Real estate developers create places where people live, work, play, and thrive. Health is emerging as a significant aspect of this work. How development projects affect health is important to users and occupants, as well as to surrounding communities. Projects that advance health may also have a market advantage. One method of determining health impacts is by conducting a health impact assessment (HIA).

Related: Building Healthy Places Toolkit | ULI’s Building Healthy Places Initiative

For example, using an HIA allowed the following to happen:

  • Plans for a seniors’ housing project in California were modified to consider the health of future residents, including orienting the entrance away from a freeway;
  • A residential project in Denver used residents’ health data to inform how it was designed and developed, and incorporated several health-focused elements;
  • The developer of an outlet mall in Ohio is considering modifying plans to include a trail and increase the amount of green space; and
  • A food market project in New Orleans is building community support and optimizing healthy food strategies.

HIA is an evidence-based process that engages the community, gathers health-related information, and identifies strategies to improve community and individual health. Used to identify potential health impacts of projects, plans, and policies, HIAs consist of six phases typically used in other types of impact assessment: screening, scoping, assessment, recommendations, reporting, and evaluation and monitoring.

HIAs can be applied to a variety of topics, ranging from natural resources to agriculture to the built environment. Using a broad definition of health that focuses on more than just the absence of disease, an HIA shows how a project, plan, or policy may affect a wide range of health indicators, including the following: noise and air pollution; access to jobs, housing, food, and community services; and opportunities for physical activity. Analysis of and recommendations from HIAs can ensure that planning and development projects maximize community benefits and minimize adverse effects.

HIAs are more flexible than other types of impact assessment, and can take various forms. A desktop HIA provides a broad overview of health impacts and may take a few weeks to complete, though it often excludes direct input from community members. A rapid HIA also is conducted relatively quickly while still having some level of community participation and input. A comprehensive HIA includes more robust community engagement and gives an in-depth assessment of health impacts, potentially taking many months to complete. Findings of HIAs—primarily those that evaluate and monitor outcomes after a project is completed—can be used to inform similar HIAs and to add evidence to advance understanding of strategies to improve health. Several databases compile completed HIAs.

Global Roots

The first documented HIA dates to the early 1990s in Manchester, England. In response to public concerns over an airport expansion, the Stockport Public Health Department analyzed health impacts as part of the planning process. While the analysis found positive community health impacts for job creation, it found negative impacts from the increased traffic. Based on the findings, the developer made adjustments to mitigate noise and provide additional public transit service.

Some countries, including Canada, Australia, and New Zealand, have integrated rigorous human health considerations into mandated environmental impact assessments (EIAs). In the United States, an EIA is mandated for certain projects with likely environmental impacts, but HIA remains a separate—and voluntary—method.

Health Impact Assessment Basics

The most effective HIAs are conducted early in the decision-making process, allowing for implementation of recommendations before a project is finalized or approved. The cost of conducting an HIA varies, ranging from $10,000 for a smaller HIA to $200,000 for a comprehensive one. HIAs are typically funded by grants from government agencies and health-focused foundations, including the Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts. HIAs are growing in popularity: according to the Health Impact Project database, fewer than 20 per year were conducted between 1999 and 2009. In 2012, however, more than 50 were completed; at present, 80 HIAs are in progress.

HIAs involve stakeholders from different disciplines and engage groups who do not typically work together. That includes developers. “It’s perfectly appropriate for developers to be wrapping HIA—or something like it—into projects,” says Aaron Wernham, former director of the Health Impact Project. “HIA practitioners are encouraged to reach out to the developer to get them involved in early and frequent consultation.”

Engaging Developers

In the United States, local governments, nonprofit organizations, or consultants typically lead HIAs. An HIA is usually conducted when a community or local government faces a decision with largely unknown health impacts or specific health concerns. Though the majority of completed HIAs have focused on plans or policies, the practice of HIA is now including more development projects, which could lead to increased engagement of developers.

A concern about HIA is that it can be time-consuming and impede development. Wernham says, “Developers already have many other considerations, including financing and permitting. The idea is not for health to add another challenge. Including health should help developers protect their investments by considering all angles, and gain support from stakeholders by demonstrating good-faith efforts to develop a well-planned project.”

U.S. developers have been involved in HIAs in a variety of ways. A 2006 rapid HIA in Oakland, California, produced findings that resulted in changes to a proposed retail and low-income housing project for seniors. One of the first HIAs conducted in Oakland, it served to raise awareness of health among residents, community-based organizations, developers, and local officials. Because of the site’s proximity to a freeway and the Port of Oakland, air pollution and pedestrian safety were major community concerns. Although the developer could not address all concerns, specific modifications included an upgraded ventilation system and a reoriented main entry away from the freeway.

In 2009, architecture and design firm Mithun suggested HIA and a health approach to the Denver Housing Authority (DHA). The DHA was seeking to improve the quality of life of the residents of Mariposa, formerly known as South Lincoln Homes. “We recommended that they should use health and well-being as a proxy for quality of life in design and development, and we recommended using HIA as a way to track and implement that,” says Erin Christensen Ishizaki, associate principal at Mithun.

