1 47620 P O V E RT Y, H E A LT H , & E N V I R O N M E N T Placing Environmental Health on Countries' Development Agendas Poverty-Environment Partnership Joint Agency Paper this publication is a joint product of staff from asian Development Bank, austrian Development agency, German Federal ministry for economic Cooperation and Development, ministry of Foreign affairs of Denmark, Department for international Development, european Commission, Finland ministry of Foreign affairs, international institute for environment and Development, irish aid, london School of Hygiene and tropical medicine, norwegian agency for Development Cooperation,SwedishinternationalDevelopmentCooperationagency, Swiss agency for Development and Cooperation, United nations Development Programme, United nations environment Programme, Water aid, World Bank, World Health organization, and World resources institute, and while consultations have been considerable, the judgments do not necessarily reflect the views of their respective governing bodies, or where applicable, the countries they represent. 2Mx1M banner 3/17/04 11:32 AM Page 1 International Institute for Environment and Development k WORLD oreignF RESOURCES Denmar ofy INSTITUTE of inistrM fairs Af P O V E RT Y, H E A LT H , & E N V I R O N M E N T Placing Environmental Health on Countries' Development Agendas Poverty-Environment Partnership Joint Agency Paper June 2008 II Cover Photo: World Bank, Above: Curt Carnemark F o r e w o r d Environmental risk factors play a role in more than 80 major However, despite its direct link with poverty reduction in most As the climate changes and environmental health effects felt diseases and injuries around the world. Diarrhea, lower developing countries, environmental health is often a forgotten by the poor further intensify, we urge countries to respond respiratory infections, various forms of unintentional injuries, agenda. Why is this? This report tries to understand the answers to the challenges described in this paper. A concerted and and malaria are largely the result of environmental risk factors. to this question. It then moves forward with some suggestions on continuous effort on the part of all of us is important to ensure These are precisely the diseases that most affect the poor in the how public officials in planning or finance departments at the that this important agenda is highlighted and implemented. poorest countries. As the world's climate changes, these existing national, state, or city level can play a role in raising the profile of We urge you to join us in this effort, which directly affects the health impacts are expected to worsen, particularly for the poor environmental health issues linked with poverty reduction efforts, health and quality of life of poor families, particularly of their and in developing countries. as well as how nongovernmental agencies (NGOs) and bilateral women and young children. and multilateral institutions can support them in their efforts. Ursula Schaefer-Preuss Stefano Manservisi Camilla Toulmin Poul Engberg-Pedersen Kemal Dervis Katherine Sierra Vice President for Knowledge Director-General of the DG Director Director General Administrator Vice President for Sustainable Management and Sustainable Development and Relations with International Institute for Norwegian Agency for Development United Nations Development Programme Development Development African, Caribbean and Pacific States Environment and Development Cooperation (NORAD) (UNDP) World Bank Asian Development Bank (ADB) European Commission (EC) (IIED) Ambassador Brigitte Ritva Koukku-Ronde Ronan Murphy Göran Holmqvist Achim Steiner David L. Heymann Walchshofer-Öppinger Director General, Department Director General Director General Executive Director Assistant Director-General ­ Health Managing Director for Development Policy Irish Aid Swedish International Development United Nations Environment Security and Environment Austrian Development Agency Finland Ministry of Foreign Affairs Cooperation Agency (SIDA) Programme (UNEP) World Health Organization (WHO) (ADA) Ambassador Ib Peterson Adolf Kloke-Lesch Sir Andy Haines Walter Fust Henry Northover Manish Bapna State Secretary Director-General, Global and Director Director General Head of Policy Executive Vice President and Ministry of Foreign Affairs of Denmark sectoral policies London School of Hygiene and Swiss Agency for Development Water Aid Managing Director (DANIDA) German Federal Ministry for Economic Tropical Medicine (LSHTM) and Cooperation World Resources Institute (WRI) Cooperation and Development (BMZ) A c k n o w l e d g m e n t s This report has been prepared by a team consisting of: The team benefited greatly from comments and suggestions The preparation of this paper has been funded by DFID, Peter Furu, Henning Nohr and Jan Reimer (Danida); Helen bythefollowingpeople:DavidMcCauley(AsianDevelopment Danida, the World Bank and the Government of the O'Connor (DFID); Simon Bibby, Sandy Cairncross, Chris Bank); Erwin Kuenzi (Austrian Development Agency); Douglas Netherlands through the Bank-Netherlands Partnership Church, Nina Iszatt, Chris Pell and Carolyn Stephens (London Sheil (CIFOR); Anne Marie Sloth Carlsen (Danish Ministry program. Publishing and printing of this paper has been School of Hygiene and Tropical Medicine); Anjali Acharya, of Foreign Affairs); Palle Lindgaard-Jřrgensen (DHI- Water & funded with contributions from Asian Development Bank and Kulsum Ahmed, Maria Fernanda Garcia, Mikko Kalervo Environment); Simon Le-Grand (EC); Tara Shine (Irish Aid); the World Bank. The translation, publishing and printing of Paunio and Pia Rockhold (World Bank); and Carlos Dora, Eva Joshua Bishop, Sue A. Mainka (IUCN); François Droz (Swiss the French version of this paper have been funded by the Swiss Rehfuess, and Michaela Pfeiffer (World Health Organization). Agency for Development and Cooperation); Phil Dobie, Peter Agency for Development and Cooperation. Hazlewood, Charles McNeill, and Paul Steele (UNDP); Jan Bojö, Peter Hawkins, Sunanda Kishore, Andreas Knapp, Pete Kolsky, Samuel Dawuna Mutono, Eduardo A. Perez, Ernesto Sánchez-Triana, Laura Tlaiye, and Kate Tulenko (World Bank). 1 tA b l e o F c o n t e n t s Glossary 2 List of Boxes List of Figures Executive Summary 3 1. Environmental Health and Sustainable Development 10 1. Disease with the Largest Environmental Contribution 11 1. Why is environmental health important in 2. Environmental Health in PRSPs: Some Good Practice Examples 24 2. Environmental Disease Burden in DALYs per 1,000 people 13 poverty reduction? 9 3. Malawi: Good Practice in Environmental Indicators 25 3. Burden of Disease Attributable to Childhood and Audience and Objectives 9 4. HELI: Health, Environment, and Economic Benefits of Water Maternal Undernutrition 14 Why Environmental Health Matters 10 Efficiency in Jordan 32 4. Environmental Health Costs 15 Environmental Health and Malnutrition Linkages 11 5. Even as a Health Measure, Infrastructure can be Cost-effective 33 5. Trends in Reporting Sanitation Access, Water Access, and Environmental Health and Poverty 12 6. Behavior Change can be Cost-effective 33 Solid Fuels in MDGRs 22 Cities and Urban Slums 13 7. Seasonality is Important in Tanzania: Findings from the PPA 34 6. Incorporating Environmental Health into Institutional Processes Environmental Health and Economic Growth 15 8. Incorporating Environment and Health into Poverty Reduction Aimed at Enhancing Development and Poverty Reduction 30 Climate Change and Impacts on the Poor 16 Strategies in Tanzania 35 7. Multiple Inputs and Outcomes in Environmental Health 39 Targeting Poverty Reduction 17 9. Changing the Policy Approach: Lessons from Yunnan Province 35 10. Philippines: A Need to Rediscover the Sanitation Code 36 List of Tables 2. Taking Stock of Environmental Health in Poverty 11. Successful Adjustment to Environmental Health Standards 38 1. MDGs and Environmental Health 18 Reduction Goals, Targets, and Strategies 21 12. How Peru Incorporated Environmental Health into National 2. Findings/Recommendations Relating to EH in Selected What do we find in Millennium Development Plans and Policies 38 MDG targets 23 Goal Reports (MDGRs)? 21 13. The Ecohealth Approach: Combating Malaria through 3. Examples of Environmental Health and Poverty Linkages 31 What do we find in Poverty Reduction Strategy Papers? 22 Agricultural Practices in Kenya 40 4. Key Environmental Health Indicators 41 Challenges Associated with Placing Environmental 14. Global Initiative on Children's Environment and Health Indicators 42 Health Issues on the Development Agenda 26 15. Building Constituencies in Colombia to Reduce Urban Air Pollution 45 3. Opportunities for Incorporating Environmental Health in 16. Environmental Health in the Media 46 Development Planning and Poverty Reduction Strategies 29 17. The Global Public-Private Partnership for Handwashing with 1. Analyzing the Linkages Between Environmental Health Soap in Ghana 46 and Poverty 31 18. Worm Control: An Opportunity for the School System 46 2. Prioritizing Environmental Health Issues 32 19. Tackling Malaria Through Work with Farmers: The Farmer 3. Assessing and Strengthening Institutional Capacity and Field School Approach 48 Governance on Environmental Health Issues 37 20. Women Take a Lead in Tackling Environmental Health Problems 49 4. Choosing Appropriate Environmental Health Interventions 40 21. A Hood Solution for a Maasai Community in Rural Kenya 49 5. Monitoring Process and Outcome Indicators 41 22. Slum Sanitation in Mumbai, India: Building Sustainable Partnerships 50 4. Building Longer-Term Constituencies to Support 23. Dhaka Two-Stroke Three-Wheelers Phaseout 51 Poverty-Environment-Health Issues 45 24. Sri Lanka: Collaboration for Urban Air Quality Management 52 Awareness-raising and Communication Strategies 45 25. Reinforcing Social Accountability for Improved Participation and Stakeholder Involvement 47 Environmental Governance in India 52 Access to Justice 52 5. Moving Toward Action 55 How Donors and NGOs can Support Government Efforts 55 Conclusion 56 References 57 2 A b b r e v i At i o n s A n d A c r o n y m s g l o s s A ry ARI Acute respiratory infection Acute Occurring over a short time, usually a few minutes or hours. An acute exposure can result in short-term or long-term CEA Country Environmental Analysis health effects. An acute effect happens within a short time after exposure. COPD Chronic obstructive pulmonary disease Attributable risk The amount of disease risk in the population that can attributed to a given risk factor CRA Comparative Risk Analysis CSO Civil society organizations Biomass fuel A renewable fuel derived from plants, animals or their byproducts. Biomass fuels include wood, dung, charcoal, and grain alcohol DALY Disability-adjusted life years Burden of disease The total significance of disease for society beyond the immediate cost of treatment. It is measured in years of life lost to ill DFID Department for International Development health as the difference between total life expectancy and disability-adjusted life expectancy. DHS Demographic and Health Surveys EH Environmental health Chronic Occurring over a long period of time--several weeks, months, or years. Used to describe recurring symptoms or disease. EIA Environmental impact assessment Climate change Refers to the buildup of man-made gases in the atmosphere that trap the sun's heat, causing changes in weather patterns on GDP Gross domestic product a global scale. The effects include changes in rainfall patterns, sea-level rise, potential droughts, habitat loss, and heat stress. GIS Geographic information system The greenhouse gases of most concern are carbon dioxide, methane, and nitrous oxides. If these gases in our atmosphere HELI Health and Environment Linkages Initiative double, the earth could warm up by 1.5 to 4.5 degrees Celsius by the year 2050. HIA Health impact assessment HIPC Highly Indebted Poor Countries DALY Disability-adjusted life year: A method of calculating the global or worldwide health impact of a disease or the global HLY Healthy life years burden of disease (GBD) in terms of the reported or estimated cases of premature death, disability, and days of infirmity IAP Indoor air pollution due to illness from a specific disease or condition. LSMS Living Standard Measurement Surveys Exposure Radiation or pollutants that come into contact with the body and present a potential health threat. The most common MDG Millennium Development Goals routes of exposure are through the skin, mouth, or by inhalation. MDGR Millennium Development Goals Report Hazard Something that could plausibly cause a risk (an increased probability) of disease. NDP National Development Plans NGO Nongovernmental organization Health outcome Changes in health status (mortality and morbidity) that result from the provision or lack of provision of health (or other) services. OECD Organisation for Economic Co-operation and Development Hygiene Practices, such as handwashing at key times, which help ensure cleanliness and good health. PEAP Poverty eradication action plan PEN Poverty-environment nexus Indoor air Chemical, physical, or biological contaminants in indoor air, principally from burning solid fuels for cooking and PEP Poverty Environment Partnership pollution heating purposes. PPA Participatory poverty assessment Morbidity Illness or disease. A morbidity rate for a certain illness is the number of people with that illness divided by the number of PRSP Poverty Reduction Strategy Paper people in the population from which the illnesses were counted. PYLL Potential years of life lost SEA Strategic Environment Assessment Mortality Number of deaths or expected deaths in a population; the death rate SSP Slum Sanitation Program Risk Possibility of injury, disease, or death TSP Total suspended particles UNDP United Nations Development Program Respiratory tract UNEP United Nations Environmental Program Lower respiratory tract The trachea and lungs WHO World Health Organization Upper respiratory tract The mouth, nose, and throat Risk factor An agent that when present increases the probability of disorder expression. A risk factor can be due to environmental exposure. Note: All dollars are U.S. dollars unless otherwise noted. Sanitation Formulation and application of measures designed to protect public health or disposal of sewage. Vector control Any method to limit or eradicate the vectors of diseases such as malaria, dengue, etc, for which the pathogen (that is, virus or parasite) is transmitted by a vector. The vector can be mammals, birds or arthropods, especially insects, and mosquitoes. 