EXECUTIVE SUMMARY OF TASK MANAGERS REPORT Human health appears in the very first principle of the Rio Declaration on Environment and Development, adopted by the world community at the 1992 Earth Summit: Human beings are at the centre of concern for sustainable development. They are entitled to a healthy and productive life in harmony with nature. Human health is essential for sustainable development since without health, human beings would not be able to combat poverty or care for their environment; in turn, care of the environment is essential for the sustenance of human well being and the development process. Human health is dependent on the environment itself being healthy. Thus it is not surprising that improved health, which is the focus of Chapter 6, is to be found throughout Agenda 21. It is at the centre of the major developmental strategies for (i) combating poverty, (ii) developing and disseminating knowledge concerning the links between demographic trends and factors and sustainable development, (iii) promoting sustainable human settlement development and (iv) promoting the full, equal and beneficial integration of women in all development activities. It is equally a central concern of other major programmes of Agenda 21: water, atmosphere, housing, agriculture, toxic chemicals, and hazardous and radioactive wastes. At the global level, Agenda 21 is beginning to lead to new health-related developments in a number of agencies. But most agencies are continuing along well established lines incorporating issues of sustainable development in a pragmatic way. Many of these policies, while not directly linked with Agenda 21, are of sufficient importance to be reported on in that context. As it is felt to be too early in the implementation of Chapter 6 of Agenda 21 to try to distinguish between what can or cannot be linked with the Earth Summit, these directions are included in this report. Chapter 6 of Agenda 21 identified the essential activities that need to be implemented. But Chapter 6 did not address the fact that much reform is needed for such a programme of activities to be realizable. Four "lines of reform" emerge from the analysis undertaken in preparing this report: (1) Community (Health) Development: protecting and educating vulnerable groups as part of more holistically conceived community development programmes; (2) Health Sector Reform: Ministries of Health increasing allocation of resources to most cost-effective programmes; (3) Environmental Health: increasing understanding of sectoral-linkages with health and mobilizing action in other sectors accordingly; (4) National Decision-Making and Accounting: strengthening health representation in national decision-making and incorporating health and its financing in new accounting systems for sustainable development. Fortunately steps have already been taken to promote reform within the health sector, as shown in this report. The additional reforms are needed to ensure that health is incorporated in all aspects of national sustainable development. Only in this manner will the pursuit of improved human health be a positive driving force for sustainable development. The CSD called upon the Task Managers to prepare "analytic" reports which would highlight "unnecessary duplication", "gaps and opportunities for cooperation and joint programming", "assessment of relevance, strength and usefulness of various programmes and activities", and "organizational responsibilities and allocation of tasks on the basis of expertise and competitive advantage". This has been done, but only to a partial degree. The analysis has not been carried out to its "logical conclusion", since any conclusion concerning, for example, "unnecessary duplication" might be counterproductive. It was felt that a logical delineation of organizational responsibilities might stall current efforts among UN agencies to support health sector reform. Without health sector reform, it is difficult to imagine the other reforms identified having any chance of success. Instead, the CSD is called upon to help the process of change by confirming that the lines of reform identified should be actively pursued by all relevant UN agencies. The CSD can further stimulate movement in the direction outlined through special action, e.g. calling upon Governments to host meetings to elaborate the reform process in more detail, calling upon donor agencies to ear-mark funds for this process in countries that are actively implementing sustainable development policies, and establishing special working groups to monitor progress within the UN system to ensure that the reform called for at national level is leading to comparable reform within and among the various agencies involved. A common understanding of sustainable development does not exist. Consequently there is a strong risk that the revolutionary changes called for by Agenda 21 will rapidly be lost sight of. This risk is particularly present in the health sector where environmental health has rarely received adequate attention. The active support of the CSD is required in carrying out the reforms listed above to ensure that the full potential of Agenda 21 is realized. TASK MANAGERS REPORT CHAPTER 6: PROTECTING AND PROMOTING HUMAN HEALTH INTRODUCTION The Task Managers report has been prepared by WHO in collaboration with FAO, IAEA, ILO, ITU, UNCHS, UNDP, UNEP, UNESCO, UNFPA, UNICEF, UNIDO, UNRWA, WFP, the World Bank and WMO, and with the assistance of the UNDPCSD. This report covers the five programme areas that constitute Chapter 6 of Agenda 21: A. Meeting primary health care needs, particularly in rural areas B. Control of Communicable Diseases C. Protecting Vulnerable Groups (Infants and children, youth, women, and indigenous people and their communities) D. Meeting the Urban Health Challenge E. Reducing Health Risks from Environmental Pollution and Hazards Other major programmes that contribute to human health, e.g. those of human settlement, agriculture and rural development, freshwater resources, and environmentally sound management of toxic chemicals and hazardous wastes are not discussed as such although there is considerable inter-connectedness with these programmes which is reflected in this review. This report is organized along the following lines: (1) current agency and inter-agency activities and future directions envisaged with respect to each of the above programmes; (2) scientific and technological means and human resources development and capacity-building that are common to these programmes; and, (3) the decision-making and financial implications of the action plan of Chapter 6. The report ends with an indication of priority future strategies for consideration by the Commission on Sustainable Development during its May 1994 session. SECTION I: HEALTH AND SUSTAINABLE DEVELOPMENT - GLOBAL POLICY UPDATE Human health appears in the very first principle of the Rio Declaration on Environment and Development, adopted by the world community at the 1992 Earth Summit: Human beings are at the centre of concern for sustainable development. They are entitled to a healthy and productive life in harmony with nature. Human health is essential for sustainable development since without health, human beings would not be able to engage in development, combat poverty and care for their environment; in turn, care of the environment is essential for the sustenance of human well being and the development process. Human health is dependent on the environment itself being healthy. Thus it is not surprising that improved health, which is the focus of Chapter 6, is to be found throughout Agenda 21. It is at the centre of the major developmental strategies for (i) combating poverty, (ii) developing and disseminating knowledge concerning the links between demographic trends and factors and sustainable development, (iii) promoting sustainable human settlement development and (iv) promoting the full, equal and beneficial integration of women in all development activities. It is equally a central concern of other major programmes of Agenda 21: water, atmosphere, housing, agriculture, toxic chemicals, and hazardous and radioactive wastes. At the global level, Agenda 21 is beginning to lead to new health-related developments in a number of agencies. But most agencies are continuing along well established lines incorporating issues of sustainable development in a pragmatic way. What follows are statements by each agency concerning "protecting and promoting human health". WHO has developed a global strategy in 1993 for health and environment which provides a new orientation for multi-disciplinary and multi-sectoral efforts to ensure that health considerations are fully incorporated and at the core of all development and environmental activities, from policy planning to project implementation, monitoring and evaluation. This strategy establishes a unifying framework for WHO action and provides the basis for WHO programmes at Headquarters, in Regional Offices and in countries to respond to Agenda 21. UNEP, in cooperation with WHO and other agencies, and through its International Register of Potentially Toxic Chemicals, the Industry and Environment Office, among others, has been providing member states with information on the health and environmental effects of chemical and physical agents; information on legal status of chemicals; incorporation of environmental measures for the control of vector-borne diseases; cleaner production technologies and preventing and preparedness of accidents; information on global trends in contamination of air, food and water through its Global Environment Monitoring System (GEMS); promotion of supportive environments for health; and in capacity building. The publication of the World Banks World Development Report of 1993 on Health and Development, which was prepared with the support of the WHO, represents a major development for the health sector. It illustrates the importance of health to national development and outlines reforms needed to achieve more cost-effective use of resources available for health. UNDP's health sector constitutes approximately 3 per cent of overall IPF expenditures. UNDP's emphasis continues to be on training of all levels of health personnel and improvement of management capacity. UNDP action is inextricably linked to the multi-sectoral objectives which characterize UNDP's overall human development approach. In