
Act 2008
The
Environment
Protection and
Biodiversity
Conservation
Act
Tasmania
Environmental
Management
and Pollution
Control Act
Public health
administration
Environmental
Health Standing
Committee
Gov Equity-focused HIAs
Netherlands The
Public
Health
Act

The City
and
Environm
ent Act
Environmental
Management
Act
the
Environment
and Planning
Act
Urban public
health agencies
EIA committee Gov 1. Quantitative methods
2. Evidence-based research
3. Two streams of HIAs,
4. public health field
5. environmental sector.
6. Same with China
Germany The North
Rhine-
Westphali
an Public
Health
Service
Act
Environmental
Impacts
Assessment
Act (UVPG)
Federal Ministry
of Health
Federal Office of
Civil Protection
and Disaster
Assistance
Federal Centre for
Health Education
Health research
institutes
Federal
Research
and
technology
departments,
EU
committee
1. An integrated approach
2. Primarily quantitative
3. The Bielefed Method
4. Probability models

13
Some Chinese basic contexts
The political structure
China has a centralized regime, so the lower governmental branches need to obey the rules set by
an upper-level administration. The highest power comes from the Standing Committee of the
Political Bureau, the CPC Central Committee, which is a committee with seven highest national
officials and centers at the General Secretary, the CPC Central Committee. The General Secretary
is the same person as the nation’s President. The decisions from the Standing Committee of the
Political Bureau are usually the foundation of policies or regulations by the State Council. The
State Council’s branches and provincial officials need to obey the policies from the State Council.
However, lower jurisdictions have the authority to adjust the policy based on local conditions. The
discretion of the adjustment varies from topic to topic.

The legislative power
The National People's Congress and its Standing Committee have the authority to make laws. All
the major laws discussed in this dissertation, including the Basic Medical Care, Sanitation, and
Health Promotion Act, the Environmental Protection Act, and the EIA Act, come from the Standing
Committee of the National People’s Congress. A top-notch national planning, the 14th Five-Year
Plan for National Economic and Social Development and Long-Range Objectives for 2035, is
approved by the National People's Congress. Hence, the 14
th
Five Year Planning is a binding policy
with the legislative power that local jurisdictions must obey and use it to make local 14
th
Five Year

14
planning schemes. A Local People’s Congress has the authority to make local statutes, though these
local statutes are not involved in this dissertation.

The administrative power
The State Council is the highest executive administration of China. The State Council is
responsible for numerous specific planning and regulations, and Healthy China 2030 is one of
them. Provincial, municipal, and district/county administrations also need to follow the rules of
the State Council. The pilot HIA policies discussed in this dissertation all come from local
government. Those policies are not local statutes made by the legislative authority but are the
administrative regulations.

The political culture of China
Unlike western countries who favor deep civic engagement to empower citizens in decision
making, China is a traditional top-down country that the government holds the power for decision
making. However, such a decision may be more or less influenced by different governmental
branches, industries, and the public. If some policies are highly controversial and receive
tremendous oppositions from industries or governmental branches, such a policy may not become
formalized in the end. This dissertation discusses two drafted policies that failed to come out in
Chapter 3. The public can also influence the policy. Usually, a policy is drafted by a governmental
branch, or it can assign some experts to research and draft. During the research, there will be some
experts, representative groups, or potential stakeholders invited to give their opinions. The

15
stakeholders do not include grassroots or civic campaigners but businessowners, residents,
professional associations, the universities, and journalists. These groups may be adjusted by topics.
For example, the youth planning will invite young adults with diverse gender, employment,
educational status, and income. Their views may impact the policy making, and sometimes these
investigations may come have a brief on the local newspapers. The draft of the policy is dominated
by the experts and governmental officials, and they need to be checked by other governmental
sectors to dissolve inappropriateness. The policy will come out to the public for open comments
when the government is confident with the draft. The commenting period may last for several
weeks. The government will consider and select the open feedback to adjust the draft. The revised
draft will become the final policy.

The uniqueness of China
China is a country with a vast territory only comparable to Russia, Canada, and the United States.
However, the Chinese political system and culture is quite different from the US and Canada.
Canada and the US both develop HIAs bottom up, but China develops it top down. The different
strategies reflect how effectively the HIA expands across a nation. From 1999 to 2007,
(Dannenberg etc, 2008) identified 27 lengthy HIAs in the United States, but the number grew
rapidly in the following decade. While for China from 2016 to 2023, this study can only identify
43 cases for limited data accessibility, so more should be done. It is true that the numeric
comparison between China and the US seems to indicate China has a faster speed, but an point is
American HIAs are mostly lengthy that each one is over dozens of pages and needs months or

16
years to complete, while Chinese ones are almost one-or-two-day desk HIAs and only generates
short reports.
Some states of the US considered to introduce bills of HIA or with its major components, but
not all these efforts were successful (Health Impact Project, 2015). Such a situation would not exist
in China when the central government decided to introduce HIA. On the other hand, the United
States was much earlier than China to heed the importance of HIAs. The US has multiple textbooks,
tools, specific journals for HIAs from CDC, academia, nonprofits, and many grassroots, indicating
a rich intellectual legacy and a vibrant social network in this field. However, the prominent HIA
player for China is the government. Other HIA participants need to wait for the invitation of the
steering institution (which will be further discussed in Chapter 2). The organizational difference
can partially explain why Chinese official HIAs are nearly all about government-invested projects
or policies, while American counterparts have a rich source from private projects with a public-
private partnership. Hence, China is a unique sample of how a large country develops its HIA
system.
Besides, China is a developing country, whose GDP per capita is about 12,000 dollars, while
most HIA early adopters are developed countries whose GDP per capita are over 20,000 dollars.
Although China experiences a decline of economic growth rate to fight for industrial upgrading,
better environment, ecological balance, and climate-responsible efforts, the huge economic growth
still represents tremendous market opportunities. Few countries’ growth rate can reach 5% as
China. HIA is a new policy tool to protect people from health hazards of projects and policies, so
it has the potential to further compromise the economic growth rate if some projects should be

17
vetoed or restricted to avoid conversely. On the other hand, the health benefits may be more
pervasive but intangible through decreased mortality and medical expenses. These policy choices
are critical to a developing country, and some are also looking for a balance between public health
and economic growth. The lessons from China will become more valuable to those developing
countries, especially those in Asia and Africa.
Lastly, aging is a big challenge for China. China had a unique history of birth control. The
strict birth control policy started from 1982 and was revised in 2016. This policy only allowed one
child per household without penalties. The legacy of this policy combines with the Chinese
demographic structure makes aging a significant social problem, including decreased labors,
declining revenues in the future, and increasing medical expense. Although aging is a pervasive
problem to the world, the huge population, the legacy of the one-child policy, and the limited
household wealth all increase the challenge that China faces. The year of 2022 was the first year
in several decades that China witnessed a decline of total population. Given the increasing aging
population and decreasing births, Chinese population is nearly certainly to drop more in the coming
years. Although HIA cannot stop the demographic change, it can somewhat alleviate the escalating
medical costs. Therefore, the Chinese lessons on HIAs seem to be valuable to indicate how HIA
can contribute to the policy package of aging in a large scale.
The structure of this dissertation
Chinese HIAs are still in their infancy because China has practiced such a tool briefly that
pilots are still under testing without transforming into a completion. This dissertation looks into

18
Chinese HIA cases and policies to identify how an HIA is done and how Chinese policymakers
and scholars perceive such a new tool. Since some cities plan to expand local HIA pilots in 2023
or 2024, this dissertation will summarize some of the lessons generated in the past six years and
provide insights for the new stage. Since HIA is a policy tool from western countries, the Chinese
HIAs should mirror some basic principles and features with European and American cases. Still,
China has centralized politics and decentralized administration (Hutchcroft, 2001), which is
significantly different from Western civilizations; Chinese culture, income level, and social norms
are also unique. Therefore, China is highly likely to provide new variations in HIA, enlarge its
diversity and applicability, and bring innovations institutionally or technically.
This dissertation is a collection of three chapters. Chapter 1 is my single-authored work. It
determines the state of the science of HIA in China from local cases or published research. It
reviews 43 instances from the Chinese Health Education Center’s books (CHEC, 2019; 2020;
2022), academic journals, Asian Development Bank’s projects, a conference paper, a report from
Organization for Economic Co-operation and Development, and a master’s thesis. Cases are
written in either Chinese or English, and a few are bilingual. This chapter summarizes the essential
elements of an HIA and its basic procedure, analytical methods, and data sources in China.
Chapter 2 is a co-authored work for which I am the first author. The co-authors are Qinbo Liu
(an urban planning Ph.D. student at School of Urban Planning & Design, Peking University
Shenzhen Graduate School) and Yuquan Zhou (an urban planning Ph.D.student at Sol Price School
of Public Policy, University of Southern California). This chapter uses text analysis to identify the
current strengths and weaknesses in the local policies. We collect twelve local Chinese pilots' HIA

19
policies, including five cities, four municipal districts, and three counties. Seven of the twelve
jurisdictions are in Zhejiang Province. This chapter dives into the structural organization of HIA
in China and how public engagement is designed in policies.
Chapter 3 is another co-authored paper for which I am the first author. The co-author is Yining
Lei, a Ph.D. student majoring in City and Regional Planning at Stuart Weitzman School of Design,
University of Pennsylvania.We try to figure out the reason for the slow development of HIA in
China, identify the barriers, and propose some possible actions to promote the agenda. We
interviewed seventeen experts by email, video, or phone. Those scholars are from multiple
professions, including urban planning, public policy, public health, occupational health and mining,
public health law, environmental studies, environmental law, construction management, and
ecology. The diversified scholars reflect the multidisciplinary expertise to conduct an HIA and
illustrate how standpoints vary from different fields. These heterogeneous expert interviews give
us a holistic view of HIAs' challenges from several perspectives. We, fortunately, invited a few
experts from the governmental sector and a few scholars with a deep connection with the
government. The experts' views reinforce our analysis's reliability to the problem and the
feasibility of our recommendations to the government. We identify four primary structural barriers
to HIA development in China and provide four recommendations for the response.
This study concludes the powerful organizational structure to implement an HIA is one of the
foundations to make it successful. The core player to govern an HIA in China is the steering
institution, who is usually acted by the local health office. The geographical disparity of practicing
HIAs exists, yet whether such a disparity comes from the availability of funding is inconclusive

20
as experts have mixed thoughts. Urban planners’ engagement is crucial to the success of HIAs,
such as in the community planning, transportation, built environment, etc. Yet, housing needs more
attention in the HIA field. Urban planners need to embed Health in All Policies in their works to
better prepare for HIAs, yet such a task has a few challenges. Building capacity is not a big concern
in this study, because China has sufficient potential experts to work on it that their potential is
likely to become real when some necessary training can help them be familiar with HIAs.
The procedure of Chinese HIAs is adapted from WHO’s model, but the Chinese government
may change the roadmap to add initial screening or just focus on the core steps based on the
demand. Quantitative and qualitative HIAs both receive significant attention, yet the government
is likely to use qualitative ones to assess the impact of public policies and quantitative ones to
measure the influence from projects. The public engagement is ignored in academic HIAs, but in
a real decision-making process, stakeholders have many channels to participate to voice their
thoughts. Whether these feedbacks will influence the results of an HIA depend on how experts and
officials synthesize them. The future HIAs can learn from EIAs and enlarge their scope for private
business. This may become a huge incentive for a growing HIA consulting business.
This study identifies a few structural barriers that may halt the development of the institution
of HIAs, including the functional differences between EIAs and HIAs, the scientific uncertainties
on the causal relationship between environmental hazards and human health, the lack of operability
of laws, and the weak multidisciplinary collaboration. A few shortcomings may be overcome in
the future. Sustainable development needs more weight on the values of HIAs in China. Asking a
quick HIA to neglect the thoroughness of the review may decrease the effectiveness to predict

21
health impacts.
China also provides some insights for the global community of HIAs. The fast development
of application of Internet communication and technology, the initial screening, and the
organizational innovation such as the joint conference, may be critical takeaways to improve other
countries’ HIAs.

22
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Chapter 1: Health Impact Assessments: Planning Lessons from China
Junteng Zhao
Abstract
HIA has been a globally popular tool to evaluate a policy, program, or project's potential health
impact, yet China has only recently adopted it. This study reviews Chinese HIA cases in Chinese
and English to clarify the state of science in this field. This review identifies 43 cases and finds
urban planning has critical involvement in Chinese HIAs, including community planning,
transportation, etc. Public engagement is valued but under the power of experts and officials. In
the future, planners can promote healthy development by using HIAs to study affordable
housing, collaborate with other sectors, and build technical capacity.
Introduction
As I mentioned in the general Introduction of this dissertation, public health and human
well-being have been core values of urban planning since ancient times (de Leeuw, 2017), for
cities are the leader in promoting health by investing in people and places (Corburn, 2021). In the
21st century, these values are demonstrated by healthy public policies (WHO et al., 1986). The
Health Impact Assessment (HIA) is a critical pillar for planners as they have increasingly looked
to the tool to improve outcomes related to community health.
US CDC (2016a) elaborates on WHO's definition by emphasizing HIA's decision-making

26
role via health impacts outside the health sectors before the project is built or the policy is
implemented. This study mainly builds on US CDC's perspective to uncover the lessons of
Chinese HIA cases for planning.
Three types of HIAs have been implemented in the 21st century, including a rapid health
impact appraisal (a mini HIA), a health impact analysis (a maxi HIA), or a health impact review
(ECHP, 1999; Parry & Stevens, 2001). A rapid appraisal is also called a mini/desk HIA, a fast
process based on discussion among experts, stakeholders, and decision-makers using known
determinants of health and existing data with little resource consumed (Ibid). A health impact
analysis is an in-depth analysis of the health impacts of a policy, a program, or a project using
available evidence, collecting new data, and listening to stakeholders' opinions.
A health impact review is for a significant policy or group of policies that are too broad to
disentangle the precise health impacts. It figures out the most significant impact with a
convincing summary estimation (Ibid). Hence, for a single policy, the rapid health impact
appraisal requires the least resources such as time and money to implement, while a health
impact analysis needs more time, data collections, funding, and detailed analysis. For a group of
policies, a health impact review may be more appropriate since it captures the most significant
impacts to inform the policymakers.
As discussed in the dissertation's introduction, HIA is regarded as a valuable tool to combine
urban planning and public health (Corburn, 2009; Sloane, 2006). Urban planning, environmental
studies, climate change, and countless sectors exert their impact through social determinants of
health. In this way, there is a call for a joint framework of urban planning and public health

27
(Northridge et al., 2003), yet for this chapter, planning interest comes first. (Northridge et al.,
2003) indicate the overarching goals of HIAs are equity and democracy, holding the values of
"ecosocial perspective, health and human rights, the precautionary principle, and sustainable
production," and working on the elements of the built environment, housing, transportation, land
use, urbanization, open space, density, urban sprawl and infill, redevelopment, and an effective
public sector. Shafie et al. (2013) illustrates the use of HIAs with shelters, urban utilities,
industry, traffic congestion, energy overuse, and air pollution. The role of planning is to combine
the improvement of quality of life and costs to the environment within "well-designed and well-
governed cities."
Due to the significance of environmental impacts, environmental risks and climate change
have received the most attention. In the US., the National Environmental Policy Act (NEPA) is a
pioneering work to protect the environment for future generations' well-being. NEPA established
the framework of Environmental Impact Assessment (EIA) and Social Impact Assessment (SIA).
EIA has an environmental perspective, intending to prevent environmental hazards, but health is
seldom discussed in an EIA (Ahmad, 2004). An EIA sometimes includes health through an
Environmental Health Impact Assessment (EHIA). An HIA is an extension focusing on physical
environmental health and broader social determinants (den Broeder et al., 2003) that usually
show in an SIA. NEPA remains the root of HIA.
China has routinely used EIAs since 1979. The combination and environmental issues and
health has been essential in China for a decade (Holdaway, 2010). However, according to the
Chinese Health Education Center (CHEC), HIA is relatively new to China (CHEC, 2020). In the

28
Introduction, I outlined the most critical national policies for HIA in China. These highest-level
policies lifted the position of HIA on the political agenda. Both theoretical discussion and the
actual practice of HIA in China gradually increased after 2016 (CHEC, 2019). However, such
progress was hardly recorded in the English academic literature. Such a gap became a significant
barrier to attracting more attention from international scholars to the use of HIAs in China.
China's practices are likely to have valuable insights for implementation outside China.
Before 2016, Chinese HIAs were typically folded into EHIAs (Ahmad, 2004). Currently,
some reviews of Chinese HIAs exist. Huang (2012) was an early attempt to summarize the
emergence and progress of Chinese HIAs, including the pioneering Yizheng Chemical Fiber
Limited and the Three Gorges Dam project. Particularly, Huang (2012) pointed out that these
cases focused on background surveys of health status with assessors rather than the professional
HIA methods and criteria, so the cases in this review cannot be regarded as real HIAs. Wu et al.
(2011) systematically compared Chinese EIAs, Pre-assessment of Occupational Hazard in
Construction Project, and the international HIA concept and found HIAs have more determinants
considered, including individual, physical environmental, social, cultural perspectives and
accessibility to health services. However, both reviews lack the elaboration on Chinese
professional HIA cases. A few recently published Chinese HIA books (CHEC, 2019; 2020; 2022)
provide a few cases, but the type of cases is limited. Therefore, there is a gap in the literature to
give an overview of the up-to-date progress of Chinese HIAs for both domestic and international
scholars. This study discloses the contents, focus, policy or project locations, and state of the
science of the current Chinese HIAs.

29
Method and Data
The literature on Chinese HIAs includes two strands—the first is about Chinese HIA cases,
and the second is about either theoretical or methodological discussion of HIA. However, many
Chinese environmental and public health studies have similar names as "HIA" that don't fit the
theme of this study. Hence, I searched and created judging criteria for real HIA cases.
I searched "Chinese Health Impact Assessment," "China + Health Impact Assessment,";
"Health Impact Assessment in China," "China + EIA + health," "China + EIA + public health,"
and "China EHIA" in Google Scholar and Web of Science. A thousand papers emerged in the
search. I skimmed the titles of the papers to exclude those titles containing any name of a disease
or nutrition. I also excluded redundant titles. About 123 articles remained for further review.
I examined the abstracts, tables, and imaged of the 123 papers. I set up eight criteria for
exclusion (US CDC, 2016b). First, Health Risk Assessments (HRAs, 27 papers). An HRA is a
"quantitative, analytic process to estimate the nature and risk of adverse human health effects
associated with exposure to specific chemical contaminants or other hazards in the environment,
now or in the future" (US CDC, 2016b). This type is confusing because an HIA can include an
HRA (Ibid) to quantify the health risks as health impacts. Many Chinese scholars are prone to
interchange these two terms. Based on health risks, further analysis can also include a Health
Economic Assessment, which monetizes the health impact (usually by the value of a statistical
life [VSL] or the willingness-to-pay method) to a concrete economic cost or benefit to compare.
Some HIAs can include both (see San Francisco Department of Public Health Program on

30
Health, Equity, and Sustainability, 2011).
Scholars tried to scope these two terms. Liang (2020) argued the HRA discusses the risks of
explosion and chemical leakage within a plant, a specific site, or a place, while HIA explores risk
for the population adjacent to the site, both within and outside the place. US CDC (2016b)
emphasizes that an HRA is "not comprehensive and tends to focus on biophysical risks from
exposure to hazardous substances." However, defining "comprehensive" is also challenging
because the scoping section of an HIA discretionarily describes what health risks and benefits
need to be included. In some cases, the biophysical risks from exposure (whether mortality,
Disability-adjusted life years [DALY] or years of life lost [YLL]) are the primary and only health
indicators to consider, making an HRA identical to or becoming a significant part of an HIA.
This study utilizes a simple standard to mark a clear boundary between an HRA and an
HIA—whether it includes the decisions of the proposed policy, program, or project from a non-
health department (US CDC, 2016b). An HIA targets the health impact of one or more policies,
programs, or projects that can be named; if it focuses more on the environment than health, it is
an EHIA; otherwise, it is an HRA. The non-health department's decisions can be potential or
imagined scenarios, as most HIAs were done to support decision-making. Such a standard fits
the ECHP (1999) 's and CDC's (2016a) definitions. As this study focuses on HIAs, pure HRAs
were excluded.
Second, pure environmental studies about emissions, resource consumption, and waste
treatment with few health issues involved (9 papers) do not meet the definition of an HIA. Third,
real EIAs with few health measures (10 articles). Fourth, pure public health studies without

31
discussing a policy, a program, or a project (7 papers), i.e., an occupational health study.
Fifth, studies are not about a policy, program, project, or related decisions. The articles in
this type (8 papers) may or may not be about health, and sometimes they can overlap with other
excluded types such as pure environmental or public health studies. The difference between the
fourth and fifth types is that the former significantly emphasizes public health issues, while the
latter is unclear about a non-health department's decision.
Sixth, studies that are not impact assessments. Seventh, articles do not discuss health, such
as a pure infrastructure study (8 papers), not including those environmental studies mentioned in
the second type. Eighth, articles are not about China (2 papers) or unavailable (1 article).
After the above exclusions, 32 cases and ten reviews remained. Then I thoroughly read the
cases and found three still HRAs because they only measured health risks (either by risk levels or
indices) or didn't provide any health response. One is an accident investigation, and two papers
were indeed literature reviews. I found another case from the clues of those cases. Therefore,
there were 26 cases written in English included in this review.
I found 12 reviews in total in this process. This study primarily incorporates the findings
from those reviews into the introduction or the discussion, with the rest focusing on cases. This
study also includes the outcomes in Chinese literature for a complete examination. Most cases
were from three Chinese HIA guidebooks by CHEC (2019, 2020, 2022). Two cases in those
books were Asian Development Bank (ADB) 's (2019; 2013) projects whose initial documents
were in English with a brief Chinese introduction. Plus, I searched " 健康影响评估" and "健康影
响评价" on the CNKI database and found about 50 studies. After a quick examination, most

32
studies only introduced the concepts of HIA or were international cases. Three studies, including
a Chinese journal article, a conference paper, and a master's thesis, provided genuine Chinese
HIA cases for the following review. Following the advice from the US CDC (2016b) focusing on
the health consequences of non-health sectors, this study excluded impact assessments for a
health sector's decision. In total, 43 cases are reviewed in this study.
Results
The classification of the cases is shown in Table 3.
Table 3.
Sorting the cases reviewed in this study
Language Number Source Number
Chinese 14 CHEC books 11
English 27 Academic journals 26
Chinese & English 2 ADB projects 3

Conference Paper 1
OECD
1
Paper 1

Master thesis 1
Total:

43

Detailed information on cases is in Appendix Table 1. I depict the locations of those cases in
ArcGIS 10.8.