3 e x e c u t i v e s u m m A ry Environmental health matters greatly to those living in poverty. Emerging issues such as climate change will further increase This report is intended primarily for officials in finance and Recent opinion polls have found that poor income groups tend poverty reduction challenges and the health burden as the planning departments at the national, state, or city level to mainly raise issues linked with clean air and water as national IPCC predicts that the poor and most vulnerable will be hit the in developing countries. It will also be of interest to various environmental concerns, suggesting that environmental health hardest (IPCC 2007). WHO notes that currently important sector officials in national and local governments in developing concerns directly affect their quality of life and therefore are a healthburdens,inparticular,arelikelytobeworsenedbyclimate countries, nongovernmental organizations (NGOs) and private priority for them (World Bank 2006c, Miller 2004). change (Campbell-Lendrum et al. 2007), thus suggesting that sector representatives, and development agency staff and sector children in poor countries are most likely to be affected. advisors in development cooperation agencies. Official data provide a consistent message. Prüss-Üstün and Corvalán (2006) estimate that environmental risk factors There are several reasons why environmental health is an This report was produced by several bilateral and multilateral currently play a role in more than 80 of the major diseases and important concern for the poor (Cairncross and Kolsky 2003). development agencies and NGOs with an interest in enhancing injuries around the world. Africa and Asia (excluding China) Poor people often live in areas with the worst environmental the quality of life of the poor through improvements in are most affected by environmental health-related diseases. conditions;theyhavelowerresistancetoinfection;theypaymore environmental health. Furthermore, Prüss-Üstün and Corvalán (2006) estimate that for environmental health services; and when they fall ill, they 24 percent of the global disease burden and 23 percent of all lose income and even their jobs. Better environmental health deaths can be prevented through environmental interventions. conditions go beyond directly improving health outcomes. On the whole, the impact of traditional hazards--that is, health Additional benefits often include saving time, lowering the risks that are a consequence of lack of access to clean water, cost of living, gender equality (security and dignity), increasing inadequate sanitation, poor waste disposal, indoor air pollution, convenience through service provision (recycling, building and vector-borne diseases such as malaria--is three times higher latrines, etc.), and reducing the burden of daily life. globally compared to modern hazards, which include urban air pollution and problems arising from industrial chemicals and The main objectives of this report are: wastes. The absolute impact of traditional risks is even larger in the poorest areas (Ezzati et al. 2004). 1. To illustrate that--despite efforts to emphasize the importance of environmental health to poverty reduction More than one-third of disease in children under the age of and sustainable development in partner countries-- five years is caused by environmental exposures. The top killers there has been limited success in countries placing of children under five are acute respiratory infections (from environmental health issues that matter to the poor high indoor air pollution), diarrheal diseases (mostly from poor on their development agendas. water, sanitation and hygiene), and malaria (from inadequate environmental management and vector control) (Prüss-Üstün 2. To provide practical guidance on how to raise the profile and Corvalán 2006). Strikingly, the mortality rate in children of environmental health issues important to the poor and under five years of age from environmentally mediated disease integrate them more successfully in (a) national and local conditions is 180 times higher in the poorest performing strategies and plans, and (b) development cooperation region, as compared with the rate in the best performing region activities that support these strategies and plans. (Prüss-Üstün and Corvalán 2006). Photo: Ray Witlin 4 Improvingenvironmentalhealthcanhelpcontributetoreducing poverty, both directly and indirectly. This is acknowledged in several Millennium Development Goals, including (a) Goal 4, which emphasizes reductions in child mortality; (b) Goal 6, which mentions combating HIV/AIDs, malaria, and other diseases; and (c) Goal 7, which emphasizes environmental sustainability. It also indirectly contributes to (a) eradicating extreme poverty and hunger, (b) achieving universal primary education, and (c) promoting gender equality. Despite its importance for poverty reduction, environmental health issues that are important for the poor are rarely a high priority on the development agenda. A special report by UNDP assessed how countries are progressing on the MDG-7 target of environmental sustainability, and found low reporting of data on targets. Reviews undertaken by WHO and the World Bank have assessed how health broadly--and environmental health more specifically--has been addressed in Poverty Reduction Strategy Papers (PRSP), which are one key vehicle for countries to address poverty reduction and achieve the MDGs. Overall, the findings reveal some progress in the incorporation of environmental health issues within PRSPs. However, concerns remain that environmental health issues are not being systematically addressed within conventional health sector interventions, and that good practice examples, especially scaled up, are still scarce. Why is this? A multitude of reasons potentially explain this lack of progress. First, environment is typically perceived as a global public good, rather than one that is also closely linked with the well-being of the poor. Many development agencies are trying to change this perception, but it is still widely held. So, as a result, issues that matter to the more well-off (and politically powerful groups) dominate. If there is an overlap between the environmental health issues that matter to both Photo: Tran Thi Hoa vulnerable and more powerful groups, action may often be vis- 5 ible, as is the case with urban air pollution in many large cities. So how can poverty-related environmental health issues be 3. Assessing the country's enabling environment specifically Indoor air pollution, on the other hand, is closely related to placed on the development agenda? This report suggests a in terms of institutional mandates and related capacity, access to cleaner fuels and therefore only impacts the poor. It two-pronged strategy. The first relates to governments putting regulations, and budgets relating to environmental is responsible for over 1.5 million deaths per year, significantly institutional mechanisms in place so that the environmental health more than in the case of urban air pollution (WHO 2006), yet health priorities that matter to the poor can be constantly there has been less progress in placing this issue high on the identified, acted upon, and monitored. The second relates to 4. Selecting and ensuring adequate financing of environmen- development agenda. external actors--such as those in the Poverty-Environment tal health interventions based on the above assessments Partnership--playing a role with respect to supporting Second, at a sectoral level, incentive structures in institutions governments in these efforts through utilizing existing financial 5. Monitoring process and outcome indicators to track are often not set up to place environmental health issues that and knowledge instruments to highlight environmental health progress and to learn and continuously improve policy matter to the poor high on the agenda. There are several issues that matter to the poor. design and implementation. reasons for this. First, environmental health is rarely placed on the agenda of many conventional health sector programs. This Within governments, environmental health issues that In addition to these direct inputs, environmental health may be because, in order to address environmental health, both matter to the poor can be incorporated into development interventions also benefit from cross-cutting issues that a preventive and a rapid treatment approach are important. plans or poverty reduction strategies at the country level at come into play through the entire process of preparing and This means that solutions arise from multiple sectors--such different stages. The institutional process of preparing and implementing these plans, including: as water, sanitation and hygiene, energy, education, and implementing such plans varies greatly among developing health--rather than primarily one sector. Often, the roles and countries, with differing types of governments, enabling 6. Stakeholder involvement and participation that give voice responsibilitiesofdifferentagenciesrelatedtoaddressingpublic environments, and circumstances. Therefore, rather than and influence to weak and vulnerable stakeholders environmental health services are not well-defined, including give specific recommendations, this report provides guidance who takes the lead in coordinating such efforts. Encouraging on how environmental health may be incorporated at the 7. Awareness raising and communication to help civil coordination and creating a sense of ownership and different stages of the institutional process of preparing and society hold governments accountable for continuous accountability are frequently big challenges. Second, actions to implementing such development plans or poverty reduction progress on this agenda. tackle environmental health issues often do not require large strategies (see figure on page 6) and how external actors budgets at least initially, but do require continuous effort; (development organizations, NGOs, universities, think tanks, At each of the first five stages, there are many tools that however, capacity is often weak in developing countries. Third, and so on) can support them to do this. public officials can draw upon to help them incorporate the indicators available for measuring environmental health environmental health into the planning and decision-making impacts are notoriously difficult to collect, and comprehensive Governments can include environmental health content in process, and the related monitoring system to evaluate data collection efforts--such a national demographic health their development and poverty-reduction strategies by taking progress. These tools include data gathering surveys (Census, surveys--may not include all the necessary information the following steps: DHS, LSMS); economic assessment methodologies (cost- for decision making. For example, in the case of energy the benefit analysis, cost-of-degradation studies); environmental survey may include questions on energy source, but not on 1. Analyzing the linkages between environmental health and health impact and institutional assessments (EIA, pricing, connection fees, seasonal variation, or quantities of and poverty SEA, CEA, HIA); and participatory exercises (participatory fuel and electricity consumed, among others (Sullivan and assessment, beneficiary assessment). Barnes 2007). Thus results can be difficult to measure and 2. Prioritizing environmental health issues within the larger disseminate, again leading to accountability challenges. poverty reduction objectives 6 Incorporating Environmental Health into Institutional Processes Aimed Different steps can be carried out at different levels of at Enhancing Development and Poverty Reduction government. Communication channels between local and national levels of government are also crucial to ensure that Institutional Process Environmental Health (EH) Input local information is translated into policy action, and equally that national policy can be