particular, the poverty/environment links to traditional health sector priorities will receive more emphasis in the future. Clean drinking water and sanitation activities will also continue to receive high priority within the linked areas of poverty and disease prevention. One of the major goals of FAO is to help member governments provide their populations with a safe, high quality, nutritious and stable food supply. FAO pursues this goal by promoting sustainable agriculture and rural development (SARD), promoting the production of safe and nutritious food through the application of good agricultural and manufacturing practices (e.g. the integrated pest management and plant nutrition systems), reducing the use of unjustified sanitary and phytosanitary barriers to international trade in agricultural products, and promoting food quality control systems which protect the economic interest and health of consumers. UNCHS (Habitat) is mandated to facilitate solutions, especially for low-income communities, which will improve the living environment and promote better health among rural and urban communities. The underlying purpose of Habitat's human settlements activities is capacity building. UNESCO's has recognized the need to strengthen its action in developing countries to improve the health and nutrition conditions of school-age children many of whom are frequently burdened by high levels of morbidity associated with infections and communicable diseases that are readily transmissible in unhealthy school environments. UNESCO approaches educational participation and the health of school-age children through interdisciplinary and intersectoral cooperation both among its specific areas of concern - education, social and human sciences, natural sciences, culture and communication - and in its work with other agencies. UNFPA is the largest multilateral agency for population assistance. It has continued to increase its support to MCH/FP activities in the developing world. The following UNFPA goals for MCH and family planning are expected to be achieved during the final decade of this century: * to increase contraceptive prevalence in the developing countries to 59 per cent. * to reduce infant mortality rates to at least below 50 per 1000 live births in all countries and also among major sub-groups within countries, and * to reduce maternal mortality by at least 50 per cent, especially in areas where the current figure exceeds 100 per 100,000 births. ITU's emphasis continues to be on the promotion of telecommunications and broadcasting in developing countries. Such technology offers a powerful tool to ensure that health messages penetrate society as a whole. As this technology becomes more widely available, it should contribute to improved management of local health services and more informed community participation. UNIDO's technical co-operation programme contributes to protecting and promoting human health through the transfer of technology and training in pharmaceutical and health care industries including, for example, promoting the local manufacturing of vaccines and essential drugs. UNIDO's programme on environment addresses almost all aspects of the environmental pollution caused not only by industry but also by other human activities. WFP's current commitment to the health sector totals over $570 million. In providing support to national health programmes, WFP contributes to improved food intake either through direct feeding of malnourished children and hospital patients or by providing take-home food supplies to expectant or nursing mothers and small children. In December, 1992 FAO and WHO held the International Conference on Nutrition (ICN) which recognized that health is an essential element of human development which required the action of many social and economic sectors in addition to the health sector. If further noted that improved nutrition, and thus health, requires the coordinated efforts of relevant government ministries, agencies and offices with mandates for agriculture, fisheries, and livestock, food, health, water and public works, supplies, planning, finance, industry, education, information, social welfare and trade. Various aspects of the effects and impact of climate and its variability and potential change on human well-being and health is dealt with in a joint project between WHO, WMO and UNEP. * * * At the national level, Agenda 21 is only beginning to affect the health sector in a handful of countries. This is not surprising as the activities called for by Agenda 21 are wide ranging, cutting across many sectors and involving different technical disciplines. Most national Ministries of Health are responsible for implementing only a part of the health-related activities outlined in Agenda 21. For example, health services in urban areas generally fall under the responsibility of the local municipal authorities, while the provision of environmental services, e.g. water and sanitation, are often in another public sector. Human health depends on the promotive and protective programmes which stem from all public sectors. The health sector, as such, is only responsible for a limited number of these programmes. Furthermore, curative services account for the major part of the human, material and financial resources available to the health sector. Preventive services are weak, and health inputs into development work of other sectors, including industry, agriculture, education, local government, etc., are hampered by lack of critical staff such as environmental epidemiologists and health policy analysts. In the current economic crisis, preventive and promotive services of the health sector must struggle to keep afloat as national health budgets are reduced. Health promoting work of other sectors is equally constrained by reduced public funds. These economic difficulties are particularly present in countries where environmental degradation and increasing health vulnerability is most severe. Thus, Chapter 6 of Agenda 21 represents an extraordinary challenge to governments and the UN system. How the various agencies of the UN system support the implementation of the programme areas identified in Chapter 6 clearly can serve to help governments meet this challenge successfully. In the next section, current activities of the UN system are briefly reviewed and indications given of the major future directions envisaged including constraints. No attempt has been made to provide a complete review of relevant ongoing activities; rather, an effort has been made to provide indicative examples of current programmes and policies with particular attention to those health programmes most conditioned by environmental factors. No effort has been made to assess activities undertaken by individual governments in response to Agenda 21. SECTION II: REVIEW OF PROGRAMME AREAS A. MEETING PRIMARY HEALTH CARE NEEDS, PARTICULARLY IN RURAL AREAS ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM At the level of international health policy, there have been major shifts in recognizing the importance of investment in the social sector and the environment which have opened up opportunities for broader intersectoral actions for health. These shifts started with the Alma-Ata conference on PHC in 1978 and the adoption by WHO of the Health for All goal with its emphasis on social justice. More recently, the publication of World Bank reports on Poverty in 1991, Development and the Environment in 1992, and Investing in Health in 1993, are a reflection of this change in emphasis. WHO's Second Evaluation report of the implementation of the Global Strategy for Health for All by the Year 2000 noted that there has been "strong political commitment to achieving health- for-all goals, and most countries have endorsed at the highest level the health-for-all policies and strategies". However, it is also reported that these policies and strategies "have not always been put into practice in appropriate ways by the countries when attempting to facilitate universal access to essential health care with all eight essential elements of PHC on a continuing basis". The report also drew attention to the growing awareness of environmental problems and their impact on health. The imbalance of basic resources such as water between developed and developing countries was found to be contributing to the increase in poverty and population growth and to the widening gap between the rich and the poor. The 1993 World Development Report on Investing in Health examined the "interplay between human health, health policy, and economic development". While recognizing that investing in health is one means of accelerating development because good health increases the economic productivity of individuals and the economic growth of countries, the report indicates that a radical reform of the health sector is needed to achieve this end. Such a reform would lead governments to redirect their spending away from specialized care and toward "packages" of public health measures and essential clinical care which are most cost-effective in terms of reducing burden of disease. UN agencies and bilateral donors are deeply involved in efforts to improve the capacities of district health systems including those of other related institutions such as local government. WHO, jointly with UNDP, and other agencies have supported the promotion of the District Health Systems concept with emphasis on collecting country experiences and supporting studies and R&D. WHO has produced a series of guidelines which are serving as the basis for implementing such programmes. Efforts have been undertaken to improve management performance of health centres and hospital, concentrating on their roles and function in the district health system. District health systems have improved in a number of countries, but in most cases limited to a number of districts. Most success has been achieved in countries which have been politically and economically stable over the past fifteen years. The continuing and prolonged economic crisis in all regions of the world has hampered extending progress more widely. District health systems aim at achieving an equitable distribution of health resources through the provision of health services, intersectoral action and community participation. Intersectoral action is particularly relevant for improving health through environmental changes (water, sanitation and