Figure 1
Locations of Chinese HIA cases

1
The explanation of this abbreviation is in Abbreviations.

33

The studies have diverse scales. A project is usually locally based, but sometimes it has a
regional impact on some environmental infrastructure. A program or policy can be countywide,
municipal, provincial, or national. Some international studies (i.e., Giani et al., 2020) compared a
policy's impact in China and Europe, while O'Connor et al. (2003) compared Guangdong
Province with the whole country.
Ten studies set the scope nationwide (Li et al., 2018; Yang et al., 2013; Zhao et al., 2018;
Xue et al., 2019; Yue et al., 2020; Maji et al., 2018; Chen et al., 2021; Yang et al., 2020;
Miyazaki et al., 2020; Giani et al., 2020). As Figure 1 shows, five studies used policies or
projects from a province (Guangdong, Shanxi, Jiangsu, or Sichuan) (O'Connor et al., 2003; Ren
et al., 2021; Li et al., 2017; Liang & Cao, 2015; Aunan et al., 2004), and other cases are from a
city (Beijing, Shanghai, Guangzhou, Hangzhou, Tianjin, Linfen, Taiyuan, Zaozhuang, Datong,
Zhengzhou, Shijiazhuang, Lincang), a county-level city (Yanji, Qionghai), or a county (Yudu,

34
Deqing), but sometimes the location may be rural areas within the political boundary of that city
or county. Beijing, Shanghai, Guangzhou, Hangzhou, and Yichang are more frequently studied.
Such a result is not a surprise, as these places are all healthy cities acclaimed by the Office of the
National Patriotic Sanitary Council (2016). Healthy cities are more likely to use HIA for
decision-making. Inner Mongolia and Northwestern China have no cases, while Northeastern
China has only one case (Yanji BRT in Jilin Province). Such a result shows that the development
of HIA is significantly uneven in China and that high-income provinces are more likely to use
this tool.
If we consider the GDP as an indicator to measure whether it influences the adoption of
HIAs, we can see Shanghai is the #1 in China, while Beijing, Guangzhou, Hangzhou, Tianjin,
Shijiazhuang, Yichang and Taiyuan rank #2, #4, #9, #12, #39, #54, #57, respectively. If we
compare these regions to the early American practices (Dannenberg et al., 2008), the pioneer of
HIA is San Francisco County-Alameda County region, which is the #4 biggest urban GDP
region. Other early adopters--Los Angeles, Boston, Atlanta, and Minneapolis, rank #2, #8, #11,
and #15 respectively. Some other smaller jurisdictions such as Trenton, Decatur, Taylor County,
and Commerce City. Therefore, the Chinese pattern and the American pattern of early HIA
adoptions are quite comparable that two to three biggest cities, coupled with two to three middle
cities and some small cities all joined the line to pilot HIAs. Therefore, GDP cannot fully explain
whether a city is likely to use HIAs early, since the evidence suggests that cities of different GDP
levels all can do as they wish.

35
The Lead Agency of an HIA
The lead agency for each HIA is the government/the project owner or institutions appointed
by the government/the project owner (designated “official” in Appendix Table 1) or other third
parties interested in studying without the appointment or authorization (unofficial). An unofficial
study can receive governmental assistance, but the assessment is not based on the government's
request to evaluate a drafted policy. Sometimes, whether the HIA is official or unofficial is not
indicated in texts, so it's labeled by likelihood.
Fifteen cases are official ones authorized by the government. Nine cases are perhaps official
as they are not clearly unofficial. In comparison, two cases are more likely to be official because
they received particular support from the government, such as the approval to use restricted
access data.
Sixteen cases belong to the unofficial category. Zhang and Deng (2021) analyze a Shanghai
residential community, but the authors are from two Changsha governmental planning
institutions, Hunan Province, without any disclosed affiliation to the community, so it is implied
that such a work is likely to be unofficial and from personal interest. Most of the unofficial
studies investigate potential policy scenarios. While sometimes they received Chinese
governmental assistance for either data or funding, attracted many international institutions,
scholars, and sponsors to participate, and were published in high impact factor journals (i.e.,
Nature Communications, Nature Climate Change, The Lancet Planetary Health, and PNAS),
their primary goal is academic research. Their potential policies are unlikely to come true as they

36
are defined by simple assumptions and idealistic scenarios (Nieuwenhuijsen et al., 2017).
In contrast, the official ones directly influence the improvement of the policy/project and are
routinely adopted for decision-making. Therefore, the following part only discusses the lead
agencies of official studies. In most cases, the agency is a health administration, such as the
Patriotic Sanitary Council, the Sanitary and Health Committee, or the Health Promotion
Committee, but sometimes it can be the Healthy City Lead Group, which includes the top
officials of that city. Urban planners are significant to HIA, but planning departments rarely
serve as the lead agency.
Procedure
Figure 2
The standard process of HIA (WHO, 2022; adapted from ECHP , 1999)

WHO (2022) identified a standard five-step procedure for HIA, including screening,
scoping, appraisal, reporting, and monitoring. CHEC (2020) elaborated a preliminary Chinese
version with nine steps (see Figure 3). In 2022, CHEC (2022) revised it and canceled the initial
screening by the authority. The core steps of this procedure are screening, scoping, appraisal,
reporting, and recommendation. The cases from CHEC followed this template, but the cases
from other sources rarely contained a screening process, and the scoping process had a minimal
selection of social determinants of health. Air pollution and greenhouse gas emissions are the
first choices in the scoping. At the same time, physical activities, traffic safety, construction
workers' health, and mental health occasionally become a part of the analysis. Hence, except for

37
a few studies (i.e., Lindhjem et al., 2007, as it uses existing EIAs), most cases from journal
articles had incomplete procedures of an HIA by merely emphasizing appraisal, reporting, and
recommendations.
Figure 3.
The whole procedures of Chinese HIAs (CHEC, 2020)

Registration
Registration aims to manage the number of HIAs under the administration's monitoring and
the types of professional fields where HIAs are implemented. (CHEC, 2022). The lead agency of
an HIA depends on what type of policy or project it is. If the lead agency is the government,
proposed policies are submitted to the local Office of the Healthy City Promotion Committee or
the Office of the Patriotic Sanitary Movement Committee. The Office will organize an HIA
(Ibid). If the lead agencies are governmental branches (sectoral policies), the sectors manage an
HIA, but they must keep a record in the Office (Ibid). Unlike an EIA, an HIA is not necessary for
a private project, so a private business' existing HIAs usually come from academic institutions

38
(i.e., Li et al., 2010) or governmental requirements (i.e., Jimei Cosmetics Chemical Co., which
will be discussed in Chapter 2, (CHEC, 2022)). So far, few for-profit private businesses
voluntarily conduct HIAs. Academic HIAs are not registered.
Making up the expert panel and the role of the academia
Academia is the intellectual supporter of HIAs. Scholars or experts are from diverse
backgrounds, including universities, think tanks, advisory institutes, nonprofit organizations can
be selected as professionals to provide the intellectual services to the government to finish an HIA.
In China, academia was the first sector to heed the international development of HIA and advocate
it on scientific journals. The action of the academia is much earlier than governmental sectors to
collect the international practice and policies. The academia provides professional opinions to the
evaluation of a policy and project and suggest revisions for the implementation to the government.
However, the action of the academia is also influenced by the government. Before President Xi
introduced the HIA on the National Sanitation and Health Conference, the published papers on
Chinese HIAs were very limited. However, this number grew rapidly after the president’s
announcement, indicating that the politics heavily influences the research interests of the academia.
Making up an expert panel is the second step of an HIA (CHEC, 2022). The cases in CHEC
books (2019; 2020; 2022) and ADB projects usually provide the sectors of experts, while for
other cases, the expertise comes from the authors' departments (see Appendix Table 1).
HIAs are collaborative work, so the experts vary from case to case. Nineteen cases manifest
the engagement of urban planning professionals and allied professions, including urban

39
construction, architecture, geographical sciences, urban management, healthy city, public
administration, urban environment, and governance. Eighteen cases have a strong existence by
public health or environmental health scholars. Over half of the cases have environmental
scholars' contributions. Six studies integrate the work of climate or energy scholars. Ten studies
invited economic scholars (economics, industrial development, finance, labor, etc.) to the expert
panel. Other players also significantly contribute to HIAs depending on their context, including
international studies, air, data system, social justice, and ecology.
To sum up, environmental sciences, economy, and public health are the most critical sectors
in the HIA field. The role of urban planning and related fields is also significant. Such a result is
in line with the role of environmental health in public health and the relationship between HIAs
and EIAs.
Screening
Screening is a decision-making process to determine the necessity of an HIA by experts and
stakeholders based on the evidence of the bridge between a policy, a program, or a project and
health (ECHP, 1999; CHEC, 2022). Most cases in academic journals lack a formal screening
process but have extensive literature reviews to confirm the necessity of the HIA. In contrast, the
screening process is much more formal for the ADB projects and CHEC (2019, 2020; 2022).
CHEC (2020) invented two forms of screening. The first form is for internal use of the expert
panel, including nine questions— whether the policy has a negative health impact, whether it has
a positive health impact, whether the scope of the influenced population will be enormous,

40
whether the negative consequences will lead to deaths, disabilities, or hospital admissions,
whether the negative impacts will have more severe outcomes on vulnerable groups, whether the
influence will significantly change economic and social development, whether it has a significant
effect on public welfare, whether it will be a public focus, and whether it needs to be further
evaluated (Ibid). The second form formally reports the decision of screening to the authority.
Scoping
Scoping determines what type of HIA to conduct, what potential health impacts to consider
(introduced in the following subsection), what population to analyze, and what approaches and
stakeholders to involve (ECHP, 1999). Both official and unofficial studies have this section,
though official assessments do it more formally. The official studies have a long list of issues and
policies marked by social determinants of health and relevant governmental sectors (CHEC,
2020; 2022). The experts conduct a group discussion for scoping. The unofficial studies usually
choose the population in default (the whole population group of a city) or by age, region, time,
and data availability. Some studies only provide the results of scoping without reason.
Health impacts and health economic impacts
A case must have health impacts or/and health economic impacts to be included in this
review. Health impacts and health economic impacts are related to the topics of the HIAs. The
major issues of these cases include climate change and energy (9 cases + 1 case from an
integrated study), air pollution (10 cases, including 2 COVID-19 lockdowns), water pollution

41
(from integrated research), community and regional planning (5 cases), building engineering (3
cases), economic programs (3 cases), social programs (2 cases), urban utilities (2 cases + 1 case
from an integrated study), a landscape project, transportation (3 cases), a comprehensive socio-
economic policy, a built environment study, an open space case, and an evaluation of an industry.
The environmental health determinants include air pollution, water pollution, climate change,
noise, stress, waste treatment, physical activity, accessibility of services, reduced barriers for
disabled people, traffic safety, etc.
Among the 43 cases, 39 have health impacts, while the remaining four instances only have
health economic impacts. A third of the cases with health impacts also provide health economic
impacts. The most used health indicators include deaths, premature deaths, mortality, DALY ,
CVD, and respiratory hospital admissions. Health economic impacts monetize the value of health
impacts (Mankiw, 2012), usually depending on the method to analyze, including willingness to
pay (WTP), cost of illness (COI), no-regret costs, and the Value of a Statistical Life (VOSL).
Although many scholars use these methods, many cases cannot find a proper baseline value, so
they reference other cities or countries (such as the Global Burden of Disease [GBD] study) and
adjust the value to local economic conditions. Besides, the value varies greatly by place, disease,
time, and contents. The models to analyze these impacts will be discussed in the appraisal
section.
Stakeholders
Stakeholders' input rarely exists in unofficial cases, while some perhaps official studies

42
surveyed residents (i.e., Liang & Cao, 2015). A few official cases interviewed representatives of
the targeting population (i.e., Hangzhou Youth Development, CHEC, 2020), not elaborating on
the selection process of representatives. The Qionghai Water Treatment project held a public
hearing (Ibid). The Gong River South Band Landscape project invited local stakeholders to the
HIA expert group (CHEC, 2019). The biomass energy project of the United Nations
Development Program (UNDP, Fischer et al., 2005) had extensive interactions between the
experts and local users. Stakeholders generally have little voice in the HIA process and much less
power than experts and the government.
Appraisal
The summary of the appraisal of Chinese HIAs is composed of Data, Assumptions,
Methods, and Variables/Indicators.
Data
These cases show a variety of data sources. Local surveys, expert opinions, and data from
other scholars are common data sources.
The demographic variables are from the National Bureau of Statistics, the local bureau of
statistics, the National Population Census, the University of Michigan China Data Center, the
China Urban Construction Statistical Yearbook, the History Database of the Global Environment,
GBD, United Nations estimates, and LandScan datasets. Some georeferenced socio-economic
data was from China in Time and Space, a University of Washington data project, although this

43
dataset has not been updated since 1997.
The air pollution data comes from the local environmental protection agency, local
monitoring stations or centers, the Chinese Environmental Monitoring Center, satellite remote
sensing, and a few from their sample collections. Some secondary datasets are from consulting
companies based on satellite data. China Environmental Yearbook, the World Bank's projects,
Environmental Statistical Bulletin International Pollution Discharge Manual, and the Industrial
Pollutant Generation and Emission Coefficient Manual are also mentioned in the cases. The US
Air Pollution 42 database can provide some sectors' coefficients.
Meteorological data is from the Chinese National Weather Sharing System, local weather
stations, or the European Centre for Medium-Range Weather Forecasts. Climate data is often
from the National Climatic Data Center.
Lindhjem et al. (2007) built their work on the project's Environmental Impact Statements
(EISs). The Qionghai Water Treatment project also uses EIAs and feasibility studies.
Health data is usually from local authorities, such as the National Bureau of Statistics, the
local big data platform, the China Health and Nutrition Household Survey, and sometimes the
World Bank. However, the exposure-response rate is frequently referenced from other studies,
such as the GBD database. Official assessments have easy access to crucial government data and
other institutions (such as hospitals), including the causes of deaths, hospital admissions,
psychological counseling, health insurance, social security, justice, local police calls, and visits
to the local accountability office, while interviews sometimes complement data. Economic data
comes from the Global Trade Analysis Project data, Statistic Bulletin of the National Economy,

44
the World Bank's Global Consumption Database, and surveys, such as Chinese Household
Income Project (CHIP) data.
For the building engineering projects, building materials, solid waste, project data,
equipment data, and ancillary data are from interviews, documents, contractor records, bills of
quantities, inquiries from the project staff, inventory databases, and observations in the case
study.
Planning programs provide documents and relevant materials, such as Geographic
Information System (GIS) maps of community boundaries, land use, urban utilities, and
transportation. Transportation projects contain local surveys and profiles.
Assumptions
Rational assumptions are the prerequisites of reliable methods. This study found
demographic change, geographic scopes, simplification of health effects, air pollution conditions,
thresholds in a model, and policy settings can categorize the assumptions. The assumptions of
demographic change include no change within a year, the same variations across scenarios, and
each city growing on its own. The geographic assumptions do not differentiate between urban
and rural areas. Different layers of risks can be added directly by locations, and affected areas of
the project are within a certain distance of the site. The assumptions of health effects are the most
comprehensive, including the valid contribution of air pollution control on people's health and
well-being, acceptable reference of coefficients from other studies, and no changes in
environmental and health investments when income increases, the omitted health variables are

45
constant, the effects are only from targeting pollutants, no cumulative of interactive effects exist,
the chosen variables can effectively represent the health burden, and Health Economic
Assessment Tool applies to China.
In one study, the authors directly state the contribution of a sewage plant to people's health
(Lindhjem et al., 2007). The assumptions of air pollution conditions include normal distribution
of the coefficients, a continuous status if a city meets the air quality standards, no difference
between indoor and outdoor pollution, and focusing on air pollutants and neglecting the water
and soil pollutants. The thresholds in a model may be a zero-threshold assumption or a specific
point based on literature or study findings. The policy assumptions include the continuity of a
policy, a "step change" instead of phasing in, etc.
Analytical Methods
Among these 43 HIAs, nine are qualitative, three use primarily qualitative methods but
contain lots of baseline data to depict the risk, and the other cases rely on quantitative
approaches. All the qualitative HIAs are official. The biomass project of UNDP (Fischer et al.,
2005) uses applied ethnography as the primary approach. Other qualitative cases depend on
literature review and expert agreements, while sometimes, they include interviews and focus
groups. Most of these qualitative cases are rapid HIAs. This phenomenon is not surprising, as
HIA is a novel tool for Chinese governmental staff, so expertise is not fully developed.
All three ADB projects are primarily qualitative HIAs. Yichang BRT is the only case with
two rounds of HIAs. The first round was in the EIS prepared by ADB in June 2013, and the

46
second was an evaluation in 2019 by the local authority to analyze the outcomes and problems of
that project after four years of operation. The EIS of Yichang BRT has 152 pages, but it only
contains 16 paragraphs related to health, and most of them are qualitative, except for the current
profile of traffic safety. The second HIA includes data from the operational reports and the local
big data platform, but it was still primarily qualitative. The other two ADB projects, Yunnan
Lincang Border Economic Cooperation Zone and Yanji BRT, are also dominantly qualitative
predictions of the impacts with quantitative current profiles.
Quantitative HIAs are much more sophisticated than their qualitative counterparts. These
quantitative studies have four subdivisions—GIS, survey, regression, and model-based methods.
Urban planners often use the GIS approach, such as buffer and raster data, to analyze the
accessibility of facilities, wind speed, service areas, and aggregated health risks. The survey-
based HIAs highlight the Delphi Method (i.e., Deqing County Barrier-free Facilities HIA) and
questionnaires from stakeholders. The survey is a critical method for quantitative HIAs.
Sometimes, the results of the surveys can be integrated into further GIS analysis. The regression-
based HIAs also build on survey results. Liang & Cao (2015) used self-rated health survey data
with the structural equation modeling method to analyze eight subdivisions with two primary
aggregated variables. Yang et al. (2020) used an ordered probit model, instrumental variable
(IV)-2SLS; an IV-ordered probit model, a Tobit model, an IV-Tobit model, and bootstrap
estimation to measure how credit constraints affect rural Chinese people's health.
The majority of quantitative studies use comprehensive computing models to predict the
results of a potential policy scenario in the future. The exposure-response function is the most

47
commonly used method to measure health impacts, using the ExternE program, GBD, or
coefficients from other studies, but the function needs the concentration of pollutants. Pollutants
are predominantly airborne, while only a few studies addressed water pollution. Air pollution
concentration usually comes from direct meteorologic observations, but satellite remote sensing
and spatial-temporal simulations are also common. One study combined these three sources (Xue
et al., 2019) with linear mixed-effect models with spatially varying coefficients, a maximum
likelihood model, and spatial interpolation.
A Chemical Transport Model is also frequently used for spatial-temporal simulations of the
concentration of pollutants, such as a long-range transport and deposition model (Chen et al.,
2007). For the random parts, the Monte Carlo method is applied. For CO2 emissions, this study
identifies the Greenhouse Gas and Air Pollution Interactions and Synergies model (Ren et al.,
2021) and other alternatives in the cases. For an overall economic impact or a comprehensive
evaluation, there is the construction environmental performance assessment system (Cao et al.,
2015), the building health impact assessment system models (Li et al., 2017), the Health
Economic Assessment Tool (CHEC, 2020), etc.
Variables/Indicators
Variables or indicators used in the cases are related to the methods. For qualitative
methodologies, this review summarizes the elements of social determinants of health as
variables; for quantitative studies, this study focuses on the critical indicators with numeric
values connecting methods and data. The health impacts or health economic impacts variables