implemented at the local level. Key actors: Understanding nature of Cross-cutting 1. Understanding linkage In that regard, government departments--such as finance or poverty themes: between EH & Poverty planning at a national or state level or a mayor's office--are Central government particularly well-suited to play a coordinating role and need to & inter-ministerials groups Choosing poverty reduction take a more active part in addressing this agenda. objectives 2. Prioritizing EH objectives 6. Participation & Parliaments, etc. Equally important are the creation of long-term constituencies Defining strategy, including: Stakeholder 3. Enabling environment: within a country to help continually raise attention to Macro-structural policies involvement Assess institutional environment-health-poverty issues and to promote social Private sector mandate and capacity for EH issues accountability among public officials for effective action on these issues (Ahmed and Sánchez-Triana 2008). These NGOs, CSOs Assess regulations on EH budgeting 7. Awareness Raising Availability of budgets not only cut across the entire development planning and and strategic implementation cycle discussed above, but are also important The public (national, communication from the perspective of enhancing results on environmental sub-regional, Implementation of program 4. Choose EH interventions household) and policies health issues by facilitating results on this agenda, as environmentalhealthoftenrequiresbothtechnologychangeas well as behavioral change to achieve improved environmental External partners Monitoring outcomes and 5. Monitoring process and evaluating impact outcome indicators health outcomes. In order to build constituencies, the first step is making Source: Adapted from Klugman 2002 PRSP Sourcebook, World Bank 2005, Ahmed and Sánchez-Triana 2008. poverty-related environmental health information available in order to raise awareness, both in terms of holding the state accountable but also to promote behavioral change within. Effective means of communicating this information and making people aware of how they can access the information is equally important. A second important step is involving the public in decision making. Encouraging participation of weak and vulnerable stakeholders is particularly important, so that all views are taken into account, rather than only the views of the more powerful and vocal stakeholders. A third step is providing access to justice for all citizens in order to promote social accountability among public officials. These three 7 aspects--namely public disclosure of information, public efforts to address environmental health issues. At a broad level, participation in decision making linked to these issues, and PEP members can make the case for linking environmental access to justice on environmental matters--are highlighted in health and poverty reduction by highlighting the related Principle 10 of the Rio Declaration and more recently in the economic case and evidence base. In addition, they can Aarhus Convention. incorporate environmental health interventions into existing tools, programs, and investments to support governmental Clearly government, at both the national and local levels, efforts to improve the quality of life of the poor. has an important role to play in facilitating the formation of constituencies. However, the role of civil society organizations There is an immediate need to tackle environmental health (CSOs) and other NGOs, as well as the private sector, is issues as part of all development plans or strategies that ad- equally important in order to design effective solutions with dress poverty reduction. Problems such as unsafe water, sani- affected stakeholders. Working through the media for effective tation, and poor hygiene; air pollution; and inadequate vec- communication and using the education system are two tor control are major contributors to the worldwide disease important ways to share information effectively and promote burden. Poor communities are disproportionately affected by greater social accountability. Legal reforms that facilitate these issues, which seem likely to worsen with climate vari- sharing of information, public participation, and ultimately ability and change. Ill-health resulting from these problems recourse to justice are another important venue. affects school attendance, incomes, and communities' efforts to improve their long-term quality of life. Progress on this im- The Poverty Environment Partnership (PEP)--a network of portant agenda and in the quality of life of the poor is essential multilateral and bilateral development partners as well as major for sustainable development. NGOs--is well-positioned to help support governments in 8 Photo: Prabir Mallik 9 1. why is environmentAl heAlth importAnt in poverty reduction? Environmental health matters greatly to those living in countries with high GDP considered the loss of rainforest and local governments in developing countries, NGOs and private poverty. In an opinion poll carried out in Colombia in 2004, wilderness, water pollution, and depletion of natural resources sector representatives, and development agency staff and sector 71 percent of low-income households placed environmental as the most serious environmental issues (Miller 2004). Similar advisors in development cooperation agencies. health as their top environmental priority, compared to only responses between low-income and high-income groups were 30 percent of the highest income group. The poll also found found in Colombia (World Bank 2006c). For the poor, the The main objectives of the report are: that poor income groups tend to mainly raise issues linked main environmental concern was air pollution (74 percent), with clean air and water as national environmental concerns, whereas for the rich it was poor management of global (a) To illustrate that--despite efforts to emphasize the suggesting that environmental health concerns directly affect resources (78 percent). Environmental health clearly matters importance of environmental health to poverty their quality of life and therefore are a priority for them (World to the poorest and most vulnerable people and countries. In reduction and sustainable development in partner Bank 2006c). the context of increasing awareness of the local consequences countries--there has been limited success in countries of global issues (such as climate change) there is clearly an with placing environmental health issues that matter to opportunity to link the two better. the poor high on their development agendas; and "A better life for me is to be healthy, Emerging issues such as climate change will increase challenges (b) To provide practical guidance on how to raise the in poverty reduction. Projected changes in the incidence, profile of environmental health issues important to peaceful and live in love without hunger. frequency, intensity and duration of climate extremes (heat the poor and hence integrate them more successfully waves, heavy precipitation, and drought) will, for example, in (i) national and local strategies and plans, and (ii) Love is more than anything. Money has aggravate water scarcity in some countries; negatively affect development cooperation activities that support these public health, especially of the poor; and will pose a real threat strategies and plans. no value in the absence of love." to food security in many countries. The impacts of climate change will disproportionately affect the poor, particularly in The first chapter shows there is ample evidence that ­ a poor older woman in Ethiopia sub-Saharan Africa.1 environmental health is important in poverty reduction. The second chapter goes on to describe the limited success of national efforts to prioritize environmental health in aUDienCe anD oBjeCtiveS development agendas and the challenges associated with this. The third chapter describes the roles that officials in a This report is the product of efforts of several bilateral and planning or finance ministry can play to better integrate At a global level, a poll by GlobeScan Inc. found that multilateral development agencies and NGOs with an environmental health issues into national development plans public opinion in poor countries considered "very serious" interest in enhancing the quality of life of the poor through and/or poverty reduction strategies. The roles described are environmental priorities to include shortage of freshwater, improvements in environmental health. It is written primarily also equally applicable at a subnational level; for example, air pollution, automobile emissions, water pollution, and for officials in finance and planning departments at the within a planning department in a state or province or within depletion of natural resources. All of these issues are related national, state, or municipal level in developing countries. It a mayor's office in the context of city development planning. to environmental health. In contrast, public opinion in will also be of interest to other sector officials in national and The fourth chapter then goes on to describe how government 10 affecting children and women in poor families. The impact Box 1. Environmental Health and Sustainable Development of such environmental health risks on men and women is substantial when measured in millions of deaths and disability- WHat iS environmental HealtH? By adopting the principles of the rio Declaration and agenda 21 as a adjusted life years (DALYs).4 This underscores the need to route to sustainable development in the 21st century, the world's leaders recognized the importance of investing design and implement environmental health interventions in improvements to people's health and their environment. Health outcomes that are a result of environmental in poor countries to improve access to safe water, provide conditions are classified under the category of "environmental health." the World Health organization (WHo) adequate sanitation, and improve air quality, both indoors has defined environmental health as those "aspects of human health, including quality of life, that are determined and outdoors. by chemical, physical, biological, social and psychosocial factors in the environment." With 1.1 billion people lacking access to safe drinking water, in general, environmental health risks are grouped into two broad categories: Traditional hazards are closely and 2.6 billion without adequate sanitation, the magnitude of linked with poverty. they refer to health risks that are a consequence of lack of access to clean water, inadequate the water and sanitation problem remains significant (WHO/ sanitation, poor waste disposal, indoor air pollution and vector-borne diseases such as malaria. Modern hazards UNICEF 2005). Each year contaminated water and poor include urban air pollution and problems arising from industrial chemicals and wastes. sanitation contribute toward the 5.4 billion cases of diarrhea worldwide per year and the 1.6 million deaths, mostly among children under the age of five (Hutton and Haller 2004). In- Source: Authors. testinal worms--which thrive in poor sanitary conditions and in the poorest communities of the developing world--have infected 2 billion people and, depending upon the severity of officials can work closely with other stakeholders, such as civil disproportionately carry the environmental burden of disease, the infection, may lead to malnutrition, anemia or retarded society organizations and the private sector, to build longer- with the total number of healthy life years lost per capita as growth, and subsequently diminished school performance term constituencies to place environmental health issues on a result of environmental burden per capita being 15-times (Ivanov et al. 2004). About 6 million people are blind from the development and poverty reduction agenda. Finally, the higher in developing countries than in developed countries trachoma, a disease caused by the lack of water combined last chapter describes how donors and NGOs can support (Prüss-Üstün and Corvalán 2006).2 Diarrhea, lower respiratory with poor hygiene practices. A further 200 million people government efforts on this agenda in the context of existing infections, other unintentional injuries, and malaria are the are infected with schistosomiasis; of these, 20 million suf- development aid. diseases with the largest environmental contribution (Figure fer severe consequences (UNICEF 2006). The most affected 1). Furthermore, Prüss-Üstün and Corvalán (2006) estimate are the populations in developing countries living in extreme that 24 percent of the global disease burden and 23 percent conditions of poverty, either in urban slums or peri-urban or WHy environmental HealtH matterS of all deaths can be attributed to environmental factors, which rural areas. can be prevented through environmental modification (such The World Health Organization (WHO), The United Nations as through provision of safe water, improved sanitation, and Indoor air pollution--a much less publicized source of Children's Fund (UNICEF), and many other agencies have adequate hygiene). poor health--is responsible for over 1.5 million deaths comprehensively shown that tackling environmental health from respiratory infection per year and for 2.7 percent of issues