housing), through better food supplies and through raising educational and socioeconomic status. It is not unusual, however, for intersectoral coordination to be weak, for example as regards an adequate supply of safe water and sanitation, even though this is one of the eight essential elements of PHC as defined at Alma-Ata. The inclusion of drinking-water supply and sanitation as one of the major programme areas in Chapter 18 of Agenda 21 (Protection of the Quality and Supply of Freshwater Resources) should help broaden efforts which aim to achieve the goal of universal access to water supply and sanitation. So important is this area that several UN agencies are involved in one way or another: WHO and UNICEF in the expansion of basic services; UNHCR and UNRWA in serving refugee populations; UNESCO in attending to the basic needs of school children; UNDP as part of over all development. Recent inter-agency efforts to integrate the various freshwater activities into a more comprehensive approach include the International Conference on Water and the Environment, held in Dublin in January 1992, and the FAO, UNICEF, UNDP, World Bank and WHO Technical Consultation on Integrated Rural Water Management, held in Rome in March 1993. Community action for health, which is the theme of the Technical Discussions organized in conjunction with the 47th World Health Assembly of WHO in 1994, remains an essential principle of the PHC approach. Related community based initiatives which complement the provision of services through PHC include: Primary Environmental Care (PEC), UNCHS' Settlement Infrastructure and Environment and Community Development Programmes, UNESCO's Education for All programme, and FAO's Community Nutrition Programme. PEC is a process by which communities - with varying degrees of external support - organize themselves and strengthen, enrich and apply their own means and capacities (know-how, technologies and practices) for the care of their environment while simultaneously satisfying their needs. PEC is emerging as an important instrument that NGOs and various UN agencies are looking to as a means of improving the quality of life of people through environmental regeneration. UNESCO's interdisciplinary and inter-agency cooperation project on the environment, population, health, education and information for human development is being developed in response to 'education for all', environment and development, population education and the emerging perspectives suggested by UNCED through Agenda 21. This initiative can provide valuable support in terms of more participatory information, education and communication to increase people's knowledge and skills relevant to health and the environment. Recognizing the crucial role of small farmers and their organizations in programmes for environmental protection, FAO has introduced participatory approaches in many of its field programmes, and is engaged in promoting 'people's participation' projects in 15 countries. FUTURE DIRECTIONS Experience has demonstrated that sustainable health systems based on PHC cannot be achieved without the full participation of communities and other sectors working in a district. This partnership is the only means by which a commitment, achieved through common objectives and priorities, can ensure that the resources needed to address health and environment issues are obtained. Decentralization and democratization are opening up new possibilities for community participation, including increased self-reliance in health. At the local level, people and communities view health and environmental problems in holistic rather than in segmented ('sectoral') terms. At this level, intersectoral cooperation becomes feasible on the basis of common interests. Linkages between health and other social sectors (such as education) can often be achieved on the basis of common actions and projects that can furnish a strong basis for sustained cooperation. Harmonious working relationships can be fostered between community health workers and other developmental workers (e.g., education, agriculture, public works, etc.). The implementation of PHC has been and continues to be pursued as a set of special vertical programmes, contrary to the integrative and holistic intent of Alma-Ata. Some multi as well as bilateral funding agencies continue to give emphasis to the eradication or reduction of diseases through such programmes, although some have now shown themselves to be unsustainable. Without addressing this basic conceptual hurdle and reorienting the approach to external agency support, difficulties will persist in the development of sustainable and responsive health infrastructures essential to implement PHC in the context of a supportive environment. Adding to these difficulties is the fact that rapidly evolving market oriented economics, in the context of newly decentralized and democratized States, has contributed to the fragmentation of services and threatened equity, intersectoral collaboration and community participation. In many developing countries, there is a growing trend towards private medical practices and the independent sale of pharmaceutical products in rural communities. These, together with the introduction of fees for services at government health centres and hospitals, has had the effect of diminishing the utilization of health services particularly among the poorest and most vulnerable members of the communities in the least developed countries. These developments carry with them serious negative consequences for sustainable healthy environments as the poor without support continue to degrade the environment and natural resources in the area where they live, undermining food production and livelihood prospects. Some of the problems identified above can be addressed in part through the current efforts of health sector reform taking place in many countries. These reforms emphasize the changing roles of Government in health, shifting from managing and financing health services to coordinating health work. At another level, there is increased recognition that external support to the development of the district health system must have an integrated approach addressing the need to build capacities not only of the health services themselves but also of other health related institutions such as local governments, community development committees, etc. The methods and managerial tools required for developing and sustaining these capacities require attention. WHO has begun work with the World Bank and UNDP to create a Network for Capacity Building in Health Sector Reform. The focus of the proposed network is on information exchange, tools development and advocacy. The network can be an important means for pooling expertise, linking people with similar visions and motivation and thus breaking the isolation many professionals charged with designing and monitoring reform efforts are facing. B. CONTROL OF COMMUNICABLE DISEASES ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM A number of major disease-related goals have been formulated through extensive consultation in various international forums attended by virtually all Governments, relevant United Nations organizations, and a number of NGOs. These were identified in Chapter 6 of Agenda 21; they remain in force. ECOSOC has placed the subject of "coordination of the activities of the United Nations system in the fields of preventive action and intensification of the struggle against malaria and diarrhoeal diseases, in particular cholera" on its agenda. The Council stressed the importance of national capacity- building - to food safety, nutrition, drinking water and sanitation, hygiene, education, especially women and, in general, to targeted investments for a better infrastructure in the health sector. The managerial review of the WHO Programme for the Control of Diarrhoeal Diseases (CDD) is entrusted to a committee made up of representatives of 4 UN agencies: UNDP, UNICEF, WHO and the World Bank. In compliance with ECOSOC recommendations, there are plans to extend involvement in CDD programme management to other UN agencies whose activities may contribute to the prevention of diarrhoeal diseases and cholera such as FAO, UNDRO, UNESCO, UNIDO, UNHCR and WFP. In the joint Panel of Experts on Environmental Management of Vector Control (PEEM), WHO, FAO, UNEP, and UNCHS have a focused arrangement for collaboration in the area of prevention and control of water resources development associated vector-borne diseases. Such diseases include malaria, schistosomiasis, Japanese encephalitis and filariasis. These diseases clearly demonstrate the role that ecological and demographic change has on health. Since 1990 the Panel's programme has become more field oriented with activities in promotion, policy formulation, research and development, and capacity building. The FAO and WHO co-sponsored International Conference on Nutrition (ICN), held in 1992, strongly emphasized the role of adequate nutrition in combatting and preventing infectious diseases and non-communicable chronic diseases and the importance of nutrition in improving immunity, increasing efficacy of vaccines and reducing the incidence and severity of infectious diseases. Food is very often the vehicle for transmission of organisms causing communicable diseases (e.g., Vibrio cholera 01). The ICN Plan of Action for Nutrition, inter alia, identifies the prevention of foodborne diseases as one of the major strategies for overcoming malnutrition. The inclusion of food safety in national action plans for communicable disease control - sustainable development is being pursued more vigorously. FAO provides assistance in building capacities for improving food safety services and developing national plans for nutrition and nutrition education programmes for the promotion and protection of health. Assistance to countries affected by the recent cholera epidemic in Latin America and Caribbean Region aims at promoting the implementation of appropriate measures to prevent food and water contamination and to improve hygienic practices among food handlers and the general public. A technical meeting was held in October 1993 by WHO in Manila with the participation of FAO on the subject of foodborne parasitic infections. The parasitic trematodes are found in foods: freshwater fish and shellfish, particularly, but also in snails and various edible plants. Their