48
are in the scoping section, so this study does not repeat them here.
The variety of qualitative variables in the cases depends on the scale of the policy, the
project or the planning. Hangzhou Thirteenth Five-Year Planning is a comprehensive economic
and social development policy with the most variables, including healthy places and facilities,
employment, living environment, housing, etc. The elements of these variables vary from basic
infrastructure to the 19th Asian Games Hangzhou 2022. The experts raised 48 recommendations
to revise the original texts. Other policies and projects are far less complicated than this HIA.
Hangzhou Youth Development program HIA focuses on the safety of physical exercise facilities,
women's rights, and the inclusion of immigrants, ethnic minorities, disabled, and ex-convicted
youths. The ecological citizens' program HIA emphasized safety at significant events and
recycling old clothing. The existing projects usually emphasize the control of noise, dust, and
odors during construction, preventing the leakage of water pollutants, a decrease of air pollution,
the safety signs and preventative measures, construction workers' occupational health, providing
more physical exercise facilities, adding landscape sites, etc.
A few macroeconomic and demographic variables are indispensable, including GDP,
population density/scale, income, and age. Other demographic variables, such as gender,
educational level, ethnicity, health insurance, family scale, family genre, consumption, debt, and
economic vulnerability only appeared in a few studies. The critical variables of air pollution
studies include the concentration of PM10/PM2.5/SO2/NOx, crop field drop, etc. The most
significant variable of climate and energy studies is the amount of CO2 emission (US EPA,
2022), but efficiency improvement and provincial/sectoral differences are also considered. The

49
policy variable is often about how much the current concentration level decreases or how many
people (in x%, Nieuwenhuijsen et al., 2017) adopt cleaner and greener technology. Policies
always consider the time effect, so the core differences between policy alternatives are when and
how much/many.
Results of selected urban planning cases
This review cannot fully summarize the results of all the HIAs. I selectively summarize the
results of two urban planning cases, Huangpu District Regional Planning and Shanghai Subway
Line 15 (CHEC, 2019; 2020). Both cases are done using GIS-based approaches by Tongji
University Healthy City Lab, the earliest urban planning institution working on HIA in China.
Huangpu District Regional Planning combined the distribution of pollutant-source buffers, wind
modeling, and density of respiratory diseases to map the health risks in Huangpu District.
Besides, the HIA also analyzes the accessibility and conformity of public infrastructure and
green spaces. This study finds a patchy distribution of risk areas, with barriers to green space
access, a lack of safe streets for active transportation, and the need to improve and enrich the
design of community physical activity and amusement facilities.
Shanghai Subway Line 15 only analyzes the part in Minhang District (CHEC, 2019). It finds
that Shanghai Subway Line 15 will improve mobility for 140,000 of people, but it does not
improve the accessibility to local health services and green spaces. The promoted physical
activity by the subway will potentially save five deaths annually and 2.15 billion RMB (about
0.32 billion USD) in health expenditure in ten years. The subway will also encourage nine

50
thousand car drivers to shift to public transport with a conservative estimate of 12,446 tons of
CO2 reduction. However, the construction period will bring dust and noise.
Reporting and Monitoring
Reporting is a crucial administrative step for official cases, as the report summarizes the
findings and conclusions of the whole HIA. For official reports, a typical format is a form with
the policy/project's name, the agency that proposed the policy/project, the lead agency of the
HIA, a summary of the findings, problems, parts waiting for revisions, and recommendations.
The Qionghai Water Treatment Project filed a detailed HIA report after submitting the
concluding form. For unofficial studies, the reporting process is to write and publish the paper.
Although unofficial reports can reach a bigger audience via academic journals, they address
imagined scenarios where monitoring is unnecessary.
Monitoring is critical to ensure the recommendations from official concluding forms and
reports are on the right track for ongoing implementation. However, there is a concern that some
reports can identify the health risks, but later they can be put aside without any genuine
precautions for public health. Wu et al. (2018) reported the investigations of a toxic land use
event in Changzhou, Jiangsu Province, that some crucial conclusions about the hazards of land
pollution in the EIS were ignored. Later, those hazards became real and poisoned students.
Monitoring needs more emphasis to avoid such a tragedy from happening again. The Hangzhou
Thirteenth Five-Year Planning HIA indicates monitoring via the Hangzhou big data platform,
which is highly operatable and timely. However, more cases regard monitoring as something

51
they purport to do, but whether it's enforced is hard to determine. Monitoring is often a loophole
in western countries as well (US EPA, 2013).
Implications for urban planning
Urban planners are indispensable participants in Chinese HIAs. Community/regional
planning, transportation, landscape, built environment, and outdoor space are highlighted in the
cases. Urban utilities, a crucial player with significant planning implications on the local and
regional economy and regulations (Marvin & Graham, 1993), often become the target of HIA.
However, unlike the practice in the United States (Corburn, 2009), no Chinese HIA case talks
about affordable housing, indicating a big research gap.
The growth of HIA manifests how urban planners must address HiAP in the future. Such a
change poses new requirements for planners' expertise. First, they must consider the ethical use
of evidence. There are some challenges for planners that the selection of robust evidence (Harris-
Roxas et al., 2012), data availability (Mindell et al., 2008), and localized contextual input
(Walker, 2010) are all not simple to solve. Second, they need to consider whether the predictions
can lead to accurate revisions of the policy (Parry & Stevens, 2001). Third, how do planners
collaborate with other sectors. Due to the fragmentation of expertise, urban planners must delve
into health data more. Currently, existing studies indicate planners can work well with self-rated
health status, physical activities, loneliness, and traffic safety by utilizing GIS to visualize the
health risks and operating the Health Economic Assessment Tool to analyze the costs and
benefits (Liang & Cao, 2015; Forsyth et al., 2010; CHEC, 2020; Yichang Municipal

52
Government, 2013). But more work on the health impacts of climate change and air pollution
needs collaboration with public health and other sectors. Many fields in the partnership have a
keen planning interest, such as the health impacts of heat islands, urban resilience, parks,
renewable energy, recyclable materials, green building codes, and health equity. The
collaboration must clarify each participant's responsibility (Dora & Racioppi, 2003). These
challenges can be partially settled by the increased capacity building of planners, but this
increase may raise a new complaint that HIA is a burden (Cole & Fielding, 2007).
HIA is primarily designed for proving effectiveness in future planning (Joffe & Mindell,
2002). Meanwhile, the number of retrospective studies, such as the Yichang BRT, APEC, and
Parade Blues air quality improvement, is increasing. Such a phenomenon indicates that planning
could integrate evidence-based approaches with projections, providing a holistic perspective for
decision-making (Douglas et al., 2001).
HIAs can add informatic values to the decision-makers, explicate trade-offs, promote
multisectoral collaboration, and build a bridge of public communication between officials,
experts, stakeholders, and citizens (Dora & Racioppi, 2003; Mindell et al., 2008;
Nieuwenhuijsen et al., 2017). Planners must remain objective even as they work in a very
political arena. (Cole & Fielding, 2007; Krieger et al., 2003). The independence and impartiality
of HIA may be compromised or undermined to ensure more considerable support (Davenport et
al., 2006). Such a concern is genuine in China, as in the Youth Development case, the expert
recommendations on revising some political words were not adopted (CHEC, 2022). Planners
must often deal with trade-offs between political demands from municipal leaders and public

53
well-being for whatever reasons.
The Gothenburg Consensus Paper (ECHP, 1999) stated four core values of HIA, democracy,
equity, sustainable development, and ethical use of evidence. All four values are respected in
Chinese practice, yet equity and sustainable development are more emphasized than the others.
Chinese official HIAs have illustrated multiple ways to hear from the public, but unofficial HIAs
hardly involve any public engagement. The initial screening by the local authority ensures the
HIA conducted according to the government's plan and reduces the possibility of a community-
defined narrative.
China does have some innovations in the HIA field. CHEC (2020) invented the initial
screening and a nine-step procedure, which extends the model of WHO with localized
applications. Hangzhou is a pioneer in developing software for facility HIA works. With the
assistance of local big data platforms, planners can use more qualified data in HIAs for better
decisions. Considering China is a vast country to apply HIA routinely, such a measure may start
a new era for Information and Communications Technology (ICT) based HIAs from China to the
world.
The number of full HIAs is still limited because China's policy tool is still immature.
However, as Chinese legislation requires local jurisdictions to apply HIA routinely, the number
will dramatically increase in the coming years. Such a trend indicates a massive demand for
urban planners and multidisciplinary professionals. Although the HIA is still mainly a
governmental product, it may touch private businesses. If this scenario comes true, the growing
demand for HIA experts from the public and private sectors will promote a new consulting field

54
in China. Simultaneously, other technical capacities, including qualified health data, market-
based criteria, regulatory policies of this business, and an association of HIA workers, are
necessary to guarantee the healthy development of this emerging enterprise.
Conclusion
This study summarizes 43 existing Chinese HIAs published in English and Chinese. These
cases include official cases that directly influence the decision-making of a policy, a program, or
a project, as well as unofficial ones for research. Urban planning is a crucial component in these
Chinese HIAs. Urban planners' engagement in the HIAs is critical but still limited as they are not
the lead of the process. In the future, planners must be fully aware of Health in All Policies and
collaborate with other sectors to achieve a comprehensive evaluation. Stakeholders have many
channels to involve in the official HIAs to influence decision-making, but whether to adopt their
voices is within experts' and officials’ discretion. Urban planners should pay closer attention to
stakeholders’ voices to ensure community needs are appropriately valued.
The popular procedure of Chinese HIAs includes nine steps, but the core steps are screening,
scoping, appraisal, reporting, and monitoring. The methods of HIAs include qualitative
(ethnography, literature review, expert agreements, interviews, focus groups, etc.) and
quantitative approaches (GIS, survey, regression, and model-based methods). The supporting
data has a variety of sources, including local authorities, local data collectors and platforms,
satellite measurements, secondary datasets, projects from international institutions, and first-hand
data. Some Chinese cities steadily promote ICT-based HIAs, a revolutionary change in this field.

55
Rapid and desk HIAs are still the majority of existing cases, indicating Chinese HIAs are
still immature. The present cases show that China still needs to develop the HIA, including a
comprehensive toolkit, measurements, and enterprise facing private projects. China will witness
a rapid growth of HIA workers in the following years, so more regulations and a professional
association are necessary.
Future studies can work on new Chinese HIA tools and software to promote the
development of this field. Besides, monitoring is a crucial step to ensure the results of HIAs are
on the right track to guide the implementation of policies and projects, but right now, it lacks
enough attention, a gap that needs filling. Current Chinese HIA cases have many blank areas,
such as housing. New studies can evaluate the health impacts of affordable housing, transit-
oriented development, and new housing policies. Moreover, the lead agency is rarely the
planning department. More research is needed to improve planning's position instead of relying
on public health professionals.

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Chapter 2: The strengths and weaknesses of Chinese Health Impact
Assessments (HIAs) —evidence from pilot HIA policies
Junteng Zhao, Qinbo Liu, Yuquan Zhou
Abstract
China started emphasizing Health Impact Assessments in 2016, but few studies explored the
pros and cons of existing practice. This study intends to fill this gap by reviewing twelve Chinese
jurisdictions' pilot HIA policies to identify their strengths, weaknesses, and takeaways for
international audiences. This study finds that Chinese HIA policies are homogenous and that many
regimes borrowed heavily from Hangzhou. The strengths include taking advantage of the pilot
HIAs, a robust governmental working network, the various channels of public engagement, the
establishment of a motivation system, and information and communications technology. The
weaknesses include a lack of regulations on private projects, an emphasis on quickness over
thoroughness, and weak measures to ensure sustainability is adequately addressed in HIA. In the
future, Chinese HIAs should regulate private projects, develop measuring and assessing tools, and
protect sustainability. At the same time, HIA practitioners should build a professional association,
create textbooks or courses, and study policies at national and provincial levels.

Keywords: China; Health Impact Assessment; pilot; public policy; Hangzhou

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Introduction
Some scholars regard the HIA as a subset of Environmental Impact Assessment (EIA) (Birley,
1995; Chang et al., 2017; Wu et al., 2011), while others argue that there are increasing
methodological and disciplinary conflicts between HIA and EIA (Kim & Haigh, 2021). The debate
on the strengths and weaknesses of HIA is not new (Parry & Stevens, 2001). Although there is rich
literature on such a discussion in developed countries (Simos, 2017), China rarely has comparable
studies, mainly because China is a newcomer to HIA practice, and its practice is still in its infancy.
Most Chinese HIA studies are written in Chinese, a significant barrier for the international
audience in learning what is happening in China. This study intends to open a window for
international scholars to better know the current practice of Chinese HIA. This study of twelve
Chinese jurisdictions answers the following questions-- What are the strengths and weaknesses of
Chinese HIA? What are the takeaways from Chinese practice? Notably, this study utilizes the
findings from the qualitative analysis of pilot HIA policies to take advantage of the most up-to-
date practice.
Strengths of HIA
Before delving into the Chinese context, we need to summarize the current knowledge of the
strengths and weaknesses of HIA in global practice. The core role of HIA is to explicate the
potential positive and negative health impacts of a policy, a program, or a project, adding value to
informed decision-making (Kemm et al., 2004; Douglas et al., 2001; Huang, 2012). The

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assessment provides information or answers to essential questions in policy-making, such as the
pathways of the policy to impact public health (sometimes unrecognized or unexpected (Cole &
Fielding, 2007)), whether the policy is beneficial for problem-solving, what are the related social
determinants of health, whether the policy is overall good to for society's health, whether the
ideology of the policy is compatible with health, and whether the policy is politically feasible
(Kemm, 2001). Such a tool is gradually becoming indispensable as people become aware of the
impacts of socioeconomic status and built environment on health (Parry & Stevens, 2001; Krieger
et al., 2003). If the policy or the project does have a significant negative health impact, HIA has
an early-involvement effect on designing countermeasures (Kemm, 2001).
Besides, HIA can monetize the health impacts into economic values, a feature that has
attracted the attention of economists and policymakers (Dora & Racioppi, 2003). When HIAs can
clarify the uncertainties and trade-offs (Ibid), policymakers are more likely to support the
necessary resources for HIA (Harris-Roxas et al., 2012). Moreover, an HIA can analyze the
distribution of health impacts for different groups, giving a clear answer of whether the evaluated
policy or the project is equitable, a political requirement in some countries, such as the UK (Kemm,
2001; Krieger et al., 2003; Collins & Koplan, 2009; Walker, 2010). If an HIA is well implemented,
it can enhance the credibility of the government and officials (Cole & Fielding, 2007).
Adaptability is a critical advantage of HIAs (Harris-Roxas et al., 2012). HIAs can work well
in many fields, such as transportation (Nieuwenhuijsen et al., 2017), living wage (Bhatia & Katz,
2001), community planning (Corburn, 2009), and sustainable development (Winkler et al., 2013.
Hence, HIA focus on a broader range of impacts than risk assessments (Cole & Fielding, 2007).

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Dora & Racioppi (2003) summarize the practice in Europe and finds that HIAs perform
satisfactorily for all transportation policies, including local, regional, and national levels. Kemm
(2001) mentions HIA is useful for both deductive and incremental policy-making processes.
HIA benefits from a standardized procedure, mentioned in Chapter 1, that is highly
comparable to EIA (ECHP, 1999). Each incremental improvement in any step increases the quality
of an HIA (Harris-Roxas et al., 2012). Standardized practice allows others to replicate the
assessment and evaluate the result with new assumptions (Cole & Fielding, 2007). In the past two
decades, many toolkits (i.e., Healthy Development Measurement Tool, San Francisco Department
of Public Health, 2008), textbooks (i.e., Ross et al., 2014), graduate courses (i.e., UC Berkeley,
Dannenberg, 2016), reviews (i.e., US EPA, 2013), and practitioners' communities have (i.e.,
Society of Practitioners of Health Impact Assessment [SOPHIA], Dannenberg, 2016) significantly
enhanced the technical capacity of this field.
The outcomes of some HIAs are very significant (Kemm, 2001). The public and the
government have been aware of health consequences and regard them as crucial in decision-
making. Such a function makes HIA an excellent tool for achieving healthy public policy (Kemm,
2001; WHO, 2010).
Moreover, HIAs act as an active bridge between experts, the government, and community
members or stakeholders. Too often, as a vivid quotation describes, "‘I feel the stress of insecure
housing, working two jobs, and unsafe streets,’ while planners, public health departments, and
health care professionals were saying, “‘We have this program to help you get more exercise and
improve your diet.’” (Corburn, 2021) HIA, then, is a tool through which stakeholders, grassroots,

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and local knowledge speak to elites (Corburn, 2005; 2009) and allows them to influence the
building of socially responsible policies (Mittelmark, 2001). As participation is a core value of
HIA (ECHP, 1999), the public can engage in the process and change the result.
What’s more, the practice of HIA can also be low technocratic, accessible, and easily
manageable for ordinary community members (Mittelmark, 2001). Therefore, HIA can be an open
and transparent tool for advocacy, creating a comfortable environment for proponents, providing
supportive evidence, getting ownership of the policy, putting their issues on a high agenda, and
gaining broader support, such as building allyship and network among stakeholders (Cole &
Fielding, 2007; Kemm, 2001). The process can also encourage non-health departments to promote
interdisciplinary and intersectoral work to minimize potential oppositions and maximize benefits
(Krieger et al., 2003).
Weaknesses of HIA
Many scholars believe the low accessibility of qualified data is a significant barrier to
conducting HIA (Parry & Stevens, 2001; Harris-Roxas et al., 2012; Cole & Fielding, 2007; Mindell
et al., 2008). Many urban evils attracting public attention, such as dog feces, discarded syringes,
and graffiti, have been barely studied (Parry & Stevens, 2001). The limited access to good data
undermines the value of HIA because people struggle to find robust and rigorous evidence (Cole
& Fielding, 2007; Mindell et al., 2010; Harris-Roxas et al., 2012). Besides, some scholars insist
on gold standards, such as random trials, to generate evidence, which is not always available
(Krieger et al., 2003). Such a problem is even more severe in low Human Development Index

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(HDI) countries, as these countries have a high demand for sound policies, but they have
insufficient resources to collect and analyze the data (Winkler et al., 2013). Therefore, Cole &
Fielding (2007) suggests that professionals should lower the standard of using evidence from a
systematic review to an appropriate level.
The time scale of health impacts is the second weakness of HIA (Krieger et al., 2003). The
demographic structure of a place is dynamic (Parry & Stevens, 2001), so a long-time health impact
may bear more uncertainty. The optimal timing is often hard to define (Krieger et al., 2003). Many
events, such as electoral cycles (Hancock et al., 2017), economic downturns, and COVID-19, have
striking impacts on a related policy or a project, but they are usually not within the expectation of
an HIA. Such uncertainty obscures how long and likely the HIA makes sense.
Third, HIAs can be expensive, and sometimes their informatic value is uncertain (Cole &
Fielding, 2007). Often, such a value can be discounted by many realistic barriers and immature
expectations (Ibid). The available resources to do an HIA are not always related to the severity of
identifiable impacts; worse, money may be scarce (Dora & Racioppi, 2003; Harris-Roxas et al.,
2012; Parry & Stevens, 2001). The investment in HIA can be a waste of money and time (Krieger
et al., 2003) if it is a mere advisory report that cannot influence the decision making of a policy or
a project. An HIA is a voluntary report, so it lacks the substantial legislative power to mandate the
adoption. The decisionmakers can either adopt or not adopt the advice in the report. Moreover,
sometimes HIAs may be incorrectly used as a pro forma document after the essential decision has
been made to cope with legislative requirements instead of a crucial guiding document to say yes
or no to the policy/project (Davenport et al., 2006). These situations may undercut HIA’s value in

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supporting decision-making.
Fourth, political feasibility is the foundation of HIA, so HIA is often subject to political drivers
(Parry & Stevens, 2001). An abrupt political change can disrupt the initial planning of HIA
development (Cole & Fielding, 2007). Some HIAs sacrifice independence and impartiality to reach
a compromise (Davenport et al., 2006). Such a situation may raise the concern that HIA becomes
a tool to serve sponsors’ interests when the funder discretionarily employs the experts to do the
assessment subjectively (Cole & Fielding, 2007; Parry & Stevens, 2001). Some problems in the
institutionalization of HIA, including health imperialism [the health department encroaching on
other departments’ fields (Kemm, 2001)] and the government regarding HIAs as burdens (Cole &
Fielding, 2007), are also political barriers.
But even if it can be institutionalized, many technical practices may become bureaucratic (Ibid)
and lose flexibility. Many politically sensitive policies are less likely to go through HIA (Davenport
et al., 2006). The changes that an HIA brings to the policy are usually incremental rather than
revolutionary since drastic changes cannot politically survive (Kemm, 2001). Moreover, many
current HIAs are conducted by academics whose potential policy scenarios are too simplified and
idealistic to put on an official’s table (Nieuwenhuijsen et al., 2017), a phenomenon also observed
in Chapter 1.
Fifth, public participation is often limited in an HIA process. Davenport et al. (2006) report
only 48 cases (55% of sample) documented community participation, and even those cases lacked
details. Plus, as the dominant genre of HIA is technocratic, community engagement can be
substantially marginalized (Mindell, 2008). Still, public participation is not a panacea. Parry &

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Stevens (2001) argue that overreliance on stakeholders’ narratives can also be problematic. For
some unpalatable decisions, officials can pass the buck to public participation.
Sixth, many scholars are concerned about the capacity building of HIA (Dora & Racioppi,
2003; Mindell et al., 2010; Winkler et al., 2013; Collins & Koplan, 2009). This difficulty is
partially due to insufficient training (Mindell et al., 2010). Some analytical models are theoretically
feasible but cannot meet users’ demands (Ibid). Limited capacity for synthesizing research findings,
low familiarity with critical appraisal, obstacles to knowledge transfer, and the ability to review
evidence all need strengthening (Ibid). The HIA field lacks a general pathway to analyze impacts
(Mittelmark, 2001). This problem is more troublesome when it incorporates obstacles mentioned
earlier, including data accessibility, rigorous evidence, and devoted resources to HIA. Plus, some
complex issues, such as climate change, are beyond low HDI countries’ capacity, so they need
more assistance than high HDI countries (Winkler et al., 2013).
Finally, Parry & Stevens (2001) express concern over whether an HIA can lead to accurate
policy implementation. Many HIA practitioners report the current neglect of monitoring in
completed HIAs (Davenport et al., 2006), which is also observed in Chapter 1. Many practitioners
hold a perceptional bias that everything is done after the appraisal—experts finished their tasks
and proponents got the approval, so few people are willing to invest in monitoring that is neither
profitable nor impactful on approval. However, monitoring is crucial to protect public welfare by
ensuring the operation of a policy/project is on the right track and all the consequences are within
the expectation. The ignorance of monitoring may result in catastrophic public health or social
events (Wu et al., 2018).