is important. Environmental risk factors play a role in Available global evidence suggests that (a) lack of access to the global burden of disease (WHO 2006). In developing more than 80 of the major diseases and injuries worldwide clean water and sanitation3 and (b) indoor air pollution are countries, indoor air pollution is largely attributed to (Prüss-Üstün and Corvalán 2006). Developing countries the two principal risk factors of illness and death, mainly smoking and the use of biomass for cooking. It is estimated 11 that half of the world's population use solid fuels (biomass Figure 1. Diseases with the Largest Environmental Contribution and coal) for household cooking and space heating, mainly in developing countries (Rehfuess et al. 2006). The burden Diarrhea of poor environmental health falls on the most vulnerable of the poor, mainly children under the age of five, women, Lower respiratory infections and the disabled and elderly. As many as half of the deaths Other unintentional injuries attributable to indoor use of solid fuel are of children under Malaria the age of five years (Smith et al. 2004). In the 21 worst- affected countries, most of them located in sub-Saharan Road traffice injuries Africa, approximately 5 percent or more of the total burden COPD of disease is caused by indoor air pollution. In 11 countries-- Perinatal conditions Afghanistan, Angola, Bangladesh, Burkina Faso, China, the Democratic Republic of the Congo, Ethiopia, India, Nigeria, Ischaermic heart disease Pakistan, and the United Republic of Tanzania--indoor air Childhood cluster diseases pollution is responsible for a total of 1.2 million deaths a year mentalLead-caused retardation (WHO 2007b). Generally, men suffer more from outdoor air Drownings pollution. Women are exposed more to indoor air pollution, since they traditionally spend more time indoors and near the HIV/AIDS stove. By far the greatest burden of disease falls on children Malnutrition under the age of five (Smith et al. 2004); they are especially Cerebrovascular Disease susceptible to environmental risks when both risk factors are considered (Ezzati et al. 2004). Asthma Tuberculosis Suicide environmental HealtH anD malnUtrition linkaGeS Depression Poisonings Recent studies show that contrary to the popular myth, Falls malnutrition is not only the result of lack of food intake, Hearing loss but more often a consequence of bad sanitation and repeated infections (World Bank 2006d). Environmental health risks Violence such as inadequate water, poor sanitation, and improper Lymphatic filariasis hygiene practices affect children's health through diarrheal Lung cancer diseases and (indirectly) through malnutrition. This in turn affects future cognitive learning and productivity. 0% 1% 2% 3% 4% 5% 6% 7% Fraction of total global burden of disease in DALYs Environmental fraction Non-environmental fraction Source: Prüss-Üstün and Corvalán 2006. 12 "The waste brings some bugs; InlargepopulousareasinSouthAsiaandsub-SaharanAfricawith human rights--the right of each person on the planet to here we have cockroaches, spiders high rates of malnutrition, there are also severe environmental health." The PEP poverty reduction framework (DFID, EC, health problems. Given the linkages among environmental UNDP, and World Bank 2002) is based on four key factors that and even snakes and scorpions." health, malnutrition, and disease, WHO in 2007 recalculated need to be addressed in any poverty reduction strategy: the burden of disease estimates, taking into account the indirect ­ Nova California, Brazil (through malnutrition) health risks associated with inadequate Enhanced livelihood security: the ability of the poor to use water and sanitation provisions and improper hygienic practices their assets and capabilities to make living conditions of (Fewtrell and Prüss-Üstün et al. 2007). WHO estimates that greater security and sustainability. almost 7 percent of the total burden of disease is attributable poor often pay proportionately more for environ- The to inadequate water supply, sanitation, and hygiene when Reduced health risks: the mitigation of factors that put the mental health services. Many people in low-income areas consideringthedirectandindirectlinkagesthroughmalnutrition poor and most vulnerable (especially women and children) buy their water from vendors, who sell it for 10 to 20 (Fewtrell et al. 2007). A forthcoming study builds on this at risk from different diseases, disabilities, poor nutrition, times more than the official water tariff charged to people analysis to assess the economic costs of environmental health and untimely death. with house connections. For example, better access to risks (including those through malnutrition) at a country level. water would enhance livelihood security as they will have These linkages between environmental health and malnutrition Reduced vulnerability: the reduction of threats from more income. have important implications for child survival strategies in environmental, economic, and political hazards, developing countries (World Bank 2008). including the impact of both sudden shocks and long- Disease contributes to poverty. When the poor fall ill, they term adverse trends. lose income and even their jobs. Children with intestinal worms may be stunted in their growth or impaired in environmental HealtH anD Poverty Pro-poor economic growth: enhanced economic growth is their intellectual performance. Improving environmental essentialforpovertyreductioninmostpartsoftheworld,but health would also reduce vulnerability. For example, This section first explores the concept of poverty and then the quality of growth, and in particular the extent to which a hygienic environment and adequate sanitation are relates poverty to environmental health. The burden of it creates new opportunities for the poor, also matters. key factors related to reducing opportunistic infections disease due to environmental factors is highest in the poorest associated with HIV/AIDS, and to the quality of life of countries and to the poorest people within those countries. Cairncross and Kolsky (2003) highlight several reasons why people living with the disease. Improved sanitation and Building on previous PEP papers on poverty reduction and the environmental health is important to the poor and can have an hygiene also helps to reduce the burden on households environment (DFID, EC, UNDP and World Bank 2002 and impact on poverty reduction. They include the following: caring for AIDS-affected family members. ADB, CIDA, DANIDA, EC, GTZ, Irish Aid, IUCN, SEI, Sida, SIWI, SDC, UNDP, UNEP, and WHO 2006), this paper Poor people live in areas with the worst environmental Better environmental health conditions go beyond health postulates that poverty needs to be understood as a complex conditions. outcomes. The main benefits often include (a) saving and multidimensional process in which environmental health time, (b) lowering the cost of living, (c) increasing gender can contribute to reducing different dimensions of poverty. burden of environmental disease falls more harshly The equality (security and dignity), (d) increasing convenience The UN (2005:ii) refers to "extreme poverty in its many on the poor. The poor are more vulnerable and exposed through service provision (recycling, building latrines, dimensions--income poverty, hunger, disease, lack of adequate to environmental disease and have lower resistance to etc), and (e) reducing the burden of daily life. These shelter and exclusion--while promoting gender equality, infection. Interventions in environmental health would benefits contribute toward better health and indirectly to education and environmental sustainability relates to...basic reduce health risks. improved productivity and economic growth. 13 Regionally, environmental health affects the poor in Sub- Figure 2. Environmental Disease Burden (DALYs per 1,000 people) Saharan Africa and South Asia the most. As Figure 2 shows, the poorest countries in these subregions have the highest environmental disease burden, measured as DALYs (also see Figure 3). In 2002, sub-Saharan Africa, with only 10 percent of the global population, accounted for 24 percent of the entire global burden of disease (DALYs) and for 29 percent of the world's environmental burden of disease (Prüss-Üstün and Corvalán 2006). Children under five years of age are disproportionably exposed to and affected by health risks from environmental hazards. In large populous areas in South Asia and sub-Saharan Africa, where environmental health problems are especially severe, malnutrition in young children is also rampant. In low-income countries, more than 147 million children under the age of five remain chronically undernourished or stunted, and more than 126 million are underweight (World Bank 2006d, Svedberg 2006, Fewtrell et al. 2007) A Poverty-Environment Nexus (PEN) study on Cambodia, Lao PDR, and Vietnam found that a shared feature of the DALYs / 1000 Pop. 10 ­ 20 20 ­ 50 50 ­ 100 100 ­ 200 No data three countries is that poverty and environment issues fall into one of two broad categories: environmental health and Source: Prüss-Üstün and Corvalán 2006. natural resource use (World Bank 2006).5 The most important aspects of environmental health are the effects of inadequate water supply and sanitation in rural and urban areas; air and CitieS anD UrBan SlUmS Physical locations where multiple poverty-environment-health water pollution from industrial activities in cities, towns, linkages overlap are a particular challenge, such as in slums.Very and villages; indoor air pollution, especially in the upland By 2030, it is estimated that urbanization in poor countries soon and for the first time, the world's urban population will be areas of Lao PDR and Cambodia; and occupational hazards will result in more than 60 million new urban inhabitants equal to the world's rural population, with a large percentage of pesticide use in agriculture (World Bank 2006).6 Another annually. The United Nations estimates that nearly all of the of city dwellers living in slums (Lee 2007).8 Asia has the largest of the study's main findings was that even when the poor population growth in the coming generation will be in cities number of slum dwellers overall with 581 million, while sub- were as aware as the nonpoor were of pollution risks, their in low- and middle-income countries. Asia and Africa, the Saharan Africa has the largest percentage (about 71 percent) of communities did not have the capacity or local institutions most rural continents today, are projected to double their its urban population living in slums (United Nations Centre for to access services or minimize risks. urban populations from 1.7 billion in 2000 to about 3.4 Human Settlements Programme 2006). The urban poor living billion in 2030.7 in slums are exposed to multiple environment health risks, 14 Figure 3. Burden of Disease Attributable to Childhood and Maternal Undernutrition(Proportion of DALYs attributable to selected risk factors) a. Unsafe water B. indoor smoke from solid fuels <0.5% 0.5 ­ 0.9% 1 ­ 1.9% 2 ­ 3.9% 4 ­ 7.9% 8 ­ 15.9% 16%+ <0.5% 0.5 ­ 0.9% 1 ­ 1.9% 2 ­ 3.9% 4 ­ 7.9% 8 ­ 15.9% 16%+ C. Urban air pollution Note: The values presented here are averages by subregion; variations occur within these subregions but are not shown here. For an explanation of subregions see the List of Member States by WHO Region and mortality stratum. <0.5% 0.5 ­ 0.9% 1 ­ 1.9% 2 ­ 3.9% 4 ­ 7.9% 8 ­ 15.9% 16%+ Source: WHO 2002. 15 including poor ventilation and inefficient cooking stoves, lack Figure 4. Economic burden associated with poor environmental health (as percentage of GDP) of access to water and sanitation, poor housing structures and construction, dirt floors, overcrowding, and poor and unsafe access to transport (Parkinson 2007). Tunisia Lebanon Rapid urbanization and the uncontrolled growth of urban slums are now creating a double environmental health burden Columbia for the urban poor. They are exposed not only to risks from Peru indoor air pollution, crowding, and poor access to water Guatemala and sanitation (generally linked with rural populations), but also to modern risks associated with transport and industrial Egypt pollution (Satterthwaite 2007). In some parts of the world, Nigeria malaria (and dengue) is increasingly becoming an urban issue Iran (Breman et al. 2004), which will be further exacerbated by the effects of climate change (Campbell-Lendrum et al. 2007). Ghana Pakistan Environmental health is increasingly an urban issue. The China concentration of population in cities is an opportunity to provide accesstoservicesandhencedramaticallyimprovehealthoutcomes 0 .5 1 1.5 2 2.5 3 3.5 4 4.5 in a cost-effective and rapid manner. Conversely, ignoring the PERCENT growingslumsettlements--withdismalenvironmentalconditions and almost negligent access to environmental services--can derail Urban Air Pollution Indoor Air Pollution Water, Sanitation and Hygiene attempts by city governments to provide healthy environments and improve health outcomes. Notes: economic burden includes the burden from mortality, morbidity and cost of illness; morbidity is usually valued using the "human capital value" approach; adult mortality is valued averaging the "value of a statistical life" approach and "human capital value" approach; with the exception of Iran, China and Nigeria, child mortality is valued using human capital value only; with the exception of China, "value of a statistical environmental HealtH anD life" is obtained through benefit transfer of international studies; WSH mortality is estimated only for children; WSH in China excludes lack of eConomiC GroWtH sanitation and hygiene costs. Sources: Lebanon and Tunisia (Sarraf, Maria, Björn Larsen, and Marwan Owaygen. 