economic impact is considerable with direct and indirect losses running into millions of dollars. A coordinated strategy between the agriculture, aquaculture and health sectors to reduce parasitic infections transmitted in plants and in fish and crustaceans was developed and agreed upon. Representatives of the commercial fishing industry have pledged their support to this strategy. WHO and UNDP have carried out joint missions to several countries this past year. A UNDP regional project for strengthening the multisectoral and community responses to the HIV epidemic in Asia and the Pacific was formulated and is being implemented in close consultation with WHO. WHO collaborated with the World Bank in the design and implementation of regional seminars on AIDS prevention and care policies for high-level policy-makers. Another recent development is the establishment of a Task Force on Tropical Diseases and the Environment by the Special Programme for Research and Training in Tropical Diseases (TDR). This programme is co-sponsored with WHO by UNDP and the World Bank with WHO serving as the Executing Agency. The Task Force will fund field research dealing with assessment of the magnitude and direction of correlation between changes in agroecosystems and risk of tropical diseases, identification of options for intervention, economic valuation of impact of environmental changes on social welfare and human health, and policy formulation and reform. UNICEF and WHO have initiated collaborative efforts in support of health mapping and geographic information systems (GIS) in the context of the WHO's Dracunculiasis Eradication Programme with particular attention to Africa where an estimated 22,000 villages are involved. Information on other tropical diseases will be linked to this effort. The WHO programme of control of tropical diseases with FAO will be bringing together data on human and animal trypanosomiasis (sleeping sickness) along with their vectors to be incorporated in a GIS system. UNITAR has been approached for training of national staff in the use of GIS in decision making. FAO and WHO are elaborating a joint proposal as a follow up to the decade old FAO training project based in Lusaka on the control of tsetse and animal trypanosomiasis. The new project is entitled Training in Trypanosomiasis Control to support sustainable agricultural development. FUTURE DIRECTIONS Effective communicable disease control requires judicious use of preventive and promotive efforts using a community-based, participatory model, broad environmental health interventions to improve living conditions, housing and water and sanitation, and improved health services. The concerned agencies of the UN system should increase their collaborative efforts with the national disease control programmes to develop more cost-effective mixes of these complementary control strategies. Moreover, monitoring and surveillance of emerging infections, as variously exemplified by resurgence of tuberculosis resistant to treatment, Cryptosporidium in municipal water supply systems or Hantavirus infections spreading from rodents to man, will require collaboration between UN and national agencies. As noted in the Report of the Secretary-General to ECOSOC concerning "malaria and diarrhoeal diseases, in particular cholera" (cited earlier): "For each of these problems (disease control and prevention), there is a balance between the effectiveness of investments narrowly made for specific disease interventions (for example drug therapy for malaria or case management for diarrhoea) and the effectiveness of broader investments in infrastructure (balanced between specific health infrastructure investments, for example training of health staff, strengthening epidemiological surveillance and rehabilitation or construction of health facilities, and broader investments, for example, in food safety, water or sanitation, primary education or education of mothers). That level of resources which might be appropriate, as well as the balance between narrow and more general investment, is different in each country, underlying the need for effective country-level decision-making." According to the World Bank Development Report 1993, "Too little (government spending) goes to low-cost, highly effective programs such as control and treatment of infectious diseases and of malnutrition". The agenda for action outlined in this report calls for increased investment in "public health activities". As a follow-up to the ICN, FAO and WHO are encouraging international collaboration between agriculture, health and other relevant sectors to prevent and control infectious diseases, especially zoonoses, and to ensuring continued access by all people, especially the socially and economically deprived groups, to sufficient and sustainable supplies of safe foods for nutritionally adequate diet. C. PROTECTING VULNERABLE GROUPS ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM Many, though not all, of the vulnerable groups have received a high level of attention with respect to health protection, promotion and care with the involvement and close collaboration of the agencies and organizations of the United Nations system, virtually all governments and a wide spectrum of nongovernmental organizations. While each of the agencies has set goals relevant to the health and development of women and children, FAO, WHO, UNICEF and UNFPA have set Common Goals which provide the framework for in-country collaboration with respect to the health of women and children. WHO and UNICEF, in follow-up of the Declaration and Plan of Action from the World Summit for Children, have established a set of indicators and a global monitoring framework that includes the dimensions of the health, education and nutrition of children, with particular note of the girl child. These goals have been reiterated and reinforced in the Declaration and Plan of Action of the FAO/WHO sponsored International Conference on Nutrition (ICN). Many of these goals, particularly focusing on the issues of equity and human rights relevant to the vulnerable groups, have been reiterated and amplified in such forums as the International Conference on Human Rights and the International Forum on Health, Accra. WHO has established an Global Commission on Women's Development and Health. National plans of action are being developed in most countries, with the support and encouragement of UNICEF, FAO, WHO and other agencies as a follow-up of the Child Summit, the ICN and other international and regional initiatives. The Bamako Initiative, with the support of UNICEF and the African region of WHO has increased its coverage and effectiveness in circumstances where the basic principles of government-community partnership, and the decentralization of authority, responsibility and management of resources have been followed. WHO and UNICEF have initiated the development of an integrated approach to the management of childhood illness. Globally, pneumonia, diarrhoea, malaria, measles and malnutrition cause almost three-quarters of deaths in children under five years of age in developing countries. Feasible case management interventions exist for these illnesses. A fully integrated training package which addresses these conditions is currently under development. UNICEF and WHO have also begun to develop a joint strategy for hygiene education in water supply and sanitation in the 1990s. Moreover, the UNDP/World Bank Water and Sanitation Program and WHO are collaborating on hygiene education in Africa and Asia. The purpose of hygiene education is to support behavioural changes that will enhance the health effectiveness of improved water and sanitation facilities. WHO and UNESCO, on advice from the ACC Sub-committee on Nutrition, have joined in an effort to improve the health of school children through improved school environments. Poor lighting, poor ventilation, lack of water supply, hand washing and toilet facilities and many other problems are the focus of this effort. WFP food aid is provided to encourage greater and more regular attendance of mothers and young children at health centres which provide such services as immunization, pre-natal and post-natal care, diarrhoea treatment, family planning and health and nutrition education. When feasible, WFP tries to combing such human resource development activities with other activities that provide poor people with opportunities to increase their income-earning potential. The Seventh WHO Expert Committee on Maternal and Child Health, with the assistance of a number of agencies, has recently completed an in-depth review of progress with respect to the health and development of women, children and families. Greatest progress globally is noted in those countries and communities where programmes address the issues of quality of care and the genuine involvement of families and communities in the planning, implementation and evaluation of health services and programmes. The issues of vulnerability and environmental concerns were addressed as well. A number of international legal frameworks relevant to Agenda 21 and vulnerable groups are being reinvigorated and actively pursued in collaboration with other agencies within the UN system. These include, the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), the Convention on the Rights of the Child, and the ILO Conventions on Child Labour(Convention 138), on Tribal and Indigenous Populations(Convention 107) and Maternity Protection. There is increasing collaboration among the organizations and agencies of the United Nations system in the monitoring, reporting and follow-up of these instruments. There has also been an increase in the collaboration with NGOs. FUTURE DIRECTIONS The conclusions of the MCH Expert Committee underlined the importance for a focus on the improvement of the quality of care by the services being provided and not extending poor quality care that will not have an impact. The fragmentation of care should be avoided, and a particular focus should be placed on reproductive health, including the environmental and toxic hazards to reproductive health. Operationally, a major emphasis is placed by the Expert Committee on decentralization of authority, responsibility and financial management to local government and community levels, with participatory approaches being adopted in the identification of priorities, improvement of health team functioning