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Methods and Data
This study uses the method of Davenport et al. (2006), who identified a series of HIA
facilitators and barriers whose background and aims were comparable to this study. They
triangulated the data sources from existing HIA cases (most from the UK), commentary papers,
reviews and discussions related to HIA, and email surveys from HIA workers and decision-makers.
This study uses their work frame but utilizes the pilot HIA policy documents instead of cases,
which are the focus of Chapter 1. Such a change has significant ramifications. The strength of
using the policy document is that the policy will be significantly consistent so that the conclusions
will be stable compared to cases with variable contexts, methods, data sources, findings, and case-
by-case quality assurance. The policy document defines what a normative practice is, so if some
pitfalls emerge in contextualized HIA cases while the original policy has a design to deal with, that
will be the problem of policy implementation or the incompetence of the practitioners rather than
the policy and HIA itself.
The weakness of using the policy document is that China’s HIA policy is usually general,
noncontextualized, limited accessible, and homogenous. In China, lower jurisdictions must obey
the policies set by the upper level. The obedience is significant because most lower jurisdictions
directly copy from the upper level’s policy document. This feature undermines the diversity of data
in this study. However, such an adaptation is reasonable for a limited timeframe and low expert
response rate, which are similar reasons mentioned in Davenport et al. (2006).
The analysis of policy documents uses qualitative methods. Currently, HIA is written in

73
national planning, mentioned in the dissertation’s introduction, but each of them only has a small
section for HIA, which lacks the necessary details. This paper aims to define how local authorities
deal with HIA, as HIA is still being piloted. The authors searched Health Impact Assessment in
Chinese on Baidu for mentions of HIA policy documents because such data is only available from
governmental websites and unavailable from an academic database. Not all the searches led to an
available policy document; many searches did indicate the existence of such a policy, but they
were unavailable at this time. The authors even tried calling the local government to request a copy,
but most of these attempts were unsuccessful. This study successfully identified eleven local
jurisdictions’ publicly available online HIA policy documents (until April 2022) and a usable news
report that summarizes the points of a twelfth one (Table 4). These jurisdictions include five cities,
four counties, and three municipal districts. Seven of the twelve jurisdictions are in Zhejiang
Province. Yuhang District has an ancillary policy to manage HIA experts, which was also included
in the analysis.
The authors coded the policy documents in Chinese on ATLAS.ti 22 (ATLAS.ti Scientific
Software Development GmbH, 2022). Two authors independently selected important terms from
Glossary of terms used for Health Impact Assessment (HIA) (WHO, 2010), the Gothenburg
Consensus Paper (ECHP, 1999), and Health Promotion Glossary (WHO, 1998). Then the two
authors discussed and reached an agreement on the selected terms. The two authors built a
conceptual framework of the preliminary codes based on the internal connections among the terms.
Such a framework was refined after coding Hangzhou to make it more adaptive to the Chinese
context. A third coder joined the coding of Hangzhou. The reason to select Hangzhou as the first

74
city to code is that it’s the capital of Zhejiang Province and has the highest likelihood of
representing all other places. During the coding process, we found that the remaining cities'
policies substantially overlap with Hangzhou or other counterparts. Some paragraphs are the same.
The first author manually marked the overlaps to offload the coding burden. We considered
geographical impacts (which also represent political impacts) more than time, so we sequenced
the policies by place (province) rather than when they came out. Then the first and third authors
continued to code the remaining policy documents. After completing all the coding work, all three
authors finalized the framework. The first author translated the framework into English using
Xmind (Xmind Ltd, 2022).
This study also triangulates the data from discussions in Chinese books (CHEC, 2019; 2020;
2022; Liang, 2020), reviews, and personal contacts with Chinese HIA practitioners. This study
integrates six reviews published in English journals about Chinese HIAs (Suwanteep et al., 2016;
Chang et al., 2017; Wu et al., 2011; Zhuang et al., 2011; Huang, 2012; Woodward et al., 2019).
For the personal contacts, at the time of writing, this study only collected a few expert responses
either by emails, social media, or phone calls. One of them was willing to provide an interview.
Two experts from Hangzhou offered valuable information about local HIA organizations. The low
response rate is the same as Davenport et al. (2006) because experts are busy and sometimes need
official approval to participate. The limited information from this channel prevents us from using
more quality assurance measures and forces us to use all we have.

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Results
Homogeneity
Table 4.
Online Available HIA Policies and Their Overlapping Rates
Places Upper
Jurisdiction
Overlapping
Rate
2

Overlap with
Hangzhou
Overlap
with other
cities
Policy
Time
Hangzhou
City
(2019)
Zhejiang
Province
-- -- -- 2019/10/29
Yuhang
District
(2021a;b)
Hangzhou,
Zhejiang
66% 66% -- 2021/10/14
2021/11/11
Jiangbei
District
(2022)
Ningbo City,
Zhejiang
54% 41% 13% 2022/3/29
Chunan
County
(2022)
Hangzhou,
Zhejiang
88% 54% 34% 2022/4/13
Deqing
County
(2020)
Huzhou City,
Zhejiang
94% 94% 0% 2020/9/10
Suichang
County
(2021)
Lishui City,
Zhejiang
55% 54% <1% 2021/10/2
Yichun
City
(2022)
Jiangxi
Province
72% 67% 5% 2022/3/14
Fengxin
County
(2022)
Yichun City,
Jiangxi
98% [~Yichun] 69% 29% 2022/4/11
Hengyang
City
(2021)
Hunan
Province
46% 44% 2% 2021/12/19
Yichang
City
(2018)
Hubei Province 5% 5% 0% 2018/5/12

2
The overlapping rate is calculated by how many words are exactly same with all former ones, using the sequence of
jurisdictions showing in this table from top to bottom. We only compare the formal texts of the policy, excluding the
announcements and attachments. For example, the overlapping rate of Yuhang District is 66%, which means 66% of the policy
texts of Yuhang District’s HIA Policy are exactly same with Hangzhou’s. Jiangbei District’s overlapping rate is 54%, while 41%
of the texts are exactly same with Hangzhou, while the remaining 13% of texts are same with Yuhang District.

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Zhongshan
City
(2022)
Guangdong
Province
26% 16% 10% 2022/2/16
Putuo
District
3

Zhoushan,
Zhejiang
24% 13% 11% Before
2021/2/27

The high overlapping rates of some places’ policy documents are astonishing. Seven
jurisdictions have an overlapping rate of over 50%. The highest rate is 98%, indicating Fengxin
County nearly copied the words of its upper municipal, Yichun City. The reasons for the extensive
overlaps are twofold. First, the top-down political structure determines lower jurisdictions must
substantially obey upper jurisdictions’ policies, reflecting on the copy of policy words. Other cities
in Zhejiang Province are prone to use Hangzhou as the template. Yuhang District, Deqing County,
Suichang County, Yichun City, and Hengyang City borrowed from Hangzhou significantly with
few other references. Second, all the policies are pilots, so they must learn from each other to avoid
unnecessary risks. Jiangbei District, Chunan County, Zhongshan City, and Putuo District
substantially used non-Hangzhou jurisdictions’ words. Chinese Health Education Center provides
technical guidance for all of them, which makes it hard to have no overlap.
Yichang City is the earliest place to pilot HIA before Hangzhou, making it unique. From the
texts, there are some similarities in the ideas between Yichang and Hangzhou, including targets to
be assessed, but Hangzhou did not use Yichang’s words and contents. Moreover, Hangzhou
developed more measures, such as the motivation system, which makes it quite different from
Yichang.
Table 5.
A Comparison between Yichang and Hangzhou’ s policy texts on HIA targets

3
This is a news article (Healthy China Initiative and Health Office of Putuo District, 2021).

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Yichang Hangzhou
Planning:
1. Yichang city planning
2. The construction planning of
Healthy City
3. Health-related sectoral planning and
mid to long-term planning
Economic and social development planning:
E.g., governmental planning, sectoral
development planning, work plans, long-
term planning (10-20 years), middle-term
planning (5 years), and annual planning.
Prioritize to assess all the governmental or
sectoral economic and social development
planning, enterprise planning, and specific
work plans
Policies:
1. Health-related policy files are to be
published by the city government
2. Non-health policies that the city
government executes
Economic or social development policies:
Primarily referred to the public policies that
benefit the massive public. Prioritize to
assess all governmental or sectoral policies
that are widely involved, covering many
people, effective for a long time, and with
significant impacts.
Relevant significant projects:
1. Water projects
2. Environmental protective projects
3. Environmental sanitary projects
Significant projects and programs:
Significant projects that are invested in by
the government and listed in the local
economic and social development planning
Relevant significant public services
Surveys of critical population health
problems

The overlaps across cities illustrate the homogeneity of Chinese HIA policies. Except for
Yichang, all the jurisdictions use the same standard of scoping, including the value of “the Great
Health,” determinants of health, physical, mental, ethical health, and social adaptability. Some of
the homogeneity is rooted in the guidance of the Chinese Health Education Center (CHEC, 2019;
2020). The Gothenburg Consensus Paper (ECHP, 1999) identifies four HIA core values, including
democracy, equity, sustainable development, and ethical use of evidence. Chinese Health
Education Center (2020) added a new one, “comprehensively dealing with health issues,” which
emphasizes the broader impact of social determinants of health on physical and mental well-being
and social adaptability. Such a change significantly influences how local jurisdictions shape

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policies.
Political drivers are another source of homogeneity. The term “the Great Health” emphasizes
health is not only the role of medical care and sanitation but many other non-health sectors. For
health, we must consider all related issues and activities (Government of Canada, 1974). The Great
Health is short for “the Great Sanitation and the Great Health,” first raised by President Xi Jinping
at the National Sanitation and Health Conference 2016, so it contained scientific and political
meanings. As Hangzhou was the second earliest city to have a pilot HIA policy and properly
combined political values with scientific guidance from CHEC, other jurisdictions tactfully used
Hangzhou as a template.
Homogeneity is a two-sided feature. The advantages and disadvantages of Hangzhou both
influence the practice of other cities. Hence, we found some common strengths and weaknesses of
all the cities. The strengths include (1) taking advantage of the pilots, (2) a robust governmental
working network, (3) the various channels of public engagement, (4) the establishment of a
motivation system, and (5) taking advantage of information and communications technology (ICT).
The weaknesses include (1) a lack of regulations on private projects, (2) emphasis on quickness
over thoroughness, and (3) weak measures to ensure sustainability is appropriately addressed in
HIA.
Taking Advantage of the Pilots
All the jurisdictions underscore in their titles that their policies are pilot HIAs. Since all the
available HIA policies are on the municipal level or below, these policies can be changed if a

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national or provincial HIA policy later comes out. Other jurisdictions without an HIA policy can
learn from the implementation of these pioneers.
Some places are proud to announce the pilot. The pilot is a reputation that the Office of the
National Patriotic Health Campaign Committee and the Office of Promoting Healthy China
Initiative favor the jurisdiction and grants it privileges to be a pioneer of HIA. Such a reputation
is a political accomplishment and is welcomed by local people. For example, Hengyang City (2021)
emphasized it was “the only city to be the pilot of HIA in Hunan Province,” underlining its
uniqueness and privilege.
Zhongshan City (2022) briefly summarized the merits of pilots, “action and pilot first, then
improve it gradually.” Pilots give jurisdictions a chance to learn by doing. Suichang County (2021)
provides a more elaborated description,
“Summarize the working methods of pilots. Take lessons from other pilot areas. Improve HIA
and its technical guidance to establish operational working mechanisms and paths. Provide
Suichang’ s lesson on HIA to the whole city [Lishui City]. After the entire city [Lishui City] finishes
the pilot work of evaluations of determinants of health, fully apply to HIA works.”

In the pilot process, jurisdictions can learn about different types of HIAs (rapid or
comprehensive) applying to other targets (policies or projects), which soon expands HIA’s variety.
Such a variety will become a great asset if the national government can periodically organize
seminars and forums to exchange thoughts and experiences.
A Robust Governmental Working Network
Hangzhou established a well-designed governmental working network (see Fig.4) with clearly

80
defined responsibilities for different participants in an HIA, and most other cities adapt such a
model. In such a network, the responsibility of an HIA belongs to the government, while different
governmental sectors execute the technical procedures, and the health sector provides professional
assistance. Non-governmental players have the right to participate, but the paths and degrees are
defined by the government and the experts, which we’ll discuss in the next section.
The core player in the network is the steering institution, usually a local health promotion
committee or the committee’s administrative office. The steering institution holds primary
responsibilities for HIA management, but it’s not accountable for the final decision of the targeting
policy/program/project. The steering institution keeps all HIA-related files, completes the initial
screening, organizes the expert panel, shares information, resources, and policy advisory with other
sectors, exchanges knowledge, and experience with the academia, trains staff, and holds a joint
conference. Hangzhou (2019) clearly defines how a joint conference works:
“…the HIA joint conference mechanism for policies (short for “the joint conference”) … guide
and regulate the implementation of policy HIAs within the administrative boundaries, study the
critical issues in the implementation, and work together to examine and promote HIA. The office
of the joint conference should be in the relative health promotion committee or the committee’ s
office.”

The Health Promotion Committee is a subordinate of the local Sanitation and Health
Committee. The Health Promotion Committee can also be called the Division/Office of the
Patriotic Sanitation Campaign. The role of such an entity is to coordinate other sectors to work
collaboratively on health and sanitation-related issues. Hence, the Health Promotion Committee
and the joint conference are both channels to promote intersectoral collaboration (WHO, 1998).
Although the steering institution has substantial power over HIA, it’s still an intermediate

81
entity. HIA is a tool to achieve health promotion and HiAP, so the steering institution needs to obey
the health promotional decisions of the governmental heads. For example, the Lead Group of the
Construction of Healthy Hangzhou is a local top decision-making entity to determine how to build
Hangzhou into a healthy city, which governs the operation of the steering institution (Fig.4). Other
governmental branches also need to maintain an appropriate relationship with the steering
institution, so Yuhang District, Jiangbei District, and Suichang County require other sectors to have
a coordinator to connect to the steering institution. Besides, the steering institution can acquire
technical support from other government-affiliated resources. Although different places may have
a few variations in the organizational structure, here we draw Hangzhou’s map as an example to
illustrate the relationships (Fig.4).
Figure 4.
The Governmental Organizational Map of HIA in Hangzhou (CHEC, 2022; Hangzhou Municipal Health
Commission, 2020a,b; and personal communications with experts)

The steering institution determines who is invited into the expert panel, usually including

82
professionals, governmental staff, and the media. While sometimes the panel may also include
stakeholders and other representatives. The professionals often include public health, law, urban
planning, environment, and industrial development scholars. However, all the cities currently rely
on a technocratic style in the government, and the experts will collect community opinions in
surveys, interviews, or focus groups. Still, the government has the discretion of using that input,
same with the official cases studied in Chapter 1.
Lower levels governments, such as the street or town government, also have a role in HIA. As
Jiangbei District (2022) illustrates,
“Each street/town needs to designate a specific office and related working staff to be
responsible for the concrete work of the street or town’ s HIA, including completion of screening,
recommendations of [the selection of] public representatives in the assessment, surveys to the
population, interviews, and other necessary field works and technical support, connecting to and
following the guidance of the district’s Office of the Health Promotion Committee, and ensuring
the accomplishment of the street/town’ s HIA.”

Evaluating the rationality of such a requirement is difficult, as a street/town’s government is
usually overwhelmed by many responsibilities with insufficient money and staff. If the
responsibility mismatches the working capacity, HIA will likely become a burden, as Cole &
Fielding (2007) suggest.
The abovementioned structure of HIA participants ensures the government leads the HIA, that
the heads make the final decision, and the steering institution and other sectors work
collaboratively to manage the HIA. The community has some chances to have a say. Such a
structure can make the plan of an HIA less likely to be influenced by external forces, and most
issues are manageable within the government.

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The Various Channels of Public Engagement
Democracy and public engagement are core values of the HIA process (ECHP, 1999). Many
cities illustrate the significance of public engagement in their HIA principles. Hengyang City uses
the Gothenburg Consensus Paper’s values to shape the policy document. Hangzhou emphasizes
the principle of the whole society’s involvement. Suichang County mentions “multisectoral
participation.” Yuhang District highlights “the principle of seeking the truth,” which requires
extensively soliciting stakeholders’ opinions.
Public engagement often is in screening, appraisal, and monitoring. Jiangbei District invites
representatives of influential people to the expert panel. Hence, these representatives can impact
the results of the screening. CHEC (2019) reports an HIA case in Yudu County, Jiangxi Province,
where local representatives were invited to the expert panel, confirming such a practice is
applicable elsewhere. Suichang County requires the expert panel to include local People’s
Congress deputies and People's Political Consultative Conference members. These political
representatives can also bring public opinion into the whole process of HIA.
Nonetheless, public participation happens more likely in the appraisal. Such participation can
be direct or indirect. The general opinion surveys done by experts are the most common mode of
participation. After the surveys, experts may continue to interview or conduct focus groups for the
selected representatives of impacted people and stakeholders. Such a way has a more substantial
influence than the survey. Hangzhou encourages the public to monitor the HIA as feedback on
implementing the policy/program/project.