2004 "Cost of Environmental Degradation: The Case of Economic growth is essential if poverty is to be reduced Lebanon and Tunisia." Environment Department Papers. World Bank: Washington, D.C.); Columbia, Ghana, Guatemala, Nigeria, Pakistan, and welfare is to be improved. However, in order to realize Peru (Country Environmental Analysis); Egypt (World Bank. 2002. "Arab Republic of Egypt: Cost Assessment of Environmental Degradation." the full impact of economic growth on poverty reduction, Sector Note. Report 25175-EGT. Washington, D.C.), Iran (World Bank. 2005. "Iran, Islami Republic of: Cost Assessment of Environmental Degradation." Sector Note. Report 32043-IR. Washington, D.C.); China (World Bank 2007. "Cost of Pollution in China: Economic Estimates reducing inequity is essential (World Bank 2006b).9 Reducing of Physical Damages", World Bank: Washington, D.C.). environmental risks through investment and other means can improve the health of current and future generations and help alleviate inequities 16 for economic losses equivalent to between 2 and 4 percent of Healthy populations are more productive populations. Without GDP, and these costs are felt most severely by the poor. In some a healthy and productive labor force, the economic growth cases in South Asia and sub-Saharan Africa, when the impacts that is necessary to break out of the cycle of poverty will not of environmental health and malnutrition-related linkages are be achieved. Improving environmental health will contribute further factored in, these damage costs increase significantly to to the MDG targets and promote sustainable and responsible almost 9 percent of a country's GDP (World Bank 2008). growth, as is explored in a later section. Diseases and ill-health can constrain economic growth and impact the productivity of a country's working population. It Climate CHanGe anD imPaCtS on has been estimated that malaria can reduce economic growth by tHe Poor more than 1 percent a year in highly endemic countries (World Bank undated). Furthermore, the perceived risk of infection The poorest countries are often the ones that are most threatened has been shown to negatively affect investment, trade, and by the degradation of the regional and global environmental crop choice decisions. This imposes long-term costs by slowing commons. The Intergovernmental Panel on Climate Change Photo: Masaru Goto economic growth and widens the gap between these countries (IPCC) Fourth Assessment Report (2007) projected the impacts and the rest of the world (Teklehaimanot et al. 2005). offuturechangesinclimatebymid-century,includingchangesin freshwater availability, crop productivity, ecosystem structure and Poor environmental health is also directly linked to human function, sea-level rise, and health. Specifically, the IPCC report Economic growth is inextricably linked with the productiv- capital deficits that affect both present and future productivity. notes that poor communities will be especially vulnerable due ity and performance of a nation's people. This productivity is Children under five--facing over 40 percent of the global to their low adaptive capacity and their dependence on climate- often constrained by poor environmental health conditions-- environmental burden of disease--are especially impacted sensitive resources, such as food and water. The IPCC report also resulting in illness and consequently lost earnings, and increased by the cognition and learning impacts of environmental risk notes that the health status of millions of people, especially those medical costs. This economic burden on society placed by poor factors. An estimated 200 million children under the age of with low adaptive capacity, is likely to be adversely affected. This environmental health can be quantified at the national level as five fail to reach their potential in cognitive development will be manifested by increased deaths, diseases, and injuries a percentage of Gross Domestic Product (GDP) (Figure 4). For because of poverty, poor environmental health and nutrition, from extreme weather events (for example, floods, heat waves, example, the estimated annual costs of environmental damage and inadequate care. Additionally, repeated illness combined and storms); an increased burden of diarrheal diseases; and an in Colombia (including water, sanitation and hygiene, urban air with cognition impacts also results in poorer educational altered distribution of some infectious disease vectors. pollution, indoor air pollution, agricultural land degradation, performance in school-age children (Alderman et al. 2006). and natural disasters) amounts to more than 3.7 percent of GDP The UN Subcommittee on Nutrition reported increasing A recently published article in the WHO Bulletin (Campbell- per year (World Bank 2006c). Two important categories con- evidence to support an association between widespread iron Lendrum et al. 2007) points out that currently important tributing to this measure are inadequate water supply, sanitation, deficiency, iodine deficiency, and helminth infection and poor health burdens, in particular, are likely to be worsened by and hygiene; and outdoor and indoor air pollution. Similarly, school performance (Hunt and Peralta 2003). This failure of climate change. From both local and global perspectives, the annual losses associated with mortality and morbidity from children to achieve satisfactory educational levels then impacts scaling up preventive environmental health interventions air pollution alone in India and China range between 2 and 3 future work productivity, and plays an important part in (such as clean water and sanitation services) to reduce the percent of each country's GDP. Figure 4 illustrates that envi- the intergenerational transmission of poverty (Grantham- current burden of disease are wise investments as well as good ronmental degradation threatens economic growth, accounting McGregor et al. 2007). "no-regrets" strategies. The authors also note that adaptation 17 to climate change is "essentially a matter of basic public health protection" and point to the need to refocus political and financial commitments to strengthen environmental management, surveillance, and response to safeguard health from natural disasters and changes in infectious disease patterns, and a more pro-active approach to ensure that development decisions serve the ultimate goal of improving human health. tarGetinG Poverty reDUCtion The Millennium Development Goals are a set of development targets endorsed by the international community that focus on halving poverty and improving the welfare of the world's poorest by 2015. The MDGs have become the driving force in establishing development targets and measuring outcomes. Recognition that improving environmental health issues can directly help to contribute to reducing poverty is recognized in several MDGs. These include (a) reducing child mortality (MDG 4), (b) combating HIV/AIDs, malaria, and other diseases (MDG 6), and (c) ensuring environmental sustainability (MDG 7). It also indirectly contributes to (a) eradicating extreme poverty and hunger, (b) achieving universal primary education, and (c) promoting gender equality. Table 1 illustrates how each MDG goal has an environmental health element, which if addressed can help achieve the goal. Photo: Curt Carnemark 18 Table 1. MDGs and Environmental Health mDGs Goal eH Determinant eH intervention Goal 1: eradicate extreme poverty ˇ Water resources management practices ˇ Improved hygiene and sanitation and hunger ˇ Expenses incurred for informal sector delivery of water, and sanitation services; as well as costs of medical treatment imposes burden on family budgets (include for food) Goal 2: achieve universal primary ˇ Availability to water & energy sources ˇ Providing safe drinking water and latrines at school, taking gender into education ˇ Hours spent gathering water or fuel account ˇ Unstable management of natural resources, including water & forests. ˇ Access to improved sources of drinking water and cleaner household energy sources, saving time children spend collecting water/fuel. Goal 3: Promote gender equality ˇ Women disproportionately suffer from: (a) exposure to smoke from ˇ Access to improved drinking water sources and empower women use of biomass for cooking, (b) drudgery and inconvenience from ˇ Better sanitation facilities for both boys and girls poor access to water, and (c) privacy and dignity issues relating to ˇ Cleaner household energy sources inadequate sanitation facilities ˇ School attendance impacted by poor sanitation facilities Goal 4: reduce child mortality ˇ Leading causes of child mortality include diarrhea, acute respiratory ˇ Cleaner household energy sources infections, and malaria ˇ Improved access to clean water; proper feces disposal, better sanitation. ˇ Indoor air pollution impacts young children (immediate exposure) ˇ Improved hygiene practices (including handwashing with soap) ˇ Sickness and deaths from inadequate hygiene, water supply, and ˇ Promote use of insecticide treated bed nets (ITNs); indoor residual spraying sanitation (IRS) Goal 5: improve maternal health ˇ Poor delivery and birthing outcomes from inadequate hygiene, and ˇ Safe water and sanitation availability of clean water ˇ Proper hygiene practices during delivery ˇ Malaria and helminthes affect pregnant women and can lead to malnutrition in child Goal 6: Combat Hiv/aiDs, ˇ HIV-infected have very special environmental health needs ˇ Safe water and sanitation malaria and other diseases ˇ Environmental conditions related to mosquito breeding, e.g. ˇ Proper agricultural practices (intermittent irrigation, crop rotation, etc.); irrigation, poor drainage and stagnant water etc. ˇ Promote use of ITNs; IRS ˇ Inadequate water resources management practices ˇ Proper drainage Goal 7: ensure env. sustainability ˇ Poor access to water & sanitation ˇ Improve access to improved sources of drinking water, sanitation, and hygiene increase access to safe drinking water ˇ Slum dwellers face dismal living conditions, congested settlements, ˇ Improve quality of life among the urban poor through targeted slum increase access to sanitation and poor access to environmental services upgrading projects achieve improvements in slums Goal 8: Develop a global ˇ Lack of multisectoral coordination on environmental health issues-- ˇ Develop holistic, multisectoral approach with the coordination of multilateral, partnership for development both horizontal and vertical links needed bilateral, national, and local institutions to implement them. ˇ Develop global partnerships Source: Cairncross et al. 2003, Prüss-Üstün and Corvalán 2006. 19 In order to address the MDG targets, countries are encouraged to report annually on progress made in the form of Millennium Development Goals Reports (MDGRs). These reports set country-specific targets and indicators and report on global Links to initiatives and further information: targets and indicators so that they can integrate them into national planning and budgeting. Countries also develop WHo: Health and environment linkages initiative: different strategies and plans. For example, for low-income http://www.who.int/heli/en/ countries to qualify for concessional loans through the Poverty ecosystem approaches to Human Health: http://www.idrc.ca/ Reduction Growth Facility or to access debt relief under the ecohealth/ev-68488-201-1-Do_toPiC.html Highly Indebted Poor Countries (HIPC) initiative, they must prepare Poverty Reduction Strategy Papers (PRSPs) (Klugman DPSeea model of health-environment interlinks: http://www. euro.who.int/eHindicators/indicators/20030527_2 2002).Thesedocumentsarepreparedbycountriesasameansof integrating sectoral priorities and poverty alleviation initiatives WHo: Health and mDGs: http://www.who.int/mdg/ into a larger macroeconomic framework of development. The publications/mDG_report_08_2005.pdf PRSPs have also to a large extent developed into a common WHo: "Preventing disease through healthy environments: strategic framework for supporting poverty alleviation towards an estimate of the environmental burden of programs by international donors and organizations. disease": http://www.who.int/quantifying_ehimpacts/ publications/preventingdisease.pdf All of the above instruments look toward targets, strategies, and plans for poverty reduction and sustainable development. WHo: "ecosystems & Human Wellbeing: Health Synthesis": http://www.who.int/globalchange/ecosys.pdf However, they address environmental health issues in varying degrees and agree that reporting on environmental health is- WHo: "Climate change strategy, implications for sues is lagging. The next chapter assesses the extent to which international public health policy": http://www.who.int/ environmental health issues are highlighted in these reports. bulletin/volumes/85/3/06-039503.pdf WHo: "Water, Sanitation, and Health.": http://www.who.int/ water_sanitation_health/publications/en/index.html World Bank: environmental health: http://go.worldbank.org/ n81rj0lX00 1. For more information on the effect of climate change on poverty please see: 5. This study looks at sustainable approaches to poverty reduction in Cambodia, 9. The 2006 World Development Report (World Bank 2006b) notes that equity, Poverty and Climate Change: Reducing the vulnerability of the Poor through Lao PDR, and Vietnam, placing particular attention on environmental health defined primarily as equality of opportunity among people, is doubly good for Adaptation: http://www.oecd.org/dataoecd/60/27/2502872.pdf issues and poverty through a distributional analysis. poverty reduction since it tends to favor sustained overall development and 2. Total number of healthy life years (HLY) lost refers to health expectancy, that it 6. This is a finding consistent with global findings; see DFID, EC, UNDP, and delivers increased opportunities to the poorest groups in a society. to say it combines information on mortality and morbidity and partitions the World Bank (2002) and the World Bank (2003). 