and in evaluation. The UNFPA's experience suggest that integrated MCH programmes need to be strengthened in order to reach poor minorities, women, non-married women, adolescents and men in providing family planning information and services. Hard-to-reach populations in typical MCH programmes are often the same groups at risk of STD/HIV infection. Extra efforts are needed in designing and implementing new models of service delivery to meet the reproductive health needs of this substantial high-risk population. These include a concern with sexually active persons, the provision of services for young adults, a focus on health and responsible reproductive behaviour, the utilization of IEC for behavioural change, and the distribution of barrier methods to prevent STDs and unwanted conceptions. Commonalities in training and modes of service delivery suggest that MCH/FP programmes and STD/HIV services should seek to work together as much as possible in a range of activities from coordinated planning to integrated services. Education and information provide the base of knowledge and skills that can equip individuals, families and communities to make positive health choices. However, the choices available to people depend upon the accessibility of health care and services. There is much potential for basic (community) education to respond to local health and environmental problems especially those affecting children and women. Basic education programmes should be assessed in terms of their responsiveness to community needs and expectations and in their effectiveness in promoting communities to develop their own basic services and people to learn new skills that will help improve the quality of their lives. Basic education should encourage self-reliance and civic participation in the social development process. The role of government should be to provide a supportive environment for family and community-based care and to provide direct services when additional care is needed. Caring should recognize the dignity and rights of vulnerable people. Actions to improve the care of the socioeconomically deprived and nutritionally vulnerable will be most successful if they are sensitive to the particular needs and traditions of a local community and respond to these. The ICN Declaration and Plan of Action encourages governments to work in a collaborative manner with local community groups, the private sector, and NGOs. In UNICEF's 1993 State of the World's Children report, vulnerable groups and the environment are brought together and linked with population growth to form the "poverty, population growth and environment" or PPE spiral. An adequate response to the PPE problem must include: (1) The prevention of common diseases and disabilities, and a steep reduction in both severe and moderate malnutrition; (2) Rapid progress towards at least a primary education for all children, and especially for all girls; (3) An unprecedented worldwide effort to improve the lives of women in poor communities - their health and education, their status and choices, their rights and opportunities; (4) The making available of family planning information and services to all who need them. D. MEETING THE URBAN HEALTH CHALLENGE ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM The UN agencies are deeply involved in efforts to improve the capacity of municipal governments to manage the urban environment and improve living conditions in cities. Efforts to strengthen health systems for rapidly urbanizing communities, particularly in cities of developing countries, have increased in recent years. Nevertheless, the number of cities in which the urban health challenge is being met adequately remains small in comparison to the total need. The WHO Healthy Cities Programme, the UNDP LIFE Programme, the ILO Labour Intensive Public Works Programme, the Metropolitan Environment Improvement Programme and Metropolitan Development Programme of World Bank/UNDP, the Sustainable Cities Programme of UNCHS, the CITYNET/Asia-Pacific 2000 Programme of ESCAP/UNDP, the Megacities Programme, the Metropolis Programme, and the WMO Tropical Urban Climate Experiment (TRUCE) are some of the initiatives at the international level. Linkages have been established among UN agencies with all of these to ensure that the municipal planning exercises that are common to all place due emphasis on protection and promotion of health. The World Health Assembly Technical Discussions in May 1991 on "Strategies for Health for All in the Face of Rapid Urbanization" has been a milestone in this development. A collaborative project has been undertaken to increase awareness, identify issues and experiences and promote the development of health programmes in several cities in various regions of the world. This project involves WHO, UNICEF, UNDP, METROPOLIS, Rockefeller, several donor agencies, and research and development institutes of both developed and developing countries. The aim is to develop a network of supporting institutions that will be able to mobilize needed technical and financial input in the implementation of projects developed by the participating cities. The "supportive environments" or "settings approach" has been widely promoted both as part of the healthy cities programme and as a health promotion programme. A fine example of this approach is the national school health programme in Ghana. By focusing attention of relevant Ministries and authorities on health conditions in key settings (village, school, workplace, city, markets, etc), the supportive environments approach is emerging as an effective and practical means of intersectoral action. The role of health institutions, particularly health centres, in the implementation of primary health care in urban areas is receiving increased attention in light of decentralization, particularly in big cities. Based on promising experiences in a number of cities, it is proposed that at least one health centre be designated in each urban district as a "reference health centre". Studies are being carried out in eight cities to further develop this approach. The FAO programme on street foods aims at promoting the role of the informal sector in providing a safe, nutritious and economically accessible food for the urban populations in large cities in both developed and developing countries. It focuses on promoting hygienic practices in food preparation and handling through appropriate educational programmes, and on improving environmental sanitation in food vending areas. FUTURE DIRECTIONS Inequitable distribution of resources, irrational duplication and overlapping of functions, limited authority at local level, and uncoordinated efforts between public, private, voluntary and nongovernmental organizations, still dominate the urban scene. The experience gained in implementation of the above-mentioned programmes should be used to overcome these constraints and problems. What has been learnt is that the "partnership approach", common to all these programmes, where communities, NGO's, Municipalities and local health departments jointly address problems using resources that essentially are mobilized locally, is the best option for urban development. It is increasingly recognised that many urban health problems are based in social issues such as social disintegration, unemployment and poverty. These need to be addressed more strongly in the formulation of municipal health plans. These social issues touch all aspects of urban development, so a greater emphasis will need to be placed on integrating health with other urban development activities. In this context, a case can (and will) be made that a proportion of the budget of every urban development activity should be allocated for the protection and promotion of health. Health in urban areas cannot, however, be improved without a healthy human environment. Air and water quality, garbage disposal, noise, etc., have to be addressed adequately as a prerequisite to better health of the urban dweller, particularly those living in poor peri-urban quarters. Consequently, there is inherent linkage between the activities to reduce health risks from environmental pollution and hazards and the urban health programmes (see programme area E below). There is also increased recognition being given to the importance of having adequate information on intra-urban differences. Simplified protocols should be further developed and more widely used by local authorities to establish base-line assessments of urban health, to monitor progress and to collect and analyze data from different socio-economic population groups. Incorporation of new information technologies, especially geographic information systems, should be pursued in conjunction with other managerial capacity-building efforts. Increased efforts will be made to expand national and international collaboration networks and to share experiences and "models of good practice". Finding additional funds to pursue the objectives of this programme area will need to be better coordinated among the UN agencies involved to prevent unproductive competition among the agencies for bi-lateral funding of projects in the same urban settings. E. REDUCING HEALTH RISK FROM ENVIRONMENTAL POLLUTION AND HAZARDS This programme area interlinks with several other chapters of Agenda 21, and particularly with chapters 8 "Integrating environment and development in decision-making", 9 "Protection of the atmosphere", 18 "Protection of freshwater resources", 19 "Toxic chemicals", 19 "Hazardous wastes" and 20 "Solid waste and sewage". ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM UNEP, FAO and WHO have been in the forefront of several activities in this field that have provided a framework for strengthened action at international and national level. These activities include the health component of GEMS (the Global Environment Monitoring System), the HEALs project (Human Exposure Assessment Locations) and the Global Networks project for education, training and research. In addition, UNEPs APELL and Cleaner Production projects have provided industry with essential information and advice that has reduced pollution and health risks. Each of these activities are active in a large number of developing countries and have created collaboration between developed and developing countries as well as among developing countries. Health-based criteria for air-quality, drinking-water quality and coastal waters have been developed through a scientific evaluation and risk assessment process. These provide the grounds upon which governments are building their national standards, and local authorities their pollution control programmes. Environmental health impact assessments have become a pre- requisite for major development projects with important environmental impacts. In support of preparing the grounds for an holistic approach to pollution risk reduction, a series of pilot countries in all world regions have been undertaken. These are expected to lead to the development of comprehensive risk analysis, pollution source identification and prioritization of remedial action needed. Ultimately, these should result in the formulation of cost- effective health protection components and prevention/control measures. UNCED has given a new impetus to these existing activities. One of the main new initiatives has been intensive collaboration between national and international agencies in preparing National Sustainable Development plans for a series of countries. UNDP, UNEP, FAO, WHO, the World Bank and other international agencies and NGOs have all been involved. The World Bank has coined the term "National Environmental Action Plans". WHO is working with selected countries to ensure that the Health sector is an active participant in the process together with all other sectors, and some of these countries have called their plans "National plans for Health and Sustainable Development". Other terms are also used. In order to put these plans into practice, more detailed plans for specific components need to be developed, and guidance and incentives for intersectoral action in the field is required. WHO has started to work with countries to formulate a rolling "Health and Environment" planning process. This would have a monitoring and assessment part, a management and pollution control part, a human resources development part and a research part. At the international level, WHO is linking with UNDP, the World Bank, Regional Banks, UNEP, ILO, FAO, UNESCO, UNIDO, IAEA, and others as appropriate, to create partnerships at country level among sectors that have in the past communicated independently with each international agency. The ultimate aim is to establish an intersectoral "problem-solving team spirit" at the local and national level, in order that the planning items can be put into practice without delay and sectoral barriers. In order to reduce health risks from environmental pollution the new approaches at national and international level will include taking advantage of cross-linkage between initiatives that focus on specific target groups. This includes the "Healthy cities project", "Supportive environment projects" and others described in other parts of the report on chapter 6. FAO is working with countries to ensure that access to adequate and safe food supplies, education and related services can and are achieved by ensuring sustainable measures that are environmentally sound. This includes the consideration of providing incentives and motivating farmers to adopt sustainable and efficient practices. A new activity in the monitoring and assessment area is a joint UNEP/WHO project to develop improved methodologies and guidance for linking data on environmental quality and health status of populations exposed. Indicators for measuring environmental conditions rather than individual pollutants or stressors is seen as a component of the evaluative process. The linkage analysis will be used to develop environmental health indicators suitable for monitoring of progress in sustainable development and Health For All implementation. It will also be used to improve the methodology for environmental health impact assessment. Due to different priorities, different indicators may be used in different countries, or even within countries, but a core minimum set will ensure that national, regional and global aggregation of information can be created. This project will be closely linked to the UNEP/UNSTAT activities to harmonize environmental statistics and sustainable development indicators. FUTURE DIRECTIONS The intersectoral work at field level needs to be based on up- to-date information about past, ongoing and planned activities in the same country, so that national and international agencies can avoid duplication and waste. Intersectoral collaboration for problem-solving at the local level needs to be further developed and tested. The area of information can be the testing ground for such an approach. The procedures for environmental health assessment and management should be streamlined down to a limited number of elements, using the core sciences, such as microbiological, chemical and physical measurements, statistics, epidemiology and social sciences. The continuing major void in information on health-related environmental quality and effects on health in developing countries must be dealt with. Hard and accurate information is needed for building general public awareness and support, obtaining political support and providing the scientific basis for national legislation, standards and programmes. The international initiatives to date, primarily through the Global Environmental Monitoring System (GEMS), provide an established framework for dealing with this problem, but such efforts need considerable strengthening. As is said in essentially all relevant chapters of Agenda 21, emphasis now must be placed on prevention of causes of environmental degradation. This is also true for the activities considered in this chapter. Opportunities exist through land use planning, transportation planning, behavioural changes, etc. Agreement that new development projects should undergo an environmental health impact assessment should be enforced. It is up to organizations such as UNDP, the World Bank and others to see that this is done. SECTION III: SCIENTIFIC AND TECHNOLOGICAL MEANS The five programme areas covered in section II stratify the overall health conditions of populations by location and social- economic characteristics. All of these strata have been and will increasingly be subjected to dramatic change: * in their relative size and location, * in the extent of the risks causing these conditions. Chapter 6 of Agenda 21 identified a series of scientific and technological means to improve the understanding, forecasting and management of the change processes affecting these population groups. These can be grouped as follows: (1) More effective planning processes and methods for strategy design at national, district and local levels; (2) Improved information (data) management and communications; (3) Models and other tools which facilitate the analysis of the variables in health problem situations, and which assist the assessment of costs and impacts of possible solutions and intervention strategies; (4) Information monitoring, analysis and sharing at the international level, including dissemination of knowledge, technology and resources through TCDC. HEALTH PLANNING AND STRATEGY DESIGN International and national health and development planning methods and practice have gone through cycles of development over the last several decades. The current situation is characterised by a continuing desire for more intersectoral planning and strategy development, but with few successes. There is also a continuing desire to ensure that cost and effectiveness considerations are attached to all political goal setting, such as Health For All and sustainable development. Nevertheless, there remains in many countries a negative assessment of the value, and therefore the need to invest in extensive health planning processes. On the other hand several recent international developments signal an opportunity for re-emphasizing health planning and related activities with the expectation of near-term benefit: (1) The use of cost-effectiveness in the design of health strategies and services and a method for monitoring the health state of a population which helps establish priorities in terms of the "burden of disease" in the World Banks World Development Report of 1993 on Health and Development. (2) The concept of "new Public Health Action" which implies among other things that health planning processes can and should review and revise the extent of public responsibility in health. (3) The "decentralization" of health planning and the use of health data and epidemiology by district staff and community leaders as they devise their own approaches for health promotion and protection (eg. through district problem-solving processes and micro-planning). (4) The growing experience with "rapid assessment" procedures for situation analysis and programme monitoring and evaluation. (5) The initiation by WHO and UNICEF of a joint monitoring programme for water supply and sanitation as a means of building national capacity to monitor and manage water and sanitation development. Thus, there seems to be an opportunity for health planning methods to be further developed and appropriately applied through revitalized international partnerships which address the agreed needs for equity, cost-effectiveness, implementability and involvement by the community. IMPROVED HEALTH DATA MANAGEMENT AND COMMUNICATIONS The rapidly advancing micro-computer technology and data communications capability offers considerable potential for improvement in the management of the extensive amounts of data generated by and felt required for the delivery of health services. While some progress is being made, the rarity of efficient health data management in most countries is striking. The tremendous under-analysis and use of routinely generated health data continues despite the means for selectively capturing and analysing it for monitoring, evaluation and control purposes. Again, concerted international partnership and action should be able to foster the use of available, inexpensive computer technology for improved heath data management and communications. Specific types of technology enhancement include: (1) development of health indicators to monitor and evaluate access, equity of access and use, efficiency and quality of health services; (2) guidance in the design and management of large data bases and training in the operation of computerized health information systems; (3) practical use of facsimile and electronic mail communications; (4) special computer