84
Therefore, the level of public engagement varies by place. In the Chinese context, the public
has multiple channels to express their pursuits, but how public opinion influences the
policy/program/project depends on how the expert panel synthesizes this input and how many
recommendations the government adopts for revision. The relationship between public
information and the final decision is non-linear. The attempt to scale how deeply the participation
is hard, but Arnstein (1969)’s ladder is still helpful to gain some insights of it. For Arnstein (1969),
“consultation” means citizens have the power to fully engage in the participation and be heard, but
they have no assurance of their views attract the decisionmakers’ attention. Such a situation
describes in the most cases how the participation of citizens can influence the results of the HIA.
A further step in Arnstein (1969)’s ladder is placation, which means citizens can advise “have-nots”
but still the result is in the decisionmakers’ hands. Under such a circumstance, the participation is
a “higher level of tokenism”. Such a situation is also common, even for some experts, their
partnerships may be the tokenism to change anything. The next level in Arnstein (1969)’s ladder-
- partnership, the citizens have the power to negotiate with the administration. This may occur for
the compensation of eminent domain or other harms, but it cannot be observed in the current HIA
practice. Hence, the level of civic participation in HIAs concentrate in consultation and placation,
but possibly partnership may happen in the future for land use planning.
The benefits of public participation in HIA are the voices of stakeholders are heard to shape
the policy/program/project affecting their well-being. It is a normative action promoting social
justice (Walker, 2010). The various channels of public participation in Chinese HIAs allow the
analysts and decision-makers to know what the community asks for and respect local knowledge

85
and culture (Corburn, 2005).
Taking Advantage of Information and Communication Technology
Hangzhou’s (2019) pilot work focuses on building an information system for the HIA-- “By
2022, … the information system for assessment will be initially established and try to operate. ”
Chunan County also intends to join Hangzhou’s system. According to Hangzhou Municipal Health
Commission (2021), the Office of the Lead Group of the Construction of Healthy Hangzhou
commissioned Hangzhou Normal University to develop the Decision Support System of HIA using
Natural Language Processing (NLP). This system allows administrators to assign tasks, select
experts directly, and check the process. The system can automatically identify keywords of
determinants of health, search literature, and intellectually output the recommendations for
revision. When experts review the proposal, it can code potential determinants of health and
remind the experts of related paragraphs. The system can automatically update the codes to
professional terms. It is also user-friendly to provide good visualization for the administrator to
follow experts’ assessments, comments, and highlighted paragraphs and generate heatmaps. As
many jurisdictions follow Hangzhou’s model, using ICT to assist HIA can soon be a working
standard.
Using ICT to facilitate HIA can reduce working time, digitalize the assessment, move the work
online, release experts from physical gatherings during the COVID-19 pandemic, and offload some
burdens. China has data and many talented ICT workers, so it’s very promising to develop ICT-
based HIAs. In the future, ICT-based HIAs may become a global standard after extensive Chinese

86
applications.
The Establishment of a Motivation System
Many jurisdictions require establishing a motivation system based on monitoring results. The
motivation system is connected to the performance appraisal of local officials. If HIA is tied to an
official’s promotion, the official and related governmental sectors are incentivized to make HIA
one of their bonuses. Some experts in personal communications believe weak connections to
performance appraisal will be much better than stronger ones because weak ties can avoid a
distorted incentive that disrupts other agendas (Waterlily, personal communication, 2022). Besides,
such a measure is usually combined with educating governmental freshmen and officials on the
significance of HIA in governance. These collective measures may mark HIA as a local brand,
similar to the reputation of pilots. Some cities strategically choose Healthy City as their
developmental goal, in which HIA is a milestone to support the plan. Yichang City is an early
advocate of such a strategy. To our knowledge, it published its HIA regulations in May 2018,
China's first local HIA policy. Such a strategy was remarkably successful, and Yichang soon
became a model Healthy City (the Office of the National Patriotic Health Campaign Committee,
2021).
Funding is a critical part of the motivation system to ensure the working capacity of HIA.
Yuhang District, Hengyang City, Yichun City and Jiangbei District all state they guarantee funding
for HIA. For Jiangbei District, as some responsibilities trickle down to the street/town level,
allocating appropriate funding to those governments is critical to alleviating their stress. Chapter

87
1 finds some high-income provinces are more likely to use HIAs, which raises the concern that
funding disparity may be a problem for HIA development. Many experts disseminated this concern
in our studies, as discussed in Chapter 3.
Lack of Regulations on Private Projects
A significant pitfall in the HIA policies is the lack of regulations on private projects. As
explained in Chapter 1, some HIA cases are about private projects, but they are unofficial or for
academic studies. All the HIA policies discussed here only assess government-owned policies or
projects. Land use or amenity projects, while they do exist, are still within the public interest
instead of private. Chapter 1 referred to a private HIA case based on the local steering institution’s
request (CHEC, 2022). This case concerns Jimei Cosmetics Chemical Company’s desire to expand
its manufacturing line. As many chemicals produce significant public health threats, such a case
can be a model for HIA applications to private businesses. The procedure for private projects is
the same with government-sponsored HIAs, but private business owners typically are unwilling to
disclose their business secrets and add new liability that may undercut their profits. New
regulations are needed to require private businesses to conduct HIA to protect their reasonable
benefits and enforce their responsibility for public well-being.
The Emphasis on Quickness over Thoroughness
Some jurisdictions believe HIA should be a fast process. Yichun City commands that all the
HIAs should take no more than 15 days; Yuhang District and Suichang County ask for no more

88
than a month, while Jiangbei District gives only two months. Yichun City (2022) illuminates the
reason for such a requirement that “the appraisal should prioritize efficiency and minimize the time
cost of political decisions.” Many foreign HIAs take years to complete. A hastened HIA may omit
some critical health impacts because of the short timeline for data collection. This situation raises
significant concerns that some comprehensive health consequences may not be thoroughly
understood quickly.
Insufficient Mechanism to Ensure Sustainability
Sustainability is a core value of HIA. HIAs should predict the health consequences in short
and extended periods. Many jurisdictions address the time factor by developing a cost-benefit
analysis without more protective measures. The cost-benefit analysis is unreliable because some
essential elements are hard to predict (i.e., the outbreak of COVID-19). Plus, the health outcomes
may depend on cumulative effects—one project’s influence can be ignored, but how about ten or
twenty projects? The current HIA policies treat all the projects and policies alone without
considering their cumulative effects. Such a loophole may threaten public well-being and
sustainability in the long run.
Discussion
Comparing the findings of Chinese HIAs to the global lessons in the introduction, we found
China shares many similar features but also has unique dimensions. Chinese HIA shares its primary
function with international counterparts as a tool to inform decision-makers about the positive and

89
negative health impacts. The existing Chinese HIAs haven’t found intolerable negative health
impacts that would veto a proposed policy or a project (CHEC, 2019; 2020; 2022), so the reported
assessments all gave the green lights to the proponent with some revisions, similar to the global
applications (Davenport et al., 2006). The tension between economic development and
environmental protection is increasing after decades of environmental degradation (Li & Lang,
2010). The Chinese government has gradually allowed lower economic growth rates in return for
a better environment, ecology, and climate (Wang, 2016). As China emphasizes “Health First” in
Healthy China 2030, health can be another criterion to compromise the growth rate (Woodward et
al., 2019). Thus, the veto of a project or a policy in an HIA is still likely to occur if its negative
consequences are truly unacceptable.
We witness political forces significantly influencing HIA in China and internationally, yet for
China, such an impact is more natural because the government defines the process. Political power
is also a contributor to Chinese HIA. Without political force, an HIA cannot move, as the private
business has no incentive to conduct an HIA (CHEC, 2020). Hence, the role of political influence
is significantly different in China compared to other countries, where the local political agenda
may drive the HIA in some unwanted ways.
Public participation is a core value of HIA but is often undermined in global practice for
multiple reasons (Mindell, 2008). Chinese HIA policies allow various ways for the public to
engage in an HIA, including opinion surveys, interviews or focus groups of interest representatives,
political representatives, membership of the expert panel, and monitoring. This public input
significantly influences the assessment but has a non-linear relationship to the final decision.

90
Western culture encourages more civic engagement leading to shared policy decision-making
(Odeyemi & Skobba, 2021), which is impossible in China. China includes public engagement, but
its HIAs are still highly technocratic. Experts and decision-makers have a much bigger say than
the public. As all the current Chinese HIAs are government-based, a low technocratic grassroot
HIA that fully represents the local community's values is hard to imagine (Mittelmark, 2001). A
grassroot effort would be unlikely to access critical data since they are confidential, a difficulty
also faced by international practitioners (Harris-Roxas et al., 2012).
Suppose a Chinese private business is required to conduct HIAs in the future. In that case, the
employed consultants may have a better situation than grassroots because they can acquire
confidential data from the employer and buy costly datasets. However, as private business aims at
profits, these HIAs are prone to be influenced by the business interest, which is unwilling to be
open to public engagement to increase the likelihood of opposition and other liabilities (Cole &
Fielding, 2007). Future regulations on private HIAs are indispensable to ensure they fulfill their
responsibilities and inform the public.
The global community can take some lessons from the Chinese HIA policies. These takeaways
include the pilots, a robust governmental network, the motivation system's establishment, and the
development of ICT-based HIAs. Chinese law (2019) has required HIA, granting pilots legitimacy.
The government can identify pilots' potential problems and risks and adjust them later. Pilots are
an essential measure for a centralized regime, as the results of pilots are the model for non-pilot
areas. China is a country with centralized politics and relatively more decentralized administration
(Hutchcroft, 2001), where pilots exemplify how decentralized jurisdictions explore the way to

91
execute centralized policies. The Chinese case may be valuable for similar regimes, such as
Vietnam.
A complete working network ensures the centered steering institution can control the progress
and organize multisectoral collaboration. The significant feature of such a working network is it
clearly defines the different responsibilities of multiple governmental sectors to avoid potential
worries that HIA becomes a tool for the health sector to encroach on other departments’ power
(Corburn, 2009). The joint conference at the steering institution also gives all sectors a platform to
discuss and study the difficulties and critical issues of ongoing HIAs. These measures promote
solid multisectoral and multidisciplinary collaboration and dissolve professional bias to facilitate
HIAs. Although the Chinese joint conference is government-based, other countries can invite
ordinary citizens to the joint conference based on local political culture. The Chinese network is
mainly within the government, so it lacks broader social support, including an HIA association,
textbooks, university courses (Dannenberg, 2016), and industry feedback. China should invest in
these areas to make HIA more accessible for social participants.
The motivation system is a pillar to ensure the working network is incentivized to perform
well with the necessary funding and other support, for which some countries often face scarcity.
The motivation system rewards the governmental sectors that conduct effective HIAs, so the
rewarded sectors will continue to strengthen their self-management, reinforcing the governmental
leadership in HIAs. Some Chinese cities brand HIA as a milestone of the development of a healthy
city, which receives substantial echoes globally. European Healthy Cities Network flagged HIA as
a core issue in Phase IV (Simos, 2017), and “Healthy City” became a reputation for many

92
municipalities and elected officials. As political drivers are vital, ensuring solid support from
politicians through incentives is beneficial for developing HIA.
Lastly, the success of ICT-based HIAs in China may encourage other countries to follow the
trend. China lacks the HIA measuring and evaluating tools usually developed by the US, Canada,
and European countries (US EPA, 2013). However, as Hangzhou is a tech hub, China was able to
develop ICT-based HIAs. The satisfactory performance of Hangzhou’s Decision Support System
of HIA attracts a subordinate, Chunan County. It has become a role model to six jurisdictions that
plan for an information system in their policy. In the future, China and global practitioners can
learn the technical merits together. As China started research on measuring and assessing tools and
integrating them into the existing software, foreign countries can follow and develop their own
HIA informational system.
Conclusion
This study reviews twelve jurisdictions' pros and cons of piloting Chinese policies. It
discovered that Chinese HIA policies are largely homogenous. This is an unexpected result since
international HIAs usually develop bottom up that brings a great diversity to the policy. Many
jurisdictions borrowed Hangzhou’s template. These policies benefit from the pilot status and build
a robust HIA governmental network, whose center is the local steering institution. The steering
institution organizes multisectoral collaboration with other departments, academia, and media.
There is an internal motivation system to reward governmental sectors’ good performance on HIAs,
and some cities are applauded for building healthy cities. Chinese HIAs allow multiple approaches

93
for public participation, including opinion surveys, interviews or focus groups of stakeholders and
representatives, voices of political representatives, and an invitation to the expert panel, though
experts and the government still dominate Chinese HIAs. Some significant shortcomings are a lack
of regulations on private projects, the emphasis on fastness rather than thoroughness, and a lack of
robust measures to protect sustainability.
Future studies can work on developing HIA measuring and assessing tools, how to regulate
private business HIAs, some long-term health impacts, and how to protect sustainability. Besides,
building an HIA association, starting professional courses in universities, and writing qualified
textbooks are essential tasks for the Chinese HIA’s future, waiting for collective actions from
academia and practitioners. Moreover, building a provincial or national HIA policy from these
local pilots needs further discussion and continuous attention.

94
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Chapter 3: Why is the development of Health Impact Assessments in
China slow? The implication from multidisciplinary perspectives on
healthy cities
Junteng Zhao, Yining Lei
Abstract
The institutional development of Chinese HIA policies is relatively slow. This chapter
considers the structural barriers that slow down HIA development in China. We used emails,
phones, and video conferences to interview seventeen scholars from multiple disciplines highly
related to current HIA practice to form a complete host understanding of the complex obstacles.
We identified four structural barriers that have slowed down the HIA adoption, including
functional differences between EIAs and HIAs, the scientific uncertainties of the process between
environmental hazards and health, poor operability of current laws, and difficulty with
multisectoral collaboration. Some of these reasons are dramatically different from the troubles
faced by the global HIA community. We further suggested some possible actions to promote the
agenda, including recognizing that an HIA's primary goal is for decision-making rather than its
scientific values, starting specific legislation for HIA and matching policies, developing an
authoritative technical guideline and increasing the number of multidisciplinary professionals in
the government.

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Introduction
In earlier chapters, we summarized the key national policies from 2016 that are fundamental
to HIAs in China. We also discussed the local pilot HIA policies in Chapter 2. Pilots are a crucial
step for the Chinese government learning by doing. The pilots discussed in Chapter 2 are formal
pilots; some informal pilots, called “health screening,” started even earlier than Yichang and
Hangzhou.
China has been piloting “Health Screening for Public Policies” in a few health promotional
districts and counties since 2014 (CHEC, 2020) as test fields and thinking of ways to promote
health impact assessment nationally. Health Screening for Public Policies is a policy that requires
the local government to screen the social determinants of health that can lead to adverse health
impacts in their proposed or completed public policies. This policy is a precursor of HIAs for
public policies.
After a few years of practice in health screening, China started formal HIA pilots following
the publication of Healthy China 2030. Since 2017, China has conducted sporadic HIA pilots
supported by CHEC (2019). Yichang (2018), Hangzhou (2019), and Shanghai (2020) were the
earliest cities to practice HIAs in China, while Zhejiang was the earliest province as a whole (Shi,
2021). China expanded the pilots on July 20, 2021 (The National Patriotic Sanitary Office, 2021),
when new cities were selected to be national pilots of HIAs, and many other cities became
provincial pilots. Some places wanted to incorporate HIAs for projects into their EIAs to be EHIAs,
so for this study, we consider both HIAs and EHIAs in China. Up to date, the establishment of

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new HIA pilots from July 2021 is far from complete.
As mentioned, China has centralized politics and relatively more decentralized administration
(Hutchcroft, 2001). Therefore, the pilots of HIAs should have been implemented fast, especially
considering HIAs are highly comparable to Environmental Impact Assessments (EIAs), a tool that
China has practiced for four decades. However, China has conducted pilots on health screening
since 2014 and formal HIAs since 2017, but it’s still in its infancy years later. Why is the
development of HIAs in China slow? What are the barriers to address? What actions can China
take to promote this agenda? This chapter is going to answer these questions.
HIAs are inherently multidisciplinary work. They require expertise in urban planning, public
health, environmental studies, and other fields (National Research Council, 2011). Each profession
has its unique role and standpoint in HIAs. The different disciplines are necessary to understand
the complexity of HIAs and identify some possible solutions in a balanced way. Therefore, this
study intends to document multidisciplinary perspectives from various professions related to HIAs
and synthesize them into a holistic outcome. To our knowledge, this is the first study written in
English to emphasize multidisciplinary voices on HIAs in China. Hopefully, this study can attract
international attention to Chinese HIA to enrich the practice of HIAs in pan-Chinese cultural areas.
Methods and Data
This study borrows the method of Davenport et al. (2006), which relies on qualitative methods
and triangulates data from communication with experts, case studies, and reviews. Interviews with
scholars are the primary data source for this study because they either know the topic or have first-

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hand experience practicing HIAs. We incorporate some findings from case studies and reviews
into our analysis, but these sources are only secondary because (1) many case studies lack the
critical information on our research questions, such as barriers for Chinese HIAs; and (2) many
reviews interchange the term HRA with HIA that contradicts the purpose of our study, which is
mentioned in Chapter 1(US CDC, 2016a).
Due to the rage of COVID-19, the authors could not conduct face-to-face interviews with
experts. All the interviews were done remotely in Chinese, including by email, video, and
telephone. Although such a choice is a compromise to the pandemic, it has pros and cons.
Emails are most extensively used but are only partially successful in this study. There are
multiple reasons for that. First, just a few scholars replied to the email. Second, interviews require
rapport, which is hard via emails (Kazmer & Xie, 2008). Third, the richness of email interviews
varies greatly, and some scholars’ replies are just a few sentences, though they are still valuable.
Other modes of interviews, such as video or phone interviews, are significantly more dynamic and
interactive, and interviewees’ verbal and occasionally nonverbal expressions can be easily detected,
but emails are static and do not allow for expression beyond plain text (Markham, 1998). Fourth,
some email addresses we collected are invalid. Although emails have many problems reaching a
satisfactory result, they are still the primary approach to contacting scholars because they are the
least intrusive, most available, and most accessible way.
Video interviews are crucial for rich interviews because they can be recorded and transcribed.
Although video interviews cannot replace in-person interactions, previous research has
demonstrated that they nonetheless offer substantial benefits, including the data richness given by

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being interviewed from home or another familiar setting and the possibility for cost-effectively
progressing qualitative study designs (Oliffe et al., 2021). The data richness aspect was also
demonstrated in this study, as some of the interviewed scholars revealed sensitive information that
they later requested these sensitive pieces to be deleted from the transcript; more study-related,
important information, however, was well preserved in the transcript, which the authors believe
that in-person interviews in a more formal setting could not generate. To arrange a video interview,
the interviewees and the authors must first develop a connection through academic conferences,
emails, and social networking. As a result of the established relationship from the outset, greater
trust and rapport are embedded in the video interviews of this study.
The phone is another interviewing medium adopted in this study. “The Phone” in this study
includes traditional calls over the telephone number and calls over social media (WeChat).
Although the non-visual characteristic may reduce rapport, the phone remains a practical means
of communication. Compared to video interviews, we believe that phone interviews would be more
appropriate for interviewees who lacked the technical expertise and access to videoconferencing
software at the time of the interview, as well as those who preferred speaking over the phone over
any other means of contact. In our case, some government employees are more accustomed to
communicating via telephone than other means. Scheduling a phone call seems straightforward,
but they depend on whether we can reasonably get the interviewee’s phone number and whether
the interviewee trusts us over the phone. The publicly available office phone number is an easily
accessible and reasonable channel to contact the targeted scholar, but it needs to be verified before
the call because sometimes it has been changed. Plus, due to the COVID-19 pandemic, many

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scholars worked from home rather than their offices, so the office phone number could not
necessarily reach them.
As different channels had unique merits and barriers, the authors had to combine all the
approaches to maximize the likelihood of successful contact. We fully use snowball sampling by
asking interviewed scholars to refer potential participants to us. We finally interviewed seventeen
scholars; two were by email, nine by video, five by phone, and one by email and video.
Since HIAs are multidisciplinary, our investigation invited scholars from many fields. Of the
scholars who participated in our interviews, one was from urban planning, one from public policy,
five from public health, one from the health law, five from environmental sciences, one from
environmental law, one from ecology, one from mining and occupational health, and one from
construction management. A few other scholars replied to our emails without essential content
related to the research questions, but they referred scholars to us. We appreciate their help but did
not include these emails as email interviews. Because of their different professions, we used
different templates in the interviews. The biggest difference among those templates is
environmental scholars, public health researchers, and urban planners focus on various laws, so
the design of templates needs to be adapted to the terms, regulations, and practices.
The length of the interviews varied greatly. Most email interviews were short. Video
interviews could last from 5 to 140 minutes, while a typical one was about 60 minutes. A phone
interview could last from 2 to 52 minutes. Some scholars were talkative, so new questions emerged
in the interview process, where semi-structured interviews were appropriate; others wanted a clear
expectation from us, so we sent the predetermined template to be a structured interview. Short

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interviews did not cover all the questions in the template, but they still provided valuable
information for our study. Interviews covered all the questions needed for at least 30 minutes.
Five phone or video interviews were based on notes, while we transcribed the recordings for
others. To protect their identity, we used flowers to give scholars a pseudo name in the notes,
emails, and transcripts.
We coded the emails and transcripts of interviews on ATLAS. ti 22-Web independently. All
the transcripts are in Chinese, so we coded them in Chinese but translated the quoted parts into
English. We identified four big themes in the coding process, (1) functional differences between
EIA and HIAs, (2) the scientific uncertainties of the process between environmental hazards and
human health; (3) the current laws have poor operability, and (4) the hardship of building a
practical collaborative framework across different sectors.
Results
We find the reasons for the slowness of developing HIA policies in China are complex.
Multiple structural difficulties are preventing China from developing its HIA policies quicker.
The functional differences between EIAs and HIAs
A critical reason from our interviews for the slow development of HIAs is the functional
differences between EIAs and HIAs. Such differences are twofold, including their different roles
and analytical methods.
Under the present Chinese law system, an EIA is a legal document equivalent to an

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environmental feasibility assessment to approve or veto a project. Hence, the power of an EIA is
apparent. In contrast, an HIA is powerless compared to an EIA. An HIA is an advisory file to
provide recommendations for a proposed policy or project based on health impacts to a
policymaking authority that can discretionarily adopt or disregard those recommendations.
“The national training tells us that the recommendations of an HIA can be partially adopted
or compromised instead of full acceptance. It is non-binding one. ” [Wistaria, a public health
official]

Besides, the power of an HIA also depends on when it starts. Suppose an HIA begins early, for
example, at the feasibility assessment phase, which is the most common type. In that case, it can
provide noticeable warnings for the design of a policy/project, but the preciseness and restriction
on practices may be weak because of many uncertainties. If an HIA starts at a late stage, such as
pre-construction or during construction, it can better predict the scope and who will be impacted
by the project, but it is also hard to revise the plan substantially because it cannot overturn the
project design and approval that has been made. Because of its limited power, an HIA is less valued,
and making an independent HIA policy out of the existing EIA system is not urgent. Then, some
jurisdictions need more time to observe other places to use HIAs before they start.
For environmentalists, their preferable format to analyze the health impacts is an
Environmental Health Risk Assessment (EHRA). An EHRA is a combination of an EIA and an
HRA. The EIAs in China are to evaluate the volume, concentration, and boundaries of pollutants
and check whether these numbers are within the standards of the national technical guidance. The
analysis of the EIA provides the exposure data for an HRA, so environmentalists can easily
combine these two assessments. This approach is usually for projects.