10. These reviews are intended to be indicative of how environmental health issues total years lived at any age into those spent in different "health" states. 7. United Nations Population Division. 2005. World Urbanization Prospects: The 2005 are being integrated into development planning processes, particularly in the 3. The linkages between improved water management and poverty reduction have been Revision Population Database. New York: United Nations Population Division. absence of broader reviews of national sustainable development plans. made by a previous PEP paper: Linking poverty reduction and water management. 8. The United Nations Global Report on Human Settlements (2003) estimated 11. For more information see: http://www.unmillenniumproject.org/reports/ 4. This is a health gap measure that extends the concept of years of life lost due that almost one-third of the world's urban population (or approximately 924 reports2.htm to premature death to include equivalent years of healthy life lost due to poor million) lived in slums in 2001. 12. This is discussed further in Chapter 3. health or disability (http://www.who.int/healthinfo/boddaly/en/). 20 Photo: Eric Miller 21 2. tAking stock oF environmentAl HEALTH IN PoVERTy REDUCTIoN GoALS, TARGETS, AND STRATEGIES Poverty Reduction Strategy Papers (PRSPs) for low-income WHat Do We FinD in millenniUm report sufficient data for monitoring progress. The causal link countries and National Development Plans for middle-income DeveloPment Goal rePortS (mDGrS)? between environment and poverty is not well-articulated, countries are good entry points for dialogue and cooperation although primary links are made to health issues (MDG-6), between and across agencies because poverty reduction strat- UNDP (2006) assessed the progress made on environmental where water contamination and air pollution are presented egies allow for, if not require cross-sectoral cooperation. Na- sustainability from a review of MDG country experiences. as risks to human health. Figure 5 illustrates improvement in tional Development Plans and PRSPs allow countries to plan Reporting on environmental sustainability (MDG-7) is low. sanitation and water access and use of solid fuels. strategies and interventions to achieve development outcomes. Of the 158 countries that had submitted MDGRs as of November 2005, 54 percent have set at least one country- A special report by UNDP (2006) assessed how countries are specific environmental target for achieving MDG-7. Through progressing on environmental sustainability and found low the Millennium Project's Task Force, UNDP also monitors reporting and incomplete data on targets relating to access results for each goal.11 to water and sanitation, among others. WHO and the World Bank reported similar results in assessing PRSPs in terms UNDP found that indicators related to water (138 countries) of how health broadly--and environmental health more and forests (133 countries) have the highest rates of reporting. specifically--has been addressed. National development plans Over half of the countries use the indicators on access to have not been subjected to cross-country systematic analysis sanitation (116 countries) and carbon dioxide and ozone- on environmental health issues. They can, however, be assessed depleting substance emissions (98 countries). However, only at the country level in order to see to what degree they have 72 countries report on energy use, 48 countries on solid fuel incorporated environmental health as a development priority. indicators, and 47 countries on slums. Africa is the continent where an indicator on slums is most addressed. This section of the paper addresses how environmental sustainability has been addressed in MDGRs (UNDP 2006), In many countries, monitoring MDG-7 progress has been how health has been incorporated into PRSPs (WHO 2004), more difficult. The report found that reporting on MDG-7 and how environmental health issues have been dealt with in progress appears to be hindered by a real or perceived lack of PRSPs (Kishore 2006).10 data.12 Apart from access to water, less than half of the countries Photo: Curt Carnemark 22 The lack of progress toward environmental sustainability lish priorities, design new policies, and collect data that will A review of health issues in poverty reduction strategies (MDG-7) is attributed to weak political will, pressure on facilitate the monitoring and targeting of MDGs. It must be undertaken by WHO in 200413 outlined gaps or limitations environmental resources from high land use and natural recognized that this is a learning process that will take time, in the health care delivery system and provided an overview disasters, insufficient governance and planning policies, yet here lies an opportunity for poor countries70 focus on Sanitation Access | to countries of child and maternal health issues, prevalent communicable social unrest, and inadequate financial resources. One of the poverty reduction through PRSPs and MDG targets. 4% diseases, and manifestations of malnourishment. The World main challenges mentioned in UNDP's analysis is a lack of 10% Bank's commissioned 2006 review of environmental health coordination among internal authorities, stemming from an in PRSPs highlighted a number of conclusions that illustrate unclear definition of roles and responsibilities. Collaboration WHat Do We FinD in Poverty how environmental health has been incorporated into PRSPs among members of the donor community also presents tension reDUCtion StrateGy PaPerS? to date.14 Overall, the findings revealed that there has been between country priorities and those of the donor community progress in the incorporation of environmental health issues (UNDP 2006). As previously discussed, PRSPs delineate comprehensive within PRSPs. However, there are continuing concerns that strategies covering a broad range of issues such86%water, as environmental health is not being systematically addressed and Improvement Regression Unchanged The Task Force Reports produced by the Millennium Project sanitation, health, energy, and education. Since 2000, about that good-practice examples are still scarce (Kishore 2006). found similar results. Table 2 summarizes someSanitation of the findings and recommendations made with respect to key MDG goals. Access 68 PRSPs and 57 interim PRSPs have been carriedcountries developing countries. Two recent reviews--one97 | 70 countries Water Access | out in 53 carried out by 4%WHOin2004,andanothercommissionedby 4% theWorldBank imProvinG BUt SkeWeD CoveraGe By incorporating MDG targets into national development 10% in 2006--have looked at a number of PRSPs and assessed the 10% plans and PRSPs, countries have the opportunity to reestab- environmental health content. BoththeWHOandWorldBankreviews,aswellasanassessment by WRI (World Resource Institute 2005), have found that water and sanitation issues feature more often in PRSPs than any other environmental health issue. The WHO study found that most Figure 5. Trends in Reporting Sanitation Access, Water Access, and Solid Fuels in MDGRs PRSPs address water and sanitation independently, rather than 86% Improvement 86%Regression (Percentage of countries showing progress and regression) as part of the health component. Reference is generally made to Unchanged the health implications of drinking from an unsafe water source. Sanitation Access | 70 countries Water Access | 97 countries Solid Fuels | 22 countries However, problems related to access to water by the poor are usually confined to physical availability; PRSPs rarely mention 4% 4% 10% 10% poor maintenance of the facilities or user fees. Box 2 shows some 27% good-practice examples of where environmental health has been incorporated in PRSPs. TheWorldBankcommissionedreviewalsosuggeststhatabetter understanding of water and environmental health linkages 86% Improvement 86%Regression Unchanged 73% could have possibly led to the inclusion of this issue within country PRSPs.15 The review goes on to say that air pollution abatement and energy-related responses often focus on energy Water Access Improvement | 97Regression countries Unchanged Solid Fuels | Note: 22 countries This figure shows countries actually reporting on these indicators. For example, 116 countries have sanitation indicators but only 70 of efficiency parameters rather than on health--thus possibly 4% those countries monitored progress on sanitation access. 10% Source: UNDP 2006. 27% 23 Table 2. Findings and Recommendations Relating to Environmental Health (selected MDG targets) SeleCteD mDG tarGet main FinDinGS anD reCommenDationS WitH eH iSSUe Child and maternal health 10.8 million children under the age of five die each year, 4 million in their first month of life.; 530,000 cases of maternal mortality each year ˇ Simple practices that can prevent illness include (1) dispose of feces, including children's feces, and washing hands with soap after defecation, before preparing meals and before feeding children, (2) protect children in malaria-endemic areas by ensuring they sleep under insecticide-treated bed nets ˇ other sectors can complement the health sector and significantly reduce the incidence of common diseases by improving water supply and sanitation and reducing indoor air pollution Controlling malaria every 30 seconds an african child dies of malaria; more than 1 million children succumb to the disease each year; and in malaria-endemic countries 300 to 500 million fall sick, incapacitating the workforce, reducing productivity and output ˇ Increase political commitment in proven solutions by key stakeholders ˇ Implement full-integrated package of malaria control measures ˇ organize communities to participate in the fight against malaria ˇ Train and deploy more skilled personnel to implement proven prevention techniques, accurate diagnosis and appropriate treatment, of malaria ˇ A global commitment that by 2008, 80 percent of at-risk population will be protected by treated bed nets, indoor spraying, and other key measures environmental sustainability Water pollution kills 2.2 million annually; more than 75 percent of the world's fish stocks are overfished; rising sea levels could displace tens of millions ˇ Address health problems caused by air and water pollution through initiatives to reduce exposure to risks ˇ Combat climate change by adopting the target of stabilizing greenhouse gas concentrations in the atmosphere ˇ Structural changes: strengthen institutions and governance; correct market failures and distortions; improve access and use of scientific and technical knowledge lack of access to water 4 in 10 people lack access to a simple pit latrine; nearly 2 in 10 (more than 1 billion people) have no source of safe drinking water--3,900 and sanitation children die daily as a result ˇ Move sanitation crisis to the top of national agendas ˇ Increase investment for sanitation ˇ Investments in water and sanitation must focus on sustainable service delivery ˇ Empower local authorities and communities with authority, resources and capacity to manage water supply and sanitation service delivery ˇ Build system for collecting revenues to users who can afford to pay for services ˇ Establish coordination mechanisms among agencies Source: Task Force Reports 2005 (http://www.unmillenniumproject.org/reports/reports2.htm). 