applications such as geographic information systems, patient flow analysis and data trend analysis; (5) improved epidemiological surveillance to identify environmental hazards and to forecast the spread of communicable diseases; (6) an epidemiological basis for developing, and then evaluating new disease control strategies. HEALTH MODELLING The availability of user-friendly modelling packages associated with the power of sophisticated data analysis and dynamic modelling has opened up the possibility of modelling to Everyman. Collaborative efforts among interested agencies and institutions should focus on practical guidance for national health administrations in the use of computer modelling to: (1) Analyze the complicated cause and effect relationships that exist in any health problem situation; (2) devise and test the cost-effectiveness of potential interventions within a problem situation; (3) forecast and design future scenarios in the health situation and system. One collaborative effort that could lead to the development of practical health-environment modelling methods is the current WHO/WMO/UNEP project to produce a book on Potential Health Impacts of Climate Change. This activity takes place in close coordination with the impact assessment work of the Intergovernmental Panel on Climate Change (IPCC), whose climatological modelling scenarios for 2020 and 2050 serve as baseline material. INTERNATIONAL GENERATION AND SHARING OF HEALTH INFORMATION The same computing and communications technology that can do so much to benefit data management in countries is also available to serve the community of nations at the global level. Reference has already been made to GEMS. Other areas for sharing and using globally available data to greater advantage include: (1) WHO and the Centres for Disease Control, Atlanta are exploring the possibility of a global monitoring of emerging infection and changing disease patterns through the use of national collaborating laboratories and global data communications facilities. (2) a similar service can be provided with respect to the rapidly advancing health and biomedical technology. A global monitoring function can be established which, with the cooperation of major research centres, can keep abreast of progress and expected breakthroughs from research and development of health technology. (3) on a less sophisticated level, the internet and gopher spaces of the world offer the ability to easily gather and share evidence of the effectiveness of new health strategies and operational approaches. What is required is the necessary staff support to administer such international electronic clearing houses. (4) an inter-agency project on Databases and Methodologies for Comparative Assessment of Different Energy Systems for Electricity Generation (DECADES), while not specific to health, is of relevance in illustrating the extent to which inter-agency cooperation is possible in this area. The Secretariat is IAEA, IIASA, OPEC, and UNIDO. Other cooperating organizations include CEC, IBRD, OECD/NEA and WMO. SECTION IV: HUMAN RESOURCES DEVELOPMENT AND CAPACITY-BUILDING This programme area is closely associated with chapters 36 "Promoting education, public awareness and training" and 37 "Capacity-building". ACTIVITIES AND POLICIES OF THE ORGANIZATIONS WITHIN THE UN SYSTEM The UN agencies actively promote and support human resources development in countries. WHO has made a major effort in the health field with other agencies playing important roles - FAO, UNEP, UNESCO, UNICEF, and UNITAR, to name just a few. Financial support has been provided by UNDP, the World Bank, Regional Banks and a number of bilateral and other agencies. WHO has been active in supporting and guiding national agencies for many years. Stress is given to the relevance of training to the work situation and efficiency of training methods used. More recently, the work of WHO has focused on district level staff, as they often have limited base training and few opportunities for continuing education. One area of importance for district level staff training has been the provision of appropriate training materials in local languages. The WHO Health Learning Programme has helped establish around 30 national centres for the translation and publication of needed training materials. To strengthen the capacity to deal with health and environment problems at local and national level, WHO has developed Global Networks of teachers and researchers in the field of health effects assessment (the Global Environmental Epidemiology Network, GEENET) and the field of environmental management and pollution control (the Global Environmental Technology Network, GETNET). These networks of more than 2000 people in 130 countries provide an important infrastructure for communication and collaboration. Specific country activities, particularly training workshop on priority topics, are sponsored via the networks and support and collaboration has been established with UNEP, UNESCO, the World Bank, and bilateral cooperation agencies. The ultimate aim of the networks activities is to facilitate the development of sustainable training activities within country institutions. Teacher training programs have therefore been started together with UNEP and ILO. In the future, it is essential to link the different training activities at national level into a common planning framework. The development of human resources in various fields related to food and agriculture is an essential component of FAO programmes. In relation to health, and as a follow-up to the ICN, emphasis has been given to the training of local health workers and nutritionists in the diagnosis and treatment of nutritional diseases including micronutrient deficiencies and on integrated approaches to improve household and community nutrition. Emphasis has also been given to the training of food control personnel and managers in various aspects related to this activity. One area of importance is the development of high-level expertise on the priority environment and health issues for each country, in order that national consultants can be provided for as many tasks as possible related to development projects. FUTURE DIRECTIONS The development of comprehensive national strategies and human resources development plans for the health and environment field is a priority and should be linked to the development of national Agenda 21 plans as a subsidiary process. These plans should highlight what knowledge and skills are needed, who should have them, how they should learn it, and who should facilitate the learning (who should teach). Internationally sponsored training should be implemented in order that national training developments are encouraged and facilitated, and should lead towards sustainable training. Funding of training should be linked to other development investments, just like funding for other infrastructure and resources is seen as a part of an investment. Another new feature of human resources development should be a more demand-driven approach rather than supply-driven. WHO is planning to offer its' environmental health training services in this way in the future. This means that modular training workshops and courses will be developed for adaptation by national programmes when and as needed. Country agencies can fit these into their national HRD plan implementation, and will seek possibilities to link specific training events to development investments in order to fund the event. International agencies need to coordinate their programmes better and make arrangements for intersectoral training opportunities, instead of duplicating training courses for different sectors. Numerous international agency information and guidance materials are produced without sufficient follow-up activities to make them used as intended by the target groups. Many of these materials could be used as resource materials for training, together with custom-made training materials based on country priorities. A collaborative effort to harness these written resources for environmental health training will be initiated by WHO, as a part of the collaboration on environmental education with UNEP, UNESCO, ILO, UNITAR, UNIDO and other agencies. UNESCO is concerned with the future role of universities in societies experiencing many challenges and profound crisis. Universities almost everywhere have been slow to accept responsibility for research and teaching in interdisciplinary fields (such as health and the environment) since they have long been organized by academic disciplines each with its own department. Universities must face the challenge of breaking down these traditional boundaries to create interdisciplinary programmes that respond to pressing health and environmental problems. This also means adopting open, creative and active methods of learning. Active and participative learning can produce relevant experiences and enable students to learn from them. New collaborative initiatives have been taken for the promotion of innovative professional training approaches by UNESCO, UNEP and WHO. SECTION V: DECISION-MAKING AND FINANCIAL IMPLICATIONS In "Our planet, our health", decision-making in the field of health and the environment is assessed in the following terms: The maintenance and improvement of health should be at the centre of concern about the environment and development. Yet health rarely receives high priority in environmental policies and development plans, rarely figures as an important item in environmental or development programmes, despite the fact that the quality of the environment and the nature of development are major determinants of health. This assessment was made in 1991. It still applies today as regards the participation of Ministries of Health (MOH) in the decision-making process of Agenda 21. Since its origin, WHO has worked with its Member States to strengthen Ministries of Health (MOHs). With the adoption of the PHC approach at Alma-Ata, with its strong intersectoral implications, the need for strengthened MOHs has grown in priority. But the reality in many countries, is that these Ministries play only a relatively small part in the affairs of overall national health systems. The MOH in many developing and developed countries does not have a policy or programme, or the capacity to influence the development of key sectors such as urban development, water and sanitation, food and