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EHRA and EHIA/HIA have substantial conceptual differences, but our interviewees use these
terms interchangeably, as we observed in the interviews with environmentalists. The two terms are
not conceptually interchangeable; EHIA/HIA comprises EHRA as, according to CDC’s definition
(2016), HRA is a quantitatively analytical part of an HIA. The results of an HRA are human health
risks, which are comprehensive results to integrate all the risks generated by complicated chemical
reactions. Therefore, an HRA does not need to answer how pollutants harm the human body
biophysically fully; it just measures an integrated numeric result of risk.
“Interviewer: Do we need to fully understand the toxicology of all the pollutants to integrate
them into the risk?
Hyacinth: No, that cannot be identified.
Interviewer: That is to say, we need to consider those pollutants comprehensively. We integrate
them into an absolute risk. Then we use this risk to determine the approval.
Hyacinth: Yes. How to build? How many kilometers away from residential areas? ” [Hyacinth,
an environmentalist]

In contrast, an HIA needs to identify what positive and negative health impacts will be. The
impacts should be complete, comprehensive, and broad as opposed to specific and technical, so
impacts are often expressed in a less quantifiable but more qualitative way. Simply put, an EHRA
focuses on “how much” with a sole concentration on one dimension (e.g., cancer incidence), while
an HIA or an EHIA should focus on “what” with many more dimensions. An EHRA does not
consider positive health outcomes, while outcomes are central to an EHIA or an HIA. Plus, in
many cases, an EHRA, as a more technical assessment, does not consider societal values such as
health equity, which is a core value of an EHIA/HIA. Therefore, although the paradigm of EHRA
is mature in China for environmentalists, they are not used to the concept of an HIA.
In practice, health risks are highly related to the assumptions set in the first place. Risks could

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be highly viable if the assumptions were changed. In contrast, the quantifiable volume of a specific
pollutant is highly measurable. Due to the ever-changing character of HIA’s outcomes,
policymakers can only use potential risks to form policy recommendations (e.g., potential negative
impacts that need attention too, or further, metrics of assessment based on possible adverse effects)
as opposed to strict, quantitative standards of exhaustion of pollutants with legislative power. With
the absence of a legislative measure for assessing risks, experts have to discretionarily give their
judgment on the project, which varies significantly across individuals and adds more uncertainties
and complexities to the report.
“As for metrics (of assessment), I can propose my metrics, and you can propose yours. Just to
make sure your proposal is scientific. ” [Hyacinth]

The conceptual and ideological differences between the EIAs and HIAs add additional
complexity to practice. The idea of EHRA and HIA is the same for environmentalists, but that’s
not how public health professionals think. Instead, public health experts want to establish a new
HIA system somewhat independent from EIAs (Kim & Haigh, 2021), which takes time to
implement.
“There are two groups of people working on HIA. One is from the environmental impact
assessors, while the other is from the Health Commission. ” [Wintersweet, an environmentalist]

The professional division between environmentalists and public health scholars is also a barrier
to multisectoral collaboration, which will be discussed later.
The scientific uncertainties of the process between environmental hazards and human health
In our interviews, we find the scholars repeatedly thought there was a scientific chasm when

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drawing the causal relationship between environmental hazards and health outcomes. These
uncertainties are about how pollutants influence population health biophysically. The
establishment of toxicologic and biophysical mechanisms is challenging for various reasons. First,
chronic diseases such as cancers have numerous causes, and pollution is only one of them. Other
factors, such as individual differences and protective measures, add more uncertainty on whether
a person will catch cancer.
“While if we focus on people, you need to know we are part of a very complicated system,
right? Human exposure is very [complicated], as people are exposed to a network of pollutants.
There are other reasons for people to have a certain disease, which makes it even more
complicated. ” [Lotus, an environmentalist]

A construction management scholar also confirmed the effect of exposure.
“That’s an issue of exposure. Pollution is that… for example, we are under the haze. We must
consider the protective measures of people exposed, including their weight and age. Because we
have a model of exposure concentration, [the health effects] are all related to your subjects.” [Lily,
a construction management professor]

Second, our environment is complex. Multiple pollutants can contaminate it from many
exhausters—factories, transportation, cooking, heating, agriculture, etc. The environment is a
medium for pollutants impacting health. The contaminants in the environment may change in
chemical reactions. These reactions make the composition of contaminants complicated. The
synergistic effects of various pollutants or chemicals on people’s health still wait for more robust
scientific research, even when, in some cases, the consequences can be determined; the pollutants
are unmanageable in the natural environment. Plus, many studies are based on foreign countries
but not Asian studies. The different environment is a significant contributor to the variations in
health outcomes.

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“Uh, for combined pollution, because there are multiple exhausters in our environment. There
are many types of pollutants. For example, heavy metals and organic compounds, VOCs, are the
most common ones. All kinds of materials. These pollutants will have their own health effects.
However, their sole effects are different from mixed with multiple pollutants. Pollutants may have
reactions. Hence, it’s really complicated... We need research to investigate their relationships..”
[Lotus]

Besides, numerous chemicals are invented every year, and the pace of toxicologic research is
far behind the invention. Environmental and medical scientists have so many unknowns on the
health effects of new chemicals.
“New problems are numberless. Same with new pollutants. The types of chemicals have
already been so many, but what we can research and know are very few. New research is necessary.
Certainly, new studies and technology cannot keep pace with new problems. ” [Lotus]

The scientific uncertainties make it unreasonable to fully hold corporations, plants, or projects
accountable for those long-term health outcomes when there are no direct environmental accident-
causing deaths or immediately recognized harms. Health Impact Assessments, then, are
inconclusive. When there is insufficient scientific evidence and base, the power of HIAs is limited,
so preparing a solid and persuasive HIA report is challenging. HIAs can only be a cautious,
advisory, and preventative measure.
“Between pollution and health, natural resources and the environmental media exist. It’s not
like beating a person with a stick. When you beat someone with a stick, that’s a direct injury to the
body. But for the environment, I discharge the pollutant into the external environment, and then
the pollutants harm the human body. The damage to the human body is not caused by a single
project; multiple pollutants from various companies cause it. Hence, Cannot [blame] a single
project, or the discharge of pollutants from a single project” [Daisy, an environmental law
professor]

The hardship to determine how much a single plant may damage people’s health is not an
excuse for no reactions to those intangible harms it generates. When pollutants are discharged,

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they are apparent health threats for human, though the final outcome may occur at some time, in
some places, and on some people. Under such a circumstance, the role of HIA is to predict possible
health impacts, mitigate those threats, and limit the impact within a controllable scale. Such a task
may be challenging using quantitative methods as the scientific relationship is difficult to establish,
so some qualitative works are useful as a preventative measure. The collective benefits from
dozens or hundreds of the preventative health measures are tremendous. These potential health
benefits legitimate the necessity of adoption of HIAs on single projects. Therefore, even though
the scientific relationship between pollutants and human’s health damages needs more research,
there is no doubt that the development of HIAs as a preventative measure should be in place.
The current laws have insufficient operability
An ineffective law system is the third deterministic reason an HIA system is hard to establish.
Currently, there are three laws related to HIAs, including the Environment Protection Act (1989,
revised in 2014), the Basic Medical Care, Sanitation, and Health Promotion Act (2019), and the
Environmental Impact Assessment Act (2002, revised in 2016 and 2018). Section 39 of the
Environmental Protection Act requires the nation to establish and improve environmental and
health monitoring, investigation, and risk assessment policies. Section 6 of the Basic Medical Care,
Sanitation, and Health Promotion Act requires the establishment of the institution of Health Impact
Assessments. The Environmental Impact Assessment Act does not indicate anything on health,
but as the HIAs of big projects are often combined with EIAs, the EIA Act is substantially relevant.
Plus, two national plans, the 14th Five-Year Plan (a plan with legislative power compared to

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law) and Healthy China 2030, also require the establishment of HIAs. The problem is not the
absence of rules on HIAs, but the laws lack sufficient operability. Such insufficiency is twofold,
including (1) a lack of specific regulation for HIAs and matching measures (Shi, 2021) and (2) a
lack of technical guidance with enough legal power and operability.
A lack of specific regulation for HIAs and matching policies
Shi (2021) points out the necessity of providing more legal foundations and matching
mechanisms for HIAs to promote HiAP. The legal foundation refers to a regulation or a local law
instructing how to do an HIA. The matching mechanisms refer to the necessary supports to ensure
the workflow of an HIA.
According to our interviews, the HIA regulations are not systematically complete from a
legislative perspective. First, the Basic Medical Care, Sanitation, and Health Promotion Act is a
fundamental law for the health field. When a law is more fundamental and general, its clauses
cannot provide detailed instructions for specific institutions, such as HIA. The instruction of HIA
needs another middle-level law. Such a middle-level law may also face significant obstacles when
the basic law has already been challenging, especially when HIA is a new thing to be tested.
Second, adding HIAs or HiAP into the regulation may meet opposition from other
governmental sectors. Such an agenda needs high-level coordination, governmental leadership,
and determination, such as from the State Council or the National People’s Congress; otherwise,
it will meet a significant legislative barrier. We will discuss multisectoral collaboration more in
the next section (Kang et al., 2011).

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“The Basic Medical Care, Sanitation, and Health Promotion Act is a comprehensive and basic
law in healthcare and public health. Section 6 is a part of the general principles because it is a
basic law. It cannot specify the procedure of HIAs. It just establishes the institution. The later
specification needs administrative regulations from the State Council or local legislation. Hence,
basic laws are to create the institution, while the concrete institution for implementation will be
then in detailed guidance or ordinance…”[Zenobia, a health law scholar]

Zenobia further explained the expected hierarchy of such a law in the Chinese legal context.
“It is lower than the Constitution and laws in the middle of the legislative hierarchy. … As for
creating a specific law for HIA, like the EIA Act, I don’t think it is practical in the public health
field. Because when you have such an indicator to evaluate, you must assess it. Then the
assessment will be about all sectors, especially the government’s performance evaluation, so it
will meet many barriers in practice and hard to promote national legislation.”

Waterlily, a public health expert with rich HIA experiences in China, explained the situation
from an operational perspective:
“Yes, we have the institution [of HIAs under laws]. But … who should be the operator of HIAs?
That is unclear in that law. Hence, we have the institution, but it lacks operability in practice. You
cannot compare it with EIA regulations. For EIAs, the subjects are apparent, but [not] for HIAs...
From our administrative perspective, currently, such as this one [HIA], a new thing, I think it is
impossible to come out with regulations from the national level in the first instance.”

Matching policies are crucial to guard the workflow of an HIA. However, the abovementioned
laws do not indicate anything about matching measures. Because of those uncertainties regarding
operation and responsibilities, local governments have to try to establish one on their own, which
needs a lot of time and effort to make it work well, slowing down the development of HIAs.
“Um, establish the institution of HIAs. This institution was installed in the Environmental
Protection Act, but the relevant matching mechanisms do not currently exist.” [Daisy]
Hangzhou was one of the earliest cities to build the matching measures to overcome these
barriers. Hangzhou dictated that the whole government is the principal, the governmental branches
are executors, the health department is the technical supporter, and the entire society is the

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participant. Hangzhou established a joint conference to promote HIAs and HiAP. The Lead Group
of the Construction of Healthy Hangzhou leads the joint conference. Governmental sectors’ heads
are members of the joint conference, and each department needs to assign a coordinator to contact
the local Health Office (which we discussed in Chapter 2). This was a local pilot effort to fill the
gap. Other cities may have similar counterparts. These efforts are decentralized. A nationally
centralized matching policy may come out based on the outcomes of these decentralized pilots a
few years later. Therefore, the missing matching mechanism is a surmountable barrier, but it
requires some time; it’s still immature and under testing.
A lack of technical guidance with enough legal power and operability
Many scholars in the interview mentioned a lack of technical guidelines for conducting an
HIA. The technical guideline should follow the regulation discussed in the above section and
provide enough technical support, such as tools, methods, parameters, indicators, etc. Currently,
CHEC (2019; 2020; 2022) introduced the basic procedure of HIA recommended by ECHP (1999).
The process was slightly adapted to Chinese political culture, as discussed in Chapter 1. Besides,
CHEC developed an extensive checklist of social determinants of health and which sectors’
policies may be responsible for. The CHEC guideline has no parameter on any indicator, and it
can only be used for qualitative predictions. When no technical guidance from the government or
legislation exists, CHEC’s work is the most widely used one, but it cannot equate to a legal,
technical guideline.
According to an environmental law professor in our interview, the standards, instructions, and

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technical guidance are a part of the law. The technical guidance indicates what the standardized
parts of an assessment are. The Technical Guidance of Environmental Impact Assessment-General
Principles (2011) [TG-2011] mentioned population health should be a part of EIAs. However, such
a requirement has no specific rules and details to follow, making it hollow and inoperable. Liang
(2020) further indicates that the EHIA technical guidance needs targeting strategies based on
project features, but TG-2011 is too general to be helpful. As discussed previously, a significant
reason that prevents TG-2011 from being more detailed on health is a lack of scientific research
on the environment and health. Technical measurements cannot work well without science, so
many scholars called it “technical immaturity.” TG-2011 was not the first technical guidance weak
in technological immaturity on health. There were two drafted precursors dropped from the table
because of technological immaturity—The Standard of Health Impact Assessment on
Environment Pollution (The Sanitary Legislation and Monitoring Bureau, 1999, short for
Standard-1999) and The Technical Guidance of Environmental Impact Assessment-Human Health
(The Ministry of Environmental Protection, 2008, short for TG-2008).
“Primarily, it was because of technological immaturity under such a circumstance. The
technical immaturity of assessments led to that. Or the methods of assessments. Because of input
and response-- the input of pollution to the response of human health. I think this is under research.
If the technical guidance [referring to Standard-1999 and TG-2008] came out hastily, that would
be biased.” [Daisy]

Besides, there was a battle that Environmental Impact Assessors strongly opposed TG-2011
to include health because it’s complex and expensive. Plus, the legal costs of lawsuits and
compensation would be enormous if the project could not meet the environmental standard,
making it unreasonable under the economic circumstances at that time (Liang, 2020). These

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complex reasons made TG-2011 unworkable on health and HIAs, significantly preventing the
establishment of a well-functioning law system.
The hardship of building a practical collaborative framework across different sectors
HIA is a multidisciplinary field. It cuts across urban planning, public health, environmental
studies, law, construction management, etc. Such work requires officials and professionals from
the abovementioned fields to cooperate and coordinate. However, such a collaborative framework
is not easy to achieve because there are gaps among different administrations and professions.
Each department and discipline have its paradigm, standpoint, concepts, and methods, which are
often incompatible with other fields. However, the government and professionals face different
situations for the same reason, so that we will discuss them individually.
According to our interviews, scholars believe that horizontal collaboration in the government
is hard because it is frequently marginalized when a governmental sector considers its core
functions.
“Fora collaborative framework, the multisectoral collaboration is a problem not only
belonging to our country. As I learned, Australia also has difficulty in multisectoral collaboration.
Because under our current institution, people focus vertically more. When the vertical pipeline is
strengthened, the horizontal one is weakened. Each sector has its Sanding Scheme
4
. Each sector
focuses on its core functions. It primarily focusses on what my core functions are. Horizontally,
more peripheral functions can be marginalized.”[Waterlily]

Waterlily further explained the logic of horizontal collaboration and its challenges in real

4
Sanding Scheme is a term of public administration. It refers to three determinants—determine the accountable sector, including
its name, essence, and funding, determine the functions of the sector, and determine the personnel, including how many leaders
and working staff.

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practice.
“When talking about working horizontally for the institution of management, we are talking
about multisectoral collaboration, shared construction, shared resources, and shared
management, for these things. But in reality, they are hard to operate, because of the standpoint
of each sector and its profession, even for the working staff’s professional background. They
consider more about their sector. For example, the environmental sector, first, certainly responds
to the government [it belongs to]; second, to the upper provincial or national environmental
administration. That’s one of its core [functions]... Then to consider horizontal collaboration”
[Waterlily]

Though horizontal governmental collaboration is challenging, it can be achievable. Scholars
indicate that there are mature institutions for multisectoral partnership within the State Council
departments for workers’ safety and biosecurity management, which are highly related to human
health, so building a multisectoral collaborative framework for HIA is not unimaginable.
“In the safe production and prevention of accidents, there is [a multisectoral collaboration].
It has always been the Safe Production Commission, for which the State Administration of Work
Safety, now called the Ministry of Emergency Management, is leading and coordinating. This
commission includes members such as the Ministry of Transport and the Ministry of Housing and
Urban-Rural Development. ” [Tulip, a mining and occupational safety professor]

Zenobia indicated the example from biosecurity management that HIAs can learn from.
“Our laws have designed different mechanisms to coordinate different sectors. For
multisectoral collaboration, a joint conference is an excellent coordination method. HIA needs the
public health administration, the ecological and environmental administration, and different
agencies. They typically want the State Council to lead to building an institution like the Joint
Prevention and Control Mechanism of the State Council. How to build such an institution for HIA,
I think we can take lessons from biosecurity management. There is coordination at the national
level, and it has an office responsible for routine activities. ” [Zenobia]

The good news is that the awareness of multisectoral cooperation on health is growing, and
some successful collaborative examples have emerged. According to a public health expert,
“For the awareness of sectors, I think in recent years, the collaborative intention among
sectors is strong because, for many sectors, it is tough to have some innovative works. For the

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problem to be solved within your sector, the root is usually in other sectors…Hence, we need to
seek external collaboration to solve the rooted cause.”[Waterlily]

An example of the growing awareness of multisectoral collaboration is the Beautiful China
Program, which is a core program in the 14
th
Five-Year planning.
“Due to the ongoing Beautiful China Program, ecological and environmental departments
repeatedly mention environmental health. The 14
th
Five-Year Working Planning for environmental
health just came out in July, indicating monitoring and evaluations on environmental health. It
also mentioned environmental health, human health, and the relationship between the environment
to human health. That illustrates the ecological and environmental departments have also been
aware of this problem [multisectoral collaboration]. ” [Waterlily]

The growing awareness of multisectoral collaboration is insufficient because integrating
knowledge from different professions is a problem. Scholars in the interviews suggest that the best
approach to solving this difficulty is to rely on multidisciplinary experts. If an expert has
professional training from several fields, they can integrate the two knowledge systems in their
mind and understand the focus from both sides. However, the number of such experts is limited.
“Although the study is multisectoral, what about the knowledge system? For example,
environmental science, life science, and public health. What does he need? Integration on a person.
Such as me. I learned environmental science, law, and economics. I can integrate those disciplines
on my own to connect the knowledge. If different persons do that, that will be hard to build the
connecting point.... The best way is to have one person learn all professions and integrate.” [Daisy]

For experts, the difficulty of professional incompatibility can be exaggerated when insufficient
time is allocated to an HIA. Since multisectoral collaboration needs more time to get each
participant understood by peers, such a process should have sufficient time. However, from an
administrative perspective, the priority of policymakers is to get the policy passed and reach a
decision as soon as possible. From their point of view, an HIA can add value to the decision, but
it is also a hurdle slowing the whole process. Hence, the policymaking entity wants to minimize