24 Box 2. Environmental Health in PRSPs: Some Good-Practice Examples the Djibouti PRSP finds that water quality is a recognized determinant of public health. Diarrheal diseases are associated with the fecal contamination of drinking water (particularly in respect of problems associated with sanitary storage and transport and polluted rural wells), cholera, and malaria. the Cameroon PRSP articulates environmental priorities that fall within the millennium Development Goal 7 (mDG-7) context. it presents targets and indicators related to water supply. it presents baseline information on protected areas and sanitation and emphasizes improvements in housing (Bojö et al. 2004.). Source: Djibouti PRSP, Bojo et al. 2004. Photo: Curt Carnemark resulting in lower attention within PRSPs. Another issue raised to suggest that cross-sectoral action for health is important. in the findings is that sanitation remains secondary to water Examples of such multisectoral collaboration in countries are "Poor men and women were unanimous in supply. Although PRSPs recognize sanitation as critical to the beginning to emerge. In Zambia, the energy sector proposes incidence of diseases such as diarrhea, sanitation is addressed to fit rural health centers with solar panels; in Burkina Faso, saying that the most important effects of as an adjunct to water supply. The importance of sanitation in sanitation facilities will be built in schools; and in Ethiopia, tackling health problems needs to be stressed more strongly. rural electrification and telecommunication schemes will be developed to meet the needs of health services (WHO 2004). poverty included illness and the inability oPPortUnitieS For CollaBoration to meet the cost of treatment. Hunger and neeD For Better Data anD monitorinG The WHO review highlights one of the potential benefits of the malnutrition were in second place" PRSP process or any multisectoral planning process; that is, it Another finding of the WHO review was that PRSPs fairly provides an opportunity for different agencies to come together consistently reflect the goals of MDGs, but they do not ­ Yemen's PRSP and undertake joint planning. PRSPs often provide information necessarily develop quantifiable targets. For example, 20 out 25 of 21 PRSPs link their strategy for safe water to the respective MDG, but very few refer to the target of halving the number of people without sustainable access to an improved water source. One exception is the Malawi PRSP (Box 3). The review also recommends that the irregularity in data and unreliability of information on environmental health issues often found in developing countries needs to be addressed through a stronger public health surveillance system. ClariFiCation oF oWnerSHiP PRSPs are often unclear on which agency within the public sector is responsible for environmental health outcomes. This is an indication that environmental health programs are difficult to implement because of their cross-cutting, multisectoral nature. Box 3. Malawi: Good Practice in Environmental Indicators the Malawi PRSP has set quantifiable environmental indicators to set targets and against which progress can be gauged. environmental health targets relating to malaria include (a) increasing the percentage of households with mosquito nets in priority areas from 70 percent in 2000 to 80 percent in 2005; and (b) reducing malaria-related mortality in children under the age of five (among children in rural hospitals) from 34 percent in 2000 to less than 18 percent in 2005. Source: Malawi PRSP. Photo: Scott Wallace 26 Progress reports on both MDGs and PRSPs recognize that the is the case with urban air pollution in many large cities. In require continuous effort, and capacity is weak in developing multisectoral nature of environmental health issues and poor other instances--for example, indoor air pollution, which is countries. Third, the indicators available for measuring institutional coordination within developing countries have related to the poor's access to cleaner fuels and therefore only environmental health impacts are notoriously difficult to resulted in weaknesses in addressing, targeting, and monitoring impacts the poor--there has been less progress in placing collect. Data collection may be very comprehensive, but may environmental health. Critical issues in environmental the issue high on the development agenda despite it being not include all the necessary information for decisionmaking. health--such as water, sanitation, and indoor air pollution-- responsible for over 1.5 million deaths per year, which is For example, in the case of energy the survey may include tend to fall through the cracks in development strategies and significantly greater than in the case of urban air pollution questions on energy source, but not on pricing, connection between the different mandates of development agencies, yet (WHO 2007b). fees, seasonal variation, quantities of fuel and electricity they are critical for poverty reduction (Lvovsky 2001, Kishore consumed, among others (Sullivan and Barnes 2007). Hence 2006, WHO 2006). Second, at a sectoral level, institutional incentive structures results can be difficult to measure and disseminate, thus again are often not set up to place environmental health issues that leading to accountability issues. matter to the poor high on the agenda. There are different CHallenGeS aSSoCiateD WitH reasons for this. First, environmental health is rarely placed on Given these challenges, the next chapter describes what PlaCinG environmental HealtH iSSUeS the agenda of many conventional health sector programs. This role officials in a planning or finance ministry can play to on tHe DeveloPment aGenDa may be because, in order to address environmental health, both better integrate environmental health issues into national a preventive and a rapid treatment approach are important. development plans and/or poverty reduction strategies. The Why do environmental health issues tend to fall through the This means that solutions arise from multiple sectors--such as roles described are also equally applicable at a subnational bureaucratic cracks? There are a multitude of reasons. First, water, sanitation and hygiene, energy, education, and health-- level; for example, within a planning department in a state environment is typically perceived as a global public good, rather than action primarily by one sector. Often, however, or province or within a mayor's office in the context of city rather than one that is also closely linked with the well-being the roles and responsibilities of different agencies related to development planning. The subsequent chapter then goes on of the poor. Recent efforts by multiple agencies are trying addressing public environmental health services are not well- to describe how government officials can work closely with to change this perception, but it is still widely held. As a defined, including who takes the lead in coordinating such other stakeholders, such as civil society organizations and the result, issues that matter to the more well-off (and politically efforts. Hence encouraging coordination and creating a sense private sector, to build longer-term constituencies to place powerful groups) dominate. If there is an overlap between the of ownership and accountability are often big challenges. environmental health issues on the development and poverty environmental health issues that matter to both vulnerable Second, actions to tackle environmental health issues often reduction agenda. and more powerful groups, action may often be visible, as do not require large budgets at least initially. But they do 27 Further reading: mDGrs and environmental sustainability: http://www.undp.org/fssd/docs/mdg7english.pdf Poverty reduction Sourcebook: http://go.worldbank.org/3i8lylXo80 Poverty reduction Strategy Papers: http://www.imf.org/external/np/prsp/prsp.asp PrSP Fact Sheet: http://www.imf.org/external/np/exr/facts/prsp.html Poverty reduction Strategy Papers: their Significance for Health: second synthesis report: http://www.who.int/hdp/prsps/en/ WHo database on health and the PrSPs: http://who.int/hdp/database millennium Project task Force reports: http://www.unmillenniumproject.org/reports/reports2.htm 13. See WHO 2004. This study builds on previous studies by WHO on tracking the 14. This assessment builds on previously published reviews of PRSPs (Böjo and 15. This may be the result of specific guidelines for incorporating water and sanitation health components of PRSPs. WHO has systematically reviewed PRSPs since 2001, Reddy 2002, 2003; Böjo et al. 2004). In those reviews, 53 PRSPs were assessed specifically that does not occur with environmental health more generally. increasingly improving the analytical framework used for assessment. For the WHO according to 17 variables for environmental mainstreaming. Sixteen PRSPs that (2004) study, 11 full PRSPs were examined and the original 10 PRSPs were revisited. had received a score of 2.0 or higher were selected for the present review. 28 Photo: Shehzad Noorani 29 3. opportunities For incorporAting environmentAl heAlth into development plAnning And poverty reduction strAtegies While the MDGs have articulated what needs to be done is social accountability of public officials to all stakeholders; "25 percent of extremely poor to address poverty reduction, countries are still learning and (c) there is an opportunity for learning to occur so how to implement these goals. One way to do this is for that continuous improvement takes place in the design and countries to incorporate MDG targets into their national implementation of public policies (Ahmed and Sánchez- households obtain their water development plans and PRSPs or at a subnational level into Triana 2008). The subsequent chapter discusses in more detail state and provincial development plans and city plans. The how to build long-term constituencies to continually place from uncovered sources. Lack of previous chapter discussed the extent to which environmental environmental health issues on the development and poverty health issues appear in poverty reduction plans and related reduction agenda. knowledge of water and disease reports. This chapter will discuss briefly the process of strategy formulation and implementation to better understand key Environmental health can be incorporated into development relationships is a major factor in entry points for incorporating environmental health into plans or strategies more targeted at poverty reduction at development and poverty reduction-related strategies and the country or subnational level at different stages. The water-point contamination" plans and their implementation processes. It also presents institutional process of preparing and implementing such plans tools that public officials can use to better inform these plans varies greatly among developing countries, with differing types ­ Gambia's PRSP as they are developed. of governments, enabling environments, and circumstances. Therefore, rather than give specific recommendations, this Strategy formulation and implementation processes are report gives process guidelines on the tools that can be used to complex at best. A study to improve our understanding incorporate environmental health issues at the different stages of how environmental issues can be integrated into the of the institutional process of preparing and implementing such formulation and implementation of development policies development plans or poverty reduction strategies (Figure 6). found that viewing the decision-making process as a rational, 2.Prioritizing environmental health issues within the larger linear process, and applying technically oriented rational Figure 6 schematically shows the various stages at which poverty reduction objectives analysis to influence it was an ineffective way of influencing environmental health inputs can be brought into the policy formulation (World Bank 2005). Rather, recognition institutional process to prepare and implement strategies and 3.Assessing the country's enabling environment specifically is needed that policy formulation and implementation is, plans aimed at development and poverty reduction. These in terms of institutional mandates and related capacity, in reality, a continuous and complex process. Strengthening steps include: regulations, and budgets relating to environmental health institutional and governance processes is essential so that (a) the voice of weak and vulnerable stakeholders is also heard (in 1.Analyzing the linkages between environmental health 4.Selectingandensuringadequatefinancingofenvironmental addition to the more politically powerful groups); (b) there and poverty health interventions based on the above assessments 30 Figure 6. Incorporating Environmental Health into Institutional Processes Aimed at Enhancing Development and Poverty Reduction Institutional Process Environmental Health (EH) Input Key actors: Understanding nature of Cross-cutting 1. Understanding linkage poverty themes: between EH & Poverty Central government & inter-ministerials groups Choosing poverty reduction objectives 2. Prioritizing EH objectives 6. Participation & Parliaments, etc. Defining strategy, including: Stakeholder 3. Enabling environment: Macro-structural policies involvement Assess institutional Private sector mandate and capacity for EH issues NGOs, CSOs Assess regulations on EH budgeting 7. Awareness Raising Availability of budgets and strategic The public (national, communication sub-regional, Implementation of program 4. Choose EH interventions household) and policies External partners Monitoring outcomes and 5. Monitoring process and evaluating impact outcome indicators Source: Adapted from Klugman 2002 PRSP Sourcebook, World Bank 2005, Ahmed and Sánchez-Triana 2008. Photo: Dominic Sansoni 5.Monitoring process and outcome indicators to track 6.Participation and involvement of stakeholders that The latter two points are discussed further in chapter 4. progress and to continuously improve policy design and give voice and influence to the weak and vulnerable implementation. stakeholders