agriculture, education, etc. This "gap in leadership" must be overcome if the health goals outlined in Agenda 21 are to be realized. No simple formula exists. The national machinery that is set up to oversee the implementation of Agenda 21 must address this problem as a matter of urgency. As noted in Chapter 8 of Agenda 21, prevailing systems for decision-making in many countries tend to separate economic, social and environmental factors at the policy, planning and management levels. This situation still largely prevails. Traditional incentives dominate; new economic incentives and new systems for integrating environmental and economic accounting have not yet begun to be put in place. Since traditional economic thinking and analysis has often ignored adverse impacts of "development" on human health and the environment, it is essential that the new systems for integrated environmental and economic accounting to be developed for sustainable development incorporate health concerns. Health budgets are largely dominated by the provision of curative services. Consequently, current financial incentives within the health sector are more tied to the magnitude of illness than its prevention. Furthermore, attempts to look at health costs and needs from a broader multi-sectoral perspective are handicapped by the near total lack of relevant data. Two important factors contribute to the state of ignorance concerning health needs and costs: (1) man-made changes to the environment are rarely made with health objectives in mind; consequently, little attention is given to the assessment of any impact on health, and thus little, if any, attention is given to the costs of reducing risks associated with these changes. (2) the health-sector, as such, is poorly positioned to monitor the impact on human health of changes introduced by other sectors, even where it is mandated to undue the damage done by others. In short, while much is known about what is spent on curative and personal care, the contribution of changes to the environment or efforts to promote health through behavioural changes are at best only understood qualitatively. Further consequences of the current situation are as follows: (1) potential health risks are not "costed" and the services provided by other sectors are not "priced" to reflect these risks; (2) the monitoring of such health risks is not budgeted for at a level comparable to the threat they pose to human health; (3) the monitoring of health risks is not built into major developmental projects. These points can be illustrated by examples drawn from the water resources development field: (1) Where the per capita water supply allowance of a large city is significantly increased, the cost of the project is not increased to cover new health hazards due to the environmental pollution resulting from increased quantities of used water. (2) Where serious epidemic outbreaks occur (especially cholera), it is public health resources that are expected to control the outbreak even though these resources are often inadequate to cope even with the task of surveillance of drinking water quality. (3) Where water development projects through flow regulation and drainage shape the local epidemiology of many diseases, for example, malaria and schistosomiasis, the potential of increased health risks is rarely incorporated into the engineering and public works infrastructural cost of these schemes. Various solutions to these problems have been proposed which suggest how the financing of health should be looked at in the context of environment and sustainable development. For example, if the health authorities could subcontract surveillance to private laboratories, or undertake any structural improvements which would allow them to carry out this task themselves, they could guarantee the delivery by the water authorities of a potable product. The cost would be but a minor part of the total expenditure required to supply water, and it could be incorporated in the selling price, as consumers would probably be more willing to pay the full cost of the service, if they were convinced of its value and health benefits. Also, capital costs associated with major water development projects could reflect total costs in a more realistic way: a proportion of the income generated by environmental improvements could be used to finance the costs of health maintenance which includes screening, surveillance, prevention, treatment, education and the control of disease vectors. These examples, which relate to water development, apply to all other sectors which contribute to changes in the environment of importance to human health: air, shelter, land, forests, coasts, etc. For human health to be both the core and the objective of sustainable development, the financing of health must account for all such sectors. Only in this way will the most cost-effective health interventions be determined and given highest priority. For such an approach to health financing to be realized, it is essential that the other sectors concerned are involved financially, technically and administratively in identifying and developing these interventions. The involvement of other sectors to such an undertaking should be commensurate with the level of inter-dependence judged to be present. Thus, for example, where communicable diseases pose a major burden of ill-health and are heavily associated with water development projects, it would be reasonable for the water development sector to be expected to play a significant role in controlling such diseases. The total contribution to health through such multi-sectoral involvement can be considered and budgeted as an environmental health line in the national health plan. In WHO's contribution on Financing of Health, the environmental health line included vector control, air pollution, safe water, other pollution, hygienic collection, reuse and disposal of wastes, hazards from toxic chemicals, protection of natural resources and promotion of the environmental infrastructure. The total "cost" associated with this line amounts to less than 12% of the 51 billion US$ per year "cost of health" quoted in Chapter 6 of Agenda 21. This figure, however, should not be taken as a definitive estimate of how much should be invested in the environment to achieve better health. Rather, it is an amount to ensure that there will be the necessary funds to develop multi-sectoral linkages, put in place environmental monitoring and surveillance systems, and, in time, to develop cost- effective instruments which can be integrated in the programmes of other sectors. According to the World Development Report 1993, a total of US$ 170 billion was spent on health in the developing countries. Thus, at least in gross quantitative financial terms, the costs for implementing the activities outlined in Chapter 6 of Agenda 21 can be met. The changes involved, however, as indicated above, will require considerable reform within the health sector and across all health-related sectors. SECTION VI: SUGGESTED DEVELOPMENT STRATEGIES FOR THE FUTURE Chapter 6 of Agenda 21 identified the essential activities that need to be implemented. But Chapter 6 did not address the fact that much reform is needed for such a programme of activities to be realizable. Four "lines of reform" emerge from the above analysis: (1) Community (Health) Development: protecting and educating vulnerable groups as part of more holistically conceived community development programmes; (2) Health Sector Reform: Ministries of Health increasing allocation of resources to most cost-effective programmes; (3) Environmental Health: increasing understanding of sectoral-linkages with health and mobilizing action in other sectors accordingly; (4) National Decision-Making and Accounting: strengthening health representation in national decision-making and incorporating health and its financing in new accounting systems for sustainable development. Fortunately steps have already been taken to promote reform within the health sector, as indicated earlier. The additional reforms are needed to ensure that health is incorporated in all aspects of national sustainable development. Only in this manner will the pursuit of improved human health be a positive driving force for sustainable development. The CSD called upon the Task Managers to prepare "analytic" reports which would highlight "unnecessary duplication", "gaps and opportunities for cooperation and joint programming", "assessment of relevance, strength and usefulness of various programmes and activities", and "organizational responsibilities and allocation of tasks on the basis of expertise and competitive advantage". This has been done in the preceding sections, but only to a partial degree. The analysis has not been carried out to its "logical conclusion", since any conclusion concerning, for example, "unnecessary duplication" might be counterproductive. It was felt that a logical delineation of organizational responsibilities might stall current efforts among UN agencies to support health sector reform. Without health sector reform, it is difficult to imagine the other reforms identified having any chance of success. Instead, the CSD is called upon to help the process of change by confirming that the lines of reform identified should be actively pursued by all relevant UN agencies. The CSD can further stimulate movement in the direction outlined through special action, e.g. calling upon Governments to host meetings to elaborate the reform process in more detail, calling upon donor agencies to ear-mark funds for this process in countries that are actively implementing sustainable development policies, and establishing special working groups to monitor progress within the UN system to ensure that the reform called for at national level is leading to comparable reform within and among the various agencies involved. A common understanding of sustainable development does not exist. Consequently there is a strong risk that the revolutionary changes called for by Agenda 21 will rapidly be lost sight of. This risk is particularly present in the health sector where environmental health has rarely received adequate attention. The active support of the CSD is required in carrying out the reforms listed above to ensure that the full potential of Agenda 21 is realized.
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Date last posted: 1 December 1999 12:18:30