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the time on HIA, as we discussed in Chapter 2. That time requirement is for the entire HIA process,
so the working time for experts is shorter. Such a time conflict not only reduces the time to
understand each other within the experts but also reduces the time to fully understand some health
impacts that may need extended time to observe; in other words, the hastiness is a challenge for
the quality of an HIA in multiple ways.
Discussion
Our study identifies some barriers slowing down the development of HIAs in China. We found
the structural obstacles to halting the growth of HIA in China are quite different from the reasons
abroad. Scholars reported funding availability (Cole & Fielding, 2007), data accessibility (den
Broeder et al., 2003; Parry & Stevens, 2001; Harris-Roxas et al., 2012; Cole & Fielding, 2007;
Mindell et al., 2008), and building capacity (Dora & Racioppi, 2003; Mindell et al., 2010; Winkler
et al., 2013; Collins & Koplan, 2009) are some common significant obstacles for HIAs in other
countries. However, in our interviews, these problems are surmountable in China and not the
fundamental causes to explain why the development of HIA is slow. As for funding, Chapter 1
finds a trend that HIAs are more likely to occur in wealthy places. Such a result raises a concern
that funding may be a barrier for the adoption of HIAs in China. The attitudes on whether funding
is a barrier are mixed in the interviews, but most scholars believed funding was not a problem.
Experts pointed out that the cost of HIAs was not much. Funding is also available from the National
Natural Science Foundation.
As for data accessibility, an urban planner shared his harrowing experience acquiring health

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data with spatial correlation. But most scholars in our interview are not concerned about data
because there are data sources from hospitals, the government, or experiments. As for building
capacity, Liu & Liu (2019) reports that HIA experts are only adept in their professions and that
working in unfamiliar fields requires more time. Such extra time is necessary for pilots to gain
experience, usually not too long, and within a regular HIA timeline, so it is acceptable. China has
sufficient scholars so that each jurisdiction will select and train experts for HIAs. CHEC also
periodically provides technical training for experts. Scholars in the interviews think building
capacity is not a big concern in China.
The genuine structural barriers for Chinese HIAs include some functional differences
between EIAs and HIAs, the scientific uncertainties of the process between environmental hazards
and health, poor operability of current laws, and difficulty with multisectoral collaboration. This
part will discuss a few possible actions to address these difficulties. The order of supposed actions
is not entirely in line with the order of relevant problems discussed before because we find some
steps are helpful for multiple problems.
Recognize the primary goal of an HIA is for decision-making, not its scientific values (Krieger
et al., 2003).
An underlining assumption of a scientific HIA is it can quantify how the toxins harm human
health and how severe it will be. However, such quantification may not always work due to limited
scientific knowledge, data accessibility, or allowable time for an HIA (National Research Council,
2011). Sometimes, overemphasizing a high standard of evidence to address the quality of an HIA

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is not a reasonable practice (Cole & Fielding, 2007). When the conclusions of an HIA may contain
a certain level of uncertainty, we need to recognize that a decision related to the assessed project
may not be directly relevant to those uncertainties. A rational HIA report provides values for
decision-making but does not overemphasize how scientific it is (Krieger et al., 2003). Hence,
when some scientific uncertainties exist, HIA experts should not be attached to those uncertainties
but think about whether these uncertainties affect the decision. Here is an example of how an HIA
works well with some uncertainties of pollutants. Qionghai City conducted an HIA for its sewage
treatment plant (Zhuang & Xiao, 2021). The facility may generate air pollutants, including
methane, cyanides, ammonia, and other uncertain chemicals. Although the components of
pollutants vary daily, the HIA report does not need to predict how much the air pollutants will be
and how these pollutants will quantitatively affect human health; instead, the essential thing is to
suggest adding a deodorizing facility.
Start the specific regulation or legislation for HIAs and build matching policies
The HIA development may be disrupted when a new governor comes into office (Cole &
Fielding, 2007). Legislation is a protective measure to prevent the disruption of HIA development
across different electoral cycles. However, the legislation has had mixed success. In the US, the
Health Impact Project (2015) found eight states considered bills containing most parts of an HIA,
but only Vermont, Massachusetts, and Washington State succeeded. Therefore, not all politicians
and jurisdictions enhance HIA into legislation globally.
In our interviews, scholars believe a middle-level regulation or legislation for HIAs is

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necessary for China, but it’s not feasible to get it done immediately. China now relies on pilot
results to see how to regulate HIAs. Matching policies cannot be omitted because they are a guard
of “a systematic and orderly progression from problem formulation to solution or a network
perspective” (Putters, 2005). Hence, local pilots must combine regulations and matching policies
to make HIAs workable. The development of matching policies should keep pace with regulations
or legislation.
Hangzhou is an advocate of this strategy. Hangzhou (2019) made up its matching measures
by establishing a joint conference (as mentioned before) for discussion, sharing information,
resources, and advisory within a network, adding incentives to the promotion of HIAs, and
educating new governmental personnel. Hangzhou’s decision-making support system for the
experts is also a part of the matching measures. As Hangzhou skillfully advanced HIA, other cities
learned a lot from Hangzhou, so many cities borrowed Hangzhou’s texts. However, it will not say
Hangzhou’s template fits everyone. A public health expert in the interview indicated that
adaptability to local conditions is essential. The pilots are still ongoing, so that new templates may
emerge in the process. Urban managers and lawmakers should keep an eye on these practices,
especially when each jurisdiction may have unique matching policies. For example, Yuhang
District (2021) enacted a policy focusing on the management of the expert panel to facilitate local
HIA policy. When China gains enough experience and knowledge on HIA, national regulation or
legislation is supposed to come out.

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Develop an authoritative technical guideline
Developing an authoritative technical guideline is tricky, as illustrated by the failure to
develop Standard-1999 and TG-2008 and the non-detailed TG-2011 (Liang, 2020). Although it is
hard, an authoritative guideline is necessary to ensure the operability of laws (Zhuang & Xiao,
2021; Shi, 2021). Experts in our interviews think HIAs will apply to private projects in the future.
These HIAs may be done by HIA companies, who also need an authoritative and standardized
guidelines to regulate. We identify a few actions that may make the guideline successful.
First, the leadership of the technical guideline for HIAs should include the Ministry of Ecology
and Environment (MEE) and the National Health Commission (NHC), suggested by an
environmentalist in our interviews. We believe such a suggestion is very reasonable because this
co-leadership can avoid professional gaps and make the guideline meet the requirements of both
environmental and health laws. This way, environmental and public health experts can have the
same guidelines regarding their professions.
Second, learn from the guidelines for compensating ecological and environmental damages
(MEE, n.d.), suggested by an ecologist in our interviews. Liang (2020) argued that a solid barrier
to the guidelines on environmental health is the costs of lawsuits and compensations are enormous
when a project cannot meet the environmental standards. MEE has worked on this problem since
2011, and some new standards and regulations came out recently to deal with the diagnosis of
damages and compensations (MEE, n.d.). Although these MEE standards and regulations focus on
biodiversity, not public health, some technical and administrative methods are similar.

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Third, develop some HIA tools (Wang & Jiang, 2020). Tools are a crucial component of
technical guidance. Forsyth et al. (2010) reported three useful tools for urban planners. US EPA
(2013) summarized 52 available tools, including some frequently used ones, such as Neighborhood
Environment Walkability Scales. The current Chinese cases rarely report the use of these tools.
Besides, China does not have its own toolkits. Developing Chinese adaptive tools of HIAs seems
to be a workable goal, though it’s not on the government’s agenda in many cases. These tools need
to consider the spatial disparities in China and select appropriate variables and parameters to make
them adaptive to each city’s demands (Wang & Jiang, 2020).
Fourth, the guideline should provide guidance on the various policies, programs, and projects.
HIA is an adaptive tool because it has the potential to apply to multiple types of targets (Harris-
Roxas et al., 2012). The guideline should have some flexibility to allow experts to adapt the
assessment of a project by its specific features (Liang, 2020). Hence, the guideline should cover
various uses and skills, such as qualitative and quantitative methods (Wang & Jiang, 2020). Since
this guideline is supposed to work for multiple professions, it needs more experience from pilots.
Thus, it is best to choose the projects diversely for different cities, summarize and review the cases
by a centralized technical institution (such as CHEC), and the institution works collaboratively
with the policymaking agencies to draft the guideline.
Fifth, address the HIAs for public policies and projects separately. For an HIA of public
policies, the health impacts are often general and hard to quantify, so qualitative HIAs are very
common. The HIAs for projects are usually in the shape of an EHRA/EHIA because an
EHRA/EHIA can integrate the law-required EIA with an HIA (Bhatia & Wernham, 2008), which

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can avoid time and money waste. Plus, a project needs more scalable environmental and public
health results, so an EHIA is preferable. However, due to the functional difference between an EIA
and an HIA we discussed, the guideline must scale what level of health risks and what kind of
health impacts are acceptable for a project. Hence, such a guideline for projects needs sufficient
parameters, standard models and cases, and clear thresholds to refer to, making it dramatically
different from the guideline for public policy. It’s best to develop the two types of guidelines
separately.
Increase the number of multisectoral professionals in the government
As we argued, multisectoral collaboration is problematic in China because governmental
sectors are prone to emphasize their core functions and marginalize those periphery roles, making
them more likely to work vertically and less likely to cooperate horizontally with peer sectors.
Such a problem was also reported in Slovakia (Mannheimer et al., 2007). Krieger et al. (2003)
argued the importance of interdisciplinary expertise to avoid partial analysis and prevent decision-
makers from facing unknown risks. In our interviews, scholars also confirmed the role of
multidisciplinary knowledge. However, the number of interdisciplinary experts is limited in China,
similar to the findings of Krieger et al. (2003). Such a shortage is an obstacle for the government
to grasp the essence of the problem and design a solution quickly. When a government cannot
quickly understand whether a technical guideline is practical, it can face significant opposition
from various stakeholders. Hence, introducing interdisciplinary experts into HIAs can reduce such
a burden, bridge the gap between different professions, and be more likely to promote the proposed

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agenda successfully.
Conclusion
This study identifies a few structural barriers that slow down the development of HIA in China.
First, the functional differences between EIAs and HIAs. An HIA is advisory and powerless
compared to an EIA on the approval of projects. Therefore, developing an HIA system is not urgent
for some governments, and they need more time to observe other pilots. Besides, environmentalists
regard an Environmental Health Risk Assessment as an HIA, but public health professionals want
to build an HIA system somewhat independent from EIA, which needs a lot of time.
Second, the scientific uncertainties regarding the causal relationships between environmental
hazards and human health. Multiple pollutants and exhausters in the environment make it
unreasonable to hold a single project accountable for adverse human health outcomes. Plus, many
newly invented chemicals still need further research on their toxicity. These facts make an HIA
inconclusive on some health effects and consequences, resulting in a hesitancy for government to
use it in decision-making.
Third, the insufficient law operability, including a lack of a specific regulation/ legislative
piece, matching policies for an HIA, and technical guidelines for HIAs. HIA is a specific institution,
so the detailed requirements cannot be written in a fundamental law, the Basic Medical Care,
Sanitation, and Health Promotion Act. It requires a specific middle-level regulation or legislation
for more details, but they are non-existent. Matching policies are supportive works to ensure the
workflow of an HIA. However, local governments must establish matching policies, which take

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time to test and observe. For the technical guideline, two failed precursors illustrate it is a tough
job. Multiple reasons contribute to the difficulty, including technological immaturity caused by
scientific uncertainties, opposition from the environmental sector, and costs related to lawsuits and
compensation.
Fourth, the immature multisectoral collaborative framework of an HIA. Governmental sectors
tend to work vertically, often marginalizing those periphery functions, making horizontal
collaboration hard. Plus, many pilots require quick feedback from HIAs, giving experts limited
time to work, which undermines communication and understanding between different professions.
Recently, some governmental sectors have been aware of the importance of multisectoral
collaboration, but a new challenge emerges in the process—a lack of multidisciplinary experts to
integrate knowledge from different professions.
We further suggested a few possible actions based on our interview results and literature.
First, prioritize the decision-making role of an HIA over its scientific values. It is unavailable
to acquire high-standard evidence, and many scientific uncertainties exist in the assessment.
However, these difficulties may not be barriers to decision-making. Hence, some problems are
surmountable when experts realize the primary goal is for decision-making.
Second, start the specific regulation or legislation on HIA and build matching policies. Local
pilots usually combine these two to create local HIA policies. Hangzhou is one of them to provide
many valuable lessons. Other places can learn from Hangzhou.
Third, continue to develop an authoritative technical guideline for HIA. Building an
authoritative guideline is the most challenging work, so we suggest a few actions to promote it,

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including the co-leadership of the Ministry of Ecology and Environment and National Health
Commission, learning from the guidelines for the compensation of ecological and environmental
damages to address potential oppositions related to lawsuits and compensation, developing some
Chinese HIA tools, containing diverse skills in the guideline to make HIAs fit multiple areas, and
addressing HIAs for public policies or projects separately.
Fourth, increase the number of multidisciplinary professionals in the government. This step is
crucial for the government to quickly grasp the nature of policies that needs multisectoral
collaboration and reduce potential opposition from various stakeholders.
Our study faces a few limits. First, the conclusions of this paper may only be effective in a
few years because the Chinese HIA system is developing, and many problems may have new
emerging solutions. Second, although we try to balance the voices from different sectors, there are
still some disparities. Some scholars’ words were quoted more than others, while a few scholars’
interviews were not quoted at all. This disparity may devalue some fields’ voices. Third, other
professions, such as journalism, should have been invited to our study because some jurisdictions
think journalists are significant to public communication for HIAs. However, we are unable to ask
a journalist to join our study. Fourth, some other policies have some compatible considerations
with HIAs, but we couldn’t fully explore them because the extent is too big.
Future studies can focus on adaptive Chinese HIA tools, what kind of multisectoral experts
need to be prioritized, and how to raise awareness of the significance of HIAs in governmental
sectors. These areas may provide new insights into HIAs that dramatically change the current
practice.

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Conclusion
This dissertation tries to illustrate how Chinese cities use Health Impact Assessment (HIA) as
a tool for urban management. First, Chinese HIAs are a new member of the global HIA community,
yet such a community knows little about Chinese variations because of China’s unique background
and language. This study makes it achievable for mutual communication on Chinese HIAs.
Although the establishment of the institution of HIA was at the National Health and Sanitation
Conference in August 2016, such an institution was still at an early stage, with many ongoing pilots
in November 2022. Although HIA has been applied to many countries since the 1980s, I believe
the exploration of Chinese HIAs is meaningful because HIA is a decision-making tool that has to
consider the political, social, economic, cultural, and technical contexts. China is a developing
country with centralized politics with a decentralized administration, fast economic growth,
competitive industries, a strong social value of collectivism, rising technological advances, and
sufficient professionals that can work on HIA. Few countries in the world have a similar
background to China. Within such a context, China must develop its unique pathway for HIA,
which is an excellent lesson for the international community.
Chinese scholars can quickly learn HIA from developed economies from English literature;
however, the rest of the world is hard to investigate China due to few professionals can read
Chinese literature. Hence, it is critical to diving into Chinese literature, cases, and publications to
synthesize Chinese takeaways for the globe. This dissertation is one of the earliest attempts to fill
such a gap to introduce the Chinese HIAs to international academia and policymakers by utilizing

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bilingual data.
Second, this study attempts to reflect to the current actions and ideas of Chinese HIA
practitioners and policymakers. China expanded the HIA pilots to allow each province to select a
city to be the national pilot, while provinces could choose other cities to be local provincial pilots
from July 2021. Many cities are joining the line to start local HIA pilots as I write. The
development of the institution is slow, so these jurisdictions can likely take lessons from this study
in May 2023. I suggested some revisions on a few cities’ HIA policy drafts in Fall 2022 using a
part of the findings from this dissertation, which received a warm welcome. Therefore, this
dissertation can contribute timely conclusions for local policymaking for those new pilots.
Third, this study it is one of the first studies in China to study HIAs from multiple perspectives.
While writing Chapter 3, the authors interviewed seventeen experts from urban planning, public
policy, public health, health law, environmental sciences, environmental law, ecology, construction
management, mining, and occupational health. These professions are crucial participants in the
development of HIA, so their perspectives are a valuable lens to understanding HIA. This study
synthesizes these lenses to provide a holistic understanding. This type of study is scarce in China
since many scholars can only discuss HIAs from their profession without a broader view. This
study tries to break the walls among fields and transform HIA into public goods for all related
disciplines. This study can be the foundation for a multidisciplinary discussion on HIA and
facilitate a collaborative framework.
This study finds Chinese HIAs also bend to political forces, same as the practice in western
countries, but China exerts it by the design of the organizational structure to craft an HIA. In China,

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the government completely dominates the official HIAs for decision-making. Chapter 2 finds some
jurisdictions, such as Hangzhou, established a robust governance structure to work on HIA and
centered on the steering institution. Unlike many western countries that a temporary committee
governs the HIA and dismisses after the completion, the Chinese steering institution is a permanent
administration. The steering institution is often the local health office (or the patriotic sanitary
office/ health promotional office), with many brands and titles, under the local health commission.
It initially screens the policy or project to be assessed before experts’ screening, organizes experts
to evaluate the health impacts, does the filing works, coordinates different sectors, exchanges
experience with internal and external practitioners, and shares information, resources, and policy
advisory to other participants. The steering institution can commission the HIA task to some third-
party professionals. Hangzhou established a joint conference led by municipal heads to coordinate
the crucial issues in the development of HIA. Hangzhou built a motivation system to include the
promotion of HIA in officials’ performance evaluation, although experts expressed mixed feelings
on such a policy. Some other jurisdictions also assign some HIA tasks to street/town-level
governmental branches. I am skeptical of this action because the street/town-level governmental
staff has already been overwhelmed with too many tasks and insufficient workers or money,
especially under COVID-19.
Political forces also influence the geographical disparity of using HIAs. The cases in Chapter
1 and the policy files reviewed in Chapter 2 indicate a significant geographical difference in the
practice of HIA. Hangzhou, Yichang, Beijing, Shanghai, and Guangzhou are the pioneers of HIAs,
while Zhejiang Province is the provincial leader. In the interviews in Chapter 3, an expert

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hypothesized that funding availability was one of the reasons. He expressed the concerns in the
government that high-income provinces have more resources than those economically constrained
provinces, and so was the interest in HIA. However, the current HIAs are usually desk or rapid
ones, finished in a couple of days, without any new data collection, so the cost should be limited.
Therefore, the cost of HIA seems not to be a financial burden. The geographic disparity can come
more from the will to promote a local health agenda (Corburn, 2004). Experts in the interviews
indicate the local governmental heads’ intention and awareness of the HIA matter. Some cities,
such as Yichang, use HIAs to brand themselves as Healthy Cities as a local achievement. Hence,
the local political and health agenda will likely be the real driver of such geographic disparity.
Chapter 1 reviews 43 Chinese HIA cases and finds that urban planning is a crucial component
of HIA, as urban planners and allied professionals engaged in 19 cases. The engagement is
expected to grow as the HIA pilots go forward. Community/regional planning, transportation,
landscape, built environment, and outdoor space are the planning topics in these cases. Urban
utilities are often assessed with significant planning implications. However, affordable housing
attracts little attention from HIA practitioners, indicating a considerable gap. Although urban
planners are essential players in HIA, they are not the leaders who are usually public health
professionals. The findings from Chapters 2 and 3 confirm that the local health department always
prepares the HIA policy draft. The number of urban planners with a long-time commitment to HIA
is minimal. As far as I know, only a group of urban planners led by Prof Lan Wang at Tongji
University have devoted themselves to HIAs for a few years in Shanghai. Since HIA is a growing
field with a deep relationship with urban planning, it requires more planners to work in this field.

141
The growing use of HIA implies that urban planners must embed Health in All Policies (HiAP)
into their minds in the future. This new idea is somewhat challenging for urban planners because
it requires them to ethically select evidence, be familiar with health data, and use HIA to properly
adjust a policy, a program, or a project and overcome the professional gaps to work with scholars
from other fields collaboratively. Interviews from experts in Chapter 3 repeatedly illustrate the
hardship of working horizontally than vertically because a department has its core functions. When
the department focuses on its core functions, it will likely neglect periphery roles to work with
others. Besides, professional boundaries are also a burden to overcome for collaboration. However,
the awareness of multidisciplinary collaboration is increasing because departments find many new
problems within their profession rooted in other arenas that they must work together to solve. In
this process, the lack of multidisciplinary professionals becomes a barrier to promoting
collaboration. Thus, this study calls for the government to include more interdisciplinary
professionals to facilitate a deeper understanding of complex issues, working across boundaries
easier, and make better decisions.
Building the capacity of HIA is a frequently mentioned concern in the literature. Chapters 2
and 3 find that many jurisdictions have measures to build local technical capability, including
workshops for experts and, seeking help from third-party professionals, creating an internal
network to share resources, information, and policy advisory. Hangzhou developed supportive
software for experts to simplify searching literature and to code the health impacts. Experts believe
that the number of potential professionals that can work on HIA is enough in China, but these
professionals need some training to be familiar with HIAs.