At Mariposa, a rapid HIA was used as part of the existing-conditions analysis. The DHA provided baseline data for the HIA, and the output showed serious health issues for the existing residents. “Once you see the disparities, it completely changes your entire attitude about what role this development can play, and how can we influence those conditions,” says Christensen Ishizaki.

The HIA inspired the DHA to create a toolkit for ongoing development, the Mariposa Healthy Living Tool, that has shaped the project overall. Completed in 2012, Phase I of Mariposa included many health-focused elements and programs for the residents such as job training, social activities, health programs, and community gardens. Since that time, the project has been almost completely built out and data collected by the DHA show a 30 percent reduction in total crime, a doubling of access to healthy food, and an overall improved quality of life for Mariposa residents.

The Delaware General Health District is conducting an HIA with community stakeholders, a residents’ advisory group, and with participation of the director of development, on a proposed outlet mall in Delaware County, Ohio. According to Susan Sutherland, a public health planner leading the HIA, the scoping phase identified two major areas of concern—the connectivity of the outlet mall to the surrounding community and the impact of traffic on an already burdened intersection.

As a result, the developer, Simon Property Group, is considering modifications to include a trail around the large retention pond and to increase the amount of planned green space, and is likely to consider other health-promoting changes based on HIA recommendations.

When the New Orleans Health Department reached out to other city agencies seeking projects that would benefit from an HIA, it was connected through the New Orleans Redevelopment Authority with planning and development consulting firm Alembic Community Development. Alembic had begun renovating a 100-year-old school building for use as a food market. Nina Johnson, HIA project manager with the New Orleans Health Department, notes, “The objective of the HIA is to inform programming for the market and the surrounding green space. With a lot of development going on in the area, we also wanted to educate other stakeholders to see if HIA could be a best practice.”

Jonathan Leit, director of the New Orleans office of Alembic, saw the HIA as an opportunity to continue to build community support around the project, which had a goal of improving health outcomes through access to healthy food and incentives to promote healthy choices. “As a developer, receiving community feedback has been greatly facilitated by partnering with the health department,” he says.

However, Leit was concerned about having the time necessary to dedicate to the HIA. “The health department has been great in letting us participate at strategic points, comment, and shape the process without dedicating an inordinate amount of staff time.” This underscores the importance of creating an efficient HIA process that meets the needs of the different players involved.

Benefits to Developers

As shapers of the built environment, developers can benefit from understanding and engaging in HIAs. A more complete understanding of health can provide new opportunities for client, community, or market assessments. Inclusion in an HIA can also reduce any delays that may arise based on findings. Says Wernham, “HIAs help planners and developers make sure they meet community needs, and proactively address any concerns that might lead to contention that could slow permitting.” Says Leit, “The nice thing about being involved is that we know findings and recommendations along the way.” Involvement helps ensure no surprises to developers due to outcomes from HIAs conducted on their projects.

And outcomes matter. Says Leit, “It’s a waste of people’s time if you go through [the HIA] and don’t allow it to be involved in decision making . . . an undesirable outcome would be to put the community through the process and nothing comes of it. We need developers to see the value in it and be engaged and committed to the process.”

HIAs also present the developer with an opportunity to showcase the health benefits of projects to a broader audience. Collecting baseline data to understand the current health conditions of the project area can help the developer and designer tailor plans to improve health. At Mariposa, indicators will be tracked to measure outcomes upon project completion. This can help advance understanding about what works for health.

In 2007, Jacoby Development partnered with Georgia Tech on an HIA of the Aerotroplis mixed-use development in Atlanta, on the site of a former Ford plant. Todd Addison, project manager with Jacoby Development, described the developer’s role within an HIA process as one of ensuring feasibility of recommendations, including the financials involved. “If there isn’t a connection between the HIA research and potential financial implications, that could be problematic,” says Addison. “There needs to be a thoughtful blend between recommendations for health and sustainability and financial implications to the project.”

Expanding Health Considerations

Though HIA is growing in use, whether to undertake one depends on many factors. HIAs may not always be an appropriate way to evaluate health impacts. Rajiv Bhatia, former director of environmental health for the city of San Francisco, current chief executive officer of the Civic Engine, and visiting scholar at the University of California at Berkeley’s Institute of Urban and Regional Development, says, “In development processes, HIAs would ideally be embedded within a planning process and called up only selectively as one of many health-supporting tools. Some of the most productive and insightful HIAs have focused on upstream policies where health was not on the table; these have facilitated a great deal of collective learning.”

HIAs should be conducted in situations where there is a great opportunity to promote health, determined during the scoping phase. “If it is a large, controversial project, HIA is a great tool to build consensus and proactively address stakeholder concerns,” says Wernham. “For smaller, less controversial decisions, a simple checklist may suffice.”

This article was produced as part of ULI’s Building Healthy Places Initiative.

Additional HIA Resources:



Health Impact Project: HIA in the United States

UCLA Health Impact Assessment Clearinghouse


Human Impact Partners

Health Impact Project, a collaboration of the Robert Wood Johnson Foundation and the Pew Charitable Trusts

National Association of County & City Health Officials

The Society of Practitioners of Health Impact Assessment (SOPHIA)