142
The procedure of HIA is adapted from WHO’s standard model, which includes screening,
scoping, appraisal, reporting, and monitoring. This study finds that the Chinese model is highly
based on CHEC’s (2020; 2022) works, but local administrations also have the discretion to change
based on their demands. CHEC (2019) suggested a nine-step model, including initial screening,
filing to register, making up the expert panel, screening, appraisal, reporting and recommending,
filing the results, using the results, and monitoring, while the initial screening is optional and many
cities do not utilize it. Some cities emphasize a four-step core model: screening, appraisal,
recommending and reporting, and monitoring. For such a model, the filing works and making up
the expert panel are not considered within a formal procedure, and scoping is integrated into the
screening. Therefore, except for the initial screening, the core steps of a Chinese HIA are the same
as WHO’s standard; the Chinese model emphasizes some administrative steps inherent in the
WHO’s model workflow.
Chapter 1 summarizes the methods and data used in HIAs. We found the official HIAs for
public policy are likely to be qualitative, and data comes from local sources and platforms. A
project’s HIA is expected to be quantitative. Unofficial HIAs for an imagined policy scenario are
also quantitative. Quantitative HIAs use multiple data sources and computer models. Experts in
the interviews believe HIAs should combine qualitative and quantitative methods because HIA is
not just a “scientific” report but more about art and policymaking.
HIA is a tool predominantly for future planning to predict health impacts. A few cases are
retrospective reviews to examine the health consequences after the enactment of a policy or the
operation of a project, such as APEC and Parade Blues, or Yichang BRT. Interviews in Chapter 3

143
indicate that some experts believe “prospective” and “retrospective” HIAs should not be separately
defined because they should be two parts of a big HIA. However, the retrospective piece is
frequently missing due to ineffective monitoring. Such a problem is also common in developed
economies (Davenport et al., 2006). As we argue in Chapter 2, monitoring is a crucial part of the
HIA in the long run because it provides feedback on the accuracy of the prospective predictions.
Although the absence of effective monitoring is not a halt to establishing the HIA institution, it
will be indispensable when the system becomes routine. Hence, monitoring is a definite field
needing more attention, resources, and studies.
The cases in Chapter 1 indicate that stakeholders' involvement is marginalized because many
cases are pure academic analyses without any community input. Chapter 2 finds that Chinese HIAs
are technocratic, but they also provide multiple channels for the engagement of stakeholders, a
takeaway confirmed in the interviews of HIA practitioners in Chapter 3. These channels often
focus on screening, appraisal, and monitoring stages, leaving other steps purely for experts and
governmental officials. The approaches for community participation include inviting influential
people to the expert panel, opinion surveys, focus groups on selected interest groups, and
encouragement on the monitoring from the public after the approval of a policy or a project.
Interviews with an environmental law professor indicate monitoring can be effective only when
the public has basic knowledge of potential harms and environmental awareness. Monitoring will
be undermined when the public has no expertise on those unknowns. Experts in the interviews
believe that the Chinese public does have a substantial interest in monitoring and fighting against
those polluters when people are aware of the detriment of a project, such as building a waste

144
incinerator around their neighborhood. Therefore, the community voices impact decision-making
in many ways, though the government still holds the final decision, and urban planners should pay
closer attention to community input.
In the long run, HIA can learn from EIA institutions that the government is a service provider
on approval and let the market pay the expense. Such an approach can take the costs off the
government’s shoulders, but it also significantly departs from the current practice. The HIA system
focuses entirely on government-organized ones, without any assessments on private projects
unless with a governmental dictation or just for academic interests. Chapter 2 suggests that private
projects should also be included in the policy because those projects may have substantial health
impacts. This suggestion receives echoes from experts in Chapter 3, and experts further suggest
accrediting credentials for those eligible Health Impact Assessors. Such advice may not be feasible
right now, for the HIA system is still immature, but it will be a workable action in a few years.
This study finds that the difference in functional roles between EIA and HIA is a structural
barrier for HIA. An EIA is a mandated file for the approval of a project, while an HIA is only an
advisory document. As the development of the institution of HIA is not urgent, a government can
wait longer for a local practice to see how other jurisdictions do. Besides, the different perceptions
from environmentalists and public health scholars also matter that environmentalists regard an
Environmental Health Risk Assessment as an HIA. In contrast, public health professionals want to
integrate more aspects of health impacts and develop a system independent from EIA.
Another structural barrier is the scientific uncertainties on the causal relationships between
environmental hazards and human health. Because of our environment's multiple polluters and

145
exhausters, holding a specific project accountable for many chronic population health impacts is
impossible. Moreover, many newly invented chemicals' toxicity may still be largely unknown. In
these cases, an HIA cannot make conclusive statements on the health outcomes, so the government
is hesitant to promote it. This study suggests prioritizing decision-making because sometimes those
uncertainties do not influence the decision on actions.
One more barrier is the laws lack sufficient operability. The Basic Medical Care, Sanitation,
and Health Promotion Act only define the HIA institution, but this fundamental law cannot provide
more details. Middle-level legislation or ordinance is required to fill such a gap; besides, due to
technical immaturity is driven by the scientific uncertainties mentioned above, sectoral conflicts,
and concerns on the compensations and lawsuits, no practical and detailed technical guidance with
legal power exists, which also undermines the operability of the law. Matching policies are also
necessary to guard the workflow of an HIA, yet there is no national standard for it, and local
jurisdictions must explore it by themselves. This study suggests that the Chinese government and
scholars should continue to work out middle-level legislation, matching policies and technical
guidelines with legal power in the coming years. Although this is a challenging goal, some steps
are achievable, including building a co-leadership between the Ministry of Ecology and
Environment (MEE) and the National Health Commission (NHC), learning from the guidelines
for the compensation of ecological and environmental damages, developing HIA tools, add
considerable skills and expertise in the procedure, and separately address HIAs for public policies
and projects.
Sustainable development is a concern when I combine the findings in Chapters 1 and 2.

146
Chapter 1 finds that many existing studies focus on sustainable development, such as energy
utilization and climate change. While sustainable development is also emphasized in HIA policy
files, the measures to support this goal are weak. The current practice relies on cost-benefit analysis,
which is not enough to protect sustainability. Besides, the cumulative impacts from many projects
are not considered. There are many shortcomings if people think about the effect of a project solely
without taking the cumulative impacts into account. The biggest pitfall is the tragedy of the
commons—when nobody can be precisely accountable for the consequences, everyone can
perceive they are free from the responsibility of their actions and prioritize their personal goals.
Although a single plant can’t be accountable for all the health damages of the pollution, HIAs are
still important because they avoid the cumulative harms from projects that each has the probability
to add negative health impacts to human bodies. HIAs are a necessary tool to measure the health
impacts qualitatively and quantitatively.
This study identifies a few other shortcomings in the development of Chinese HIAs. The first
one is the emphasis on quickness over thoroughness. Chinese governmental sectors want an HIA
to provide recommendations on their policies or projects as soon as possible, so many jurisdictions
only give a short time for HIAs, usually less than two months. Such a short time prevents China
from having many comprehensive HIAs to thoroughly examine the health consequences that may
be observed in an extended period. Most Chinese HIAs are desk or rapid HIAs that do not review
the health consequences in detail. Such a feature may undermine the quality of HIAs.
This study finds that China has some unique contributions to the practice of HIA. First, it
promotes using of supportive software for experts. Interviews in Chapter 3 indicate that only a

147
Dutch company tried to develop such software, and it seemed unsuccessful later. China has a strong
interest in developing the software because China emphasizes the quickness of an HIA that the
software can save time for experts. This feature is significantly different from global counterparts
because HIAs in the western world usually take a long time to complete and the demand to save
time via software or searching literature is not so strong. Hangzhou allows all municipal
jurisdictions and nearby counties to use its software, which may be available for broader use later.
Although Hangzhou’s software is a governmental sponsored project, such a success implies that
information communication and technology on HIA may grow if the demand for private HIAs
dramatically increases.
Another Chinese innovation is within the procedure. Some Chinese HIAs start with “initial
screening,” which is a screening process within the steering institution before the screening by
experts, different from the standard procedure from WHO (ECHP, 1999). This step is suggested
by CHEC (2020), although not all jurisdictions follow such a suggestion. This step can make sure
that the HIA is within the government’s interest and avoid redundancy if the government thinks it
is unnecessary.
One more invention is it allows local jurisdictions to build a high-level joint conference to
discuss and solve the critical issues of HIA development. The municipal heads lead the joint
conference, and each governmental sectoral director participates in the decisions. In contrast, the
execution of those decisions is done by coordinators from each sector and the steering institution.
This is a good model for a multisectoral collaborative framework, though it is still under testing.
This study suffers from a few limitations. First, because of data availability, our review of the

148
cases and policy documents is not a complete collection of all the existing Chinese works. Experts
in the interviews told me that a think tank working for the National Health Commission has many
extraordinary data and reports; however, we don’t have access to them. Second, some jurisdictions
also include journalists as professionals in HIAs, but this study fails to include them. Third,
although this study tried its best to balance the views of scholars, disparities still exist so that some
professions may express a stronger voice than others in Chapter 3.
Future studies can study new HIA tools designed for China, how to evaluate the health impacts
of private projects, how to strengthen the measures to protect sustainability, establish a monitoring
system, determine what types of multidisciplinary experts need to be prioritized, and how to raise
further the awareness of the significance of HIAs in governmental sectors. Besides, building an
HIA association, starting professional courses in universities, and writing qualified textbooks are
essential tasks for the Chinese HIA’s future, waiting for collective actions from academia and
practitioners. Moreover, since the pilots will end in a few years, synthesizing the findings from
those pilots to draft a provincial or national-level HIA policy is also a field that needs more research.

149
References
Chinese Health Education Center. (2019). Theory and Practice Research of Health Impact
Assessment. China Environment Publishing Group

Chinese Health Education Center. (2020). The Implementation Manual Booklet of Health Impact
Assessment (2019 Edition). People's Medical Publishing House Co., LTD

Chinese Health Education Center. (2022). The Implementation Manual Booklet of Health Impact
Assessment (2021 Edition). People's Medical Publishing House Co., LTD

Corburn, J. (2004). Confronting the Challenges in Reconnecting Urban Planning and Public Health.
American Journal of Public Health, 94(4), 541–549. https://doi.org/10.2105/AJPH.94.4.541

Davenport, C., Mathers, J., & Parry, J. (2006). Use of health impact assessment in incorporating
health considerations in decision making. Journal of Epidemiology & Community Health,
60(3), 196–201. https://doi.org/10.1136/jech.2005.040105

European Centre for Health Policy. (1999). Gothenburg consensus paper-Health Impact
Assessment-Main concepts and suggested approach. WHO Regional Office for Europe

150
Appendices

Appendix Table 1. The cases reviewed in this study
Case Location Type Officiality Lead Agencies Expertise
(Aunan et al.,
2004)
Shanxi
Province
Policy-Climate change/
energy/air pollution
Unofficial (China Meteorological
Administration etc)
CC, Env, Econ, IS
(Chen et al.,
2007)

Shanghai

Policy-Energy

Unofficial

Env; PH; EH; etc
(Li et al.,
2018)

China
Policy-Climate change/ low
carbon

Unofficial

Econ;
Env;
(Fischer et al.,
2005)
Hechengli
Village, Jilin
Province

Project-Energy

Official

UNDP

EH; Anthropology

(O’Connor et
al., 2003)
Guangdong
Province vs
China

Policy-Climate change

Unofficial

(OECD)

Local Env
(Wang &
Mauzerall, 2006)
Zaozhuang,
Shandong
Province

Policy-Climate change/energy

Unofficial

Science
Tech; IS
(Yang et al.,
2013)

China
Policy-Climate
change/energy

Unofficial

Eng; Env; Econ
(Zhao et al., 2021) Linfen,
Shanxi
Province

Policy-Energy/air pollution

Unofficial
Env
Gov
PH
(Zhao et al.,
2018)

China
Policy-Energy/Air
pollution/ transportation

Unofficial

EH;CC, etc

151

(Chen et
al.,2009)

Shanghai
Policy-Air pollution/
transportation

Unofficial
(China Ministry of
Environmental Protection)

Env; PH; etc
(Lin et al.,
2017)

Beijing

Policy-Air pollution
Perhaps
official
(Beijing Municipal
Environmental Monitoring

PH & SJ

Centre, China Meteorological
agencies, Guangdong CDC)

(Ren et al.,
2021)
Guangdong
Province

Policy-Air pollution

Unofficial

Eng & Env
(Tang et al.,
2014)
Taiyuan,
Shanxi
Province

Policy- Air pollution

Perhaps
official

PH & EH
(Lin et al.,
2016)

Guangzhou

Policy-Air pollution

Unofficial

(Guangdong CDC)

PH & SJ
(Xue et al.,
2019)

China

Policy-Air pollution
Perhaps
official

Earth &Atmo
(Yue et al.,
2020)

China

Policy-Air pollution
Perhaps
official

Env; Eco; Geo;
(Maji et al.,
2018)

China

Policy-Air pollution

Unofficial
Urban Env,
etc

(Miyazaki et
al., 2020)

China
Policy-Air
pollution/COVID-19
lockdown

Unofficial

Air; Earth; Env

(Giani et al.,
2020)

China and
Europe
Policy-Air
pollution/COVID-19
lockdown

Unofficial

Env; M&S; CC

152

(Li et al.,
2010)

Beijing
Project-Building
engineering
Perhaps
official

CM
(Chen et al.,
2021)

China
Policy-Economics/Poverty
Alleviation

Unofficial

Econ;
(Liang &
Cao, 2015)
Sichuan
Province
Policy-
Economics/Employment
assistance
Perhaps
official
Social Policy/
Social work M&S
(Yang et al.,
2020)

China
Policy-Economics/Credit
Constraints
Likely
official
(National Bureau of
Statistics)
Labor;
Accounting; Econ
Border
Economic
Cooperation
Zone
(ADB, 2018a;
Habib et al.,
2020)
Lincang City,
Yunnan
Province
Program/Project-
Planning/ADB
Official ADB
Hangzhou 13
th

Five Year
Planning
(CHEC, 2022)

Hangzhou

Policy-Economic/Social
Development

Official

Healthy Hangzhou Construction
Lead Council

PH, law
SM; HP
Qionghai
Water
Treatment
Project
(CHEC, 2020)

Qionghai,
Hainan
Province

Project-Water pollution

Official
Qionghai City Patriotic Sanitary
Council. Beijing Association for
Healthy City Promotion and
Development
was assigned to do the HIA.

HC; HP; Econ;

153

Gong River
South Band

Yudu County,

Landscape
(CHEC, 2019)
Jiangxi
Province

Project-Landscape

Official
The Office of Yudu County
Health Promotion Committee
UP; Env;
Tourism; etc
(Cao et
al.,2015)
Beijing Project-Building
engineering
Perhaps
official
CM
(Li et al.,
2017)
Jiangsu
Province
Project-Building
engineering
Perhaps
official

CM
Hangzhou

Decremental

Waste

Complex

Project-Solid Waste

Healthy Hangzhou Env; PH; Econ;
(CHEC, 2022) Hangzhou Treatment Plant Official Construction Lead Council management
Jimei
Makeup Yichang,

The Office of Yichang

Company Hubei

Sanitary and PH, Env, EIA, HP
(CHEC, 2022) Province Project-Chemical Co. Official Health Committee

Datong, Project- (The State Environmental
(Lindhjem et Zhengzhou, EEIA/Energy/Sewage/Irritat Likely Protection Administration of Econ; and Resource
al., 2007) Shijiazhuang ion official China) Management; Env;
Youth
Development

Program-Youth

Healthy Hangzhou

(CHEC, 2020)

Hangzhou Development Official Construction Lead Council Soc; PA; SM; HP;

154

Ecological Yichang, Xiling District Health Law; Education;
Citizens Hubei Program-Ecological

Promotion Committee and PH; Env; UP;
(CHEC, 2019) Province Development Official Propaganda Department civil affairs.
Program-Community
(Hou, 2018) Tianjin planning/Children Unofficial

Arch; UP
Huangpu
Regional Huangpu

Planning District,

Perhaps Tongji University’s Healthy

(CHEC, 2020) Shanghai Program-Planning official City Lab HC; UP
Yichang, The Office of Yichang
B-WJ18 Parcel Hubei

Sanitary and Health

(CHEC, 2022) Province Program-Planning Official Committee;
Yichang Natural Resource
and Planning Bureau
PH; EH; Geo HP
A Community
(CHEC, 2022)
Hangzhou Program-Planning Official Healthy Hangzhou
Construction Lead Council;
Tongji University Healthy City
Lab was assigned to do
the HIA
HC; UP
(Zhang &
Deng, 2021)

Shanghai

Program-Planning
Likely
unofficial

UP

(Zhu et al.,
2021)
Deqing
County,
Zhejiang
Province

Program-Planning/Built
environment/Disability

Official
Deqing County Sanitary and
Health Bureau; Fudan
University Public Health
School

Gov

155

Subway 15
(CHEC, 2019;
2022)

Shanghai

Project-Transportation

Official
Tongji University Healthy City
Lab was assigned to do
the HIA.

HC; UP
Yanji BRT
(CHEC, 2020;
ADB, 2018b;
Habib et al.,
2020)

Yanji City,
Jilin Province

Project-Transportation/ADB

Official

ADB

PH; UP; Env; Soc
Yichang BRT
(CHEC, 2020;
Yichang
Municipal

Yichang,

Government,
2013)
Hubei
Province

Project-Transportation/ADB

Official
ADB & Yichang Healthy
City Expert Committee
Urban construction
PH; HP;
Soc; Env; EH;

Abstract (if available)

Abstract China started developing Health Impact Assessments (HIAs) in 2016. However, most current studies focusing on Chinese HIAs center on the introduction of the practice from western countries or the implementation of pilot case studies in local places. Few studies exist to systematically review Chinese practices and policies. This study builds on the work of existing Chinese HIA case studies and pilot policies to try to uncover the state of the science in China and identify the pros cannot be applied. This study also tries to identify the structural barriers halting the development of HIA and suggest a few feasible recommendations to promote the tool.

In Chapter 1, this study summarizes the findings regarding locations of Chinese HIA cases, lead agencies, procedures, screening, scoping, health impacts and health economic impacts, stakeholders, appraisal, and reporting and monitoring. It further implies some takeaways for urban planning, including the significant role of urban planners, the value of Health in All Policies, the need to the respect community voices, the merits of Chinese innovations, and the prosperity of a growing HIA consulting enterprise.

Chapter 2 finds there is significant homogeneity based on text analysis of the regulatory files. Strengths include taking advantage of the pilot status, building a powerful governmental working network, creating multiple channels for public participation, utilizing information and communication technology, and establishing a motivation system. The weaknesses include no regulation on private projects, emphasis on fastness over thoroughness, and weak measures to protect sustainability.

Chapter 3 examines the structural barriers of HIAs. Interviews revealed four structural barriers, including the functional inconsistency between EIAs and HIAs, the scientific uncertainties of the process between environmental pollutants and human health, insufficient operability of current laws, and challenges for multidisciplinary collaboration. The authors recommend four actions, including emphasizing the HIA’s role of decision-making instead of scientific values, starting the specific legislation or regulation on HIA and relevant matching policies, developing an authoritative technical guideline, and employing more multidisciplinary staff in the governmental sectors.

This study concludes HIAs are a significant tool to promote the combination of public health and urban planning in China. Urban planners’ engagement is one of the most crucial factors to the success in the HIA field. Urban planners need to keep Health in All Policies in mind for better planning, yet such a task has a few challenges. The public engagement is non-existent in academic HIAs, but in a real decision-making process, stakeholders are important. Chinese insights for the global HIA community, include the fast development of application of Internet communication and technology, the initial screening, and the organizational innovation. To serve private business, it is expected the professionals working in this field will grow and a HIA consulting enterprise will thrive. Yet, to achieve the healthy development of HIAs in China, urban planners, policy and law makers, and other professionals should work closely and collaboratively to develop practical technical guidelines, proper regulations on the delivery of HIAs, and expand the applications to all kinds of scenarios.

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Creator Zhao, Junteng (author)

Core Title Health impact assessment, the concept, science, and application in China

School School of Policy, Planning and Development

Degree Doctor of Philosophy

Degree Program Urban Planning and Development

Degree Conferral Date 2023-05

Publication Date 03/31/2023

Defense Date 03/06/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag China,Hangzhou,health impact assessment,OAI-PMH Harvest,pilot,Public Policy

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Advisor Sloane, David Charles (committee chair), Lewis, LaVonna Blair (committee member), Lowery, Bryce Christopher (committee member)

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