Despitetheschematicillustration,thepolicycycleisnotrational andlinear,butacontinuousprocess.Itisalsoimportanttonote In addition to these direct inputs, environmental health 7.Awareness-raising and communication to help civil that these different steps could be carried out at different levels interventions also benefit from cross-cutting issues that society hold government accountable for continuous of government. The communication channels between local come into play through the entire process of preparing and progress on this agenda. and national levels of government are crucial to ensure that implementing these plans: local information is translated into policy action, and equally 31 that national policy can be implemented at the local level. In (World Bank 2007). Table 3 provides some examples of Health Surveys (DHS), Living Standard Measurement the case of environmental health, this is further complicated environmental health and poverty linkages. Surveys (LSMS), national health surveillance systems, by the necessity for cross-sectoral coordination horizontally at national environmental monitoring systems, and exposure/ the national and local levels of government. Understanding these linkages is an important first step. epidemiological studies. In most cases, however, information However, equally important is using local information to assess may be scarce. It is important to develop a local evidence base The rest of this chapter discusses tools that can be used these linkages within the country at a national or subnational through additional questions in existing survey instruments by public officials during stages 1 to 5 above to facilitate level. In this context, data can be drawn from several different or through strengthening existing environmental monitoring integration of environmental health issues into national tools, including national census data, Demographic and and health surveillance systems. A recent study analyzes some and local development agendas and the related monitoring system to evaluate progress. Good practice examples are also described. The application of these tools could be carried out directly by the government officials or could be facilitated Table 3. Examples of Environmental Health and Poverty Linkages and/ or financed by development partners. eH tHeme eXamPle oF eH­Poverty linkaGeS analyzinG tHe linkaGeS BetWeen Water supply and ˇ Lack of water supply and sewage treatment infrastructure in rural areas leads to increased risk of environmental HealtH anD Poverty sanitation water-related disease; early childhood diarrhea leads to lower education and cumulative earnings ˇ Poor people pay a high percentage of their income for water, which cuts the household food budget The first step in incorporating environmental health into indoor air pollution ˇ Burning biomass in poor households for cooking and heating leads to increased risk of acute national or local development plans is through an assessment respiratory infections of poverty-environment-health linkages. There is already industrial & ˇ Uncollected household waste increases rodent infestation and provides a breeding ground for flies, much information in the public domain regarding public municipal waste which leads to environmental health problems health impacts linked to major environment risks, both at a global level and a regional level (WHO 2002, Cairncross et ˇ Contamination of surface water, groundwater, and soil by industrial toxic wastes results in health risks, especially in marginal areas al. 2003, World Bank 2007). Indeed, the very idea that poor environmental health conditions were the root cause of poverty ˇ Leaching from unsanitary landfill sites located in poor areas contaminates water resources and was behind the great environmental health reforms that started causes health risks in the 19th century in the United Kingdom (Rosen 1958) and malaria ˇ Vector-borne diseases such as malaria are linked to a wide range of environmental conditions produced significant reductions in the burden of disease. For related to mosquito breeding, including irrigation, poor drainage, and stagnant water example, the links between water, sanitation and hygiene, and Urban air pollution ˇ Emissions from energy and transport sources are contributors to respiratory disease burden and infectious diseases such as diarrhea are now well-established. premature deaths Research shows that public investment in environmental institutional ˇ Inadequate institutional capacity and legal frameworks underlie the specific environmental health infrastructure should target poor communities rather than development and poverty issues described above poor households, because investment in clean water and sanitation creates positive externalities for household health Source: Dale 2005. 32 of the questions that could be included in existing surveys understanding and changing behavior, such as that relating PrioritizinG environmental linked to energy-environment topics. The study found that to hygiene practices. As noted in chapter 1, a recent opinion HealtH iSSUeS LSMS surveys typical lacked sufficiently detailed questions poll conducted in Colombia found that the poor had very on (a) the prices households pay for fuels and electricity, different environmental health priorities compared with Environmental health issues can be prioritized in terms of their (b) connection fees, (c) service quality and supply reliability people in higher-income brackets. effect on both economic development and poverty reduction. from service providers, (d) seasonal variation as it related to Both quantitative and participatory techniques are needed to pricing and service reliability, (e) household coping costs (e.g. Once officials have a broad understanding of the most select themes or sectors for which there is a definite recognition what do households do when there is a power outage?), and important environmental health factors relating to poverty, the of the severity of environmental health issues. The prioritization (f) quantities of fuels and electricity consumed and attitudes next stage is for governments to prioritize the public actions of environmental health issues can be done in terms of health toward various energy sources (for example, are some types that will be most effective and cost-efficient in changing these impacts, economic costs, or welfare benefits to vulnerable of energy perceived to be cleaner, more convenient, reliable environmental conditions. populations such as the poor. Some of the tools with which to or expensive in comparison to others?) (Sullivan and Barnes carry out these prioritization exercises are discussed below. 2007). In the case of water and sanitation, efforts have been made to harmonize the water- and sanitation-related questions included in national surveys in order to help countries identify the needs of the population while seeking to make data across Box 4. HELI: Health, Environment, and Economic Benefits of Water Efficiency in Jordan countries more comparable (WHO, UNICEF et al. 2004). in jordan, Uganda, and thailand, the joint WHo/UneP Health and environment linkages initiative (Heli) conducted While it is clear based on hard evidence that the poor are dis- pilot projects that used qualitative and quantitative analysis to compare the benefits of different policy choices. proportionately affected by many environmental risks, such as indoor air pollution, it is also important to overlay the environ- the jordan pilot project considered the health and environment benefits of improved water efficiencies. the ment-health data with poverty data to gain a better understand- assessment included a cost-benefit analysis of three scenarios for government investments in water efficiency ing of the risks faced by the poor in a particular area. Distribu- improvements over a time span of 10 to 25 years. the assessment involved all major government agencies-- tional analysis--for example, overlying health impact data with health, environment, agriculture, and finance--along with key civil society actors. it optimized the scope income data graphically using GIS information, or including and quality of the assessment and allowed clear, wide-ranging consensus recommendations. this analysis income questions in existing health surveys such as DHS, as identified a wide range of benefits, and assigned a money value to selected benefits for which quantitative well as including health questions in traditional living standard analysis could reasonably be conducted. one of these involved an estimate of economic gains that could surveys to enable econometric analysis--is one important way result from investments in domestic water infrastructure, yielding improvements in consumer water supplies to gather specific data to better assess these linkages. and consequently reduced incidence of water-related diarrheal diseases. In the absence of quantitative data or to complement the assessment concluded that the "maximum investment" scenario extending between 2005 and 2015 could existing data, qualitative means to collect information potentially yield a 2.4:1 benefit-over-cost ratio in terms of both illness averted as well as environmental savings on environmental health aspects that are perceived to be from energy and agricultural efficiencies (for example, increased use of drip irrigation). important by the poor themselves for their well-being are also crucial. Focus groups and opinion polls are two instruments to gather information. This is especially important for Source: WHO 2007c. 33 Burden of disease analysis strategies. A recent example includes the 192 country profiles of Recent studies have demonstrated that direct health impacts as- Two questions--How much disease is currently caused by environmental burden of disease, which mapped major sociated with environmental risk factors cost countries between environmental risks? How much of the disease burden could be environmental risks by country . 2 to 4 percent of their GDP (Figure 4). Newer analysis, which averted by environmental improvements?--are important when includes indirect effects through malnutrition, put the figure it comes to decision making in disease prevention and reduction. Costs of degradation studies closer to 9 percent of a country's GDP in some regions (World Environmental burden of disease analyses are methods to These studies place an economic value on health impacts and Bank 2008). Such studies help establish environmental priori- quantify health impacts caused by various environmental risks on loss of productivity associated with environmental degrada- ties that directly affect sustainable growth. (WHO 2007d). Such quantitative information is essential, tion, and offer policy makers instruments for integrating envi- both as a basis for further calculating the economic value of this ronment into economic development decisions. Additionally, Cost-benefit analyses health burden (such as in cost of degradation studies), as well as by expressing damage costs as a percentage of GDP, it allows InJordanacost-benefitanalysiswasundertakentodemonstrate alongside information on effectiveness and costs of intervention for comparison with other economic indicators (Sarraf 2004). that a "complete cost, incomplete benefit" analysis would show that water efficiency measures were a "good deal" (Box 4). In Box 5, another cost-benefit analysis was carried out showing that the costs from a cholera epidemic were higher Box 5. Even as a Health Measure, Box 6. Behavior Change can be Cost-effective than improving safe drinking water. Infrastructure can be Cost-effective DFiD funded the Community Health Clubs in rural Cost-effectiveness studies These studies get away from the difficulties of assessing the net cost of the 1991 cholera epidemic tsholotsho District, zimbabwe. the project increased the health benefits in economic terms and help to compare to Peru's economy has been estimated at $1 proportion of households using a ladle to draw water interventions. As the Zimbabwe example shows, it can be billion (epstein 2001). By comparison, the from 3 percent to 93 percent and the proportion with an cost-effective to invest in changing behavior (Box 6). total cost of providing safe drinking water at improved pit latrine from 40 percent to 80 percent, as public standposts for Peru's 5.9 million people well as improving other aspects of hygiene behavior, at a In addition to quantitative studies, bottom-up participatory who are still unserved, at an average of $41 cost of $3.33 per household. approaches, where the poor can voice their concerns and per head, would be only $242 million. as well needs, can help establish the community's environmental as controlling the cholera epidemic, this would a recent hygiene promotion project in the town of Bobo health priorities and provide low-cost solutions. have saved millions of women from hours of Dioulasso (population 341,000) in Burkina Faso was drudgery collecting water, enabled the poor found to have changed the hygiene practices of only Participatory Poverty Assessments (PPAs) to avoid the exorbitant charges for water 18.5 percent of the mothers of young children, and This tool allows policymakers to consult the poor directly made by vendors, and improved people's to have cost $292,000 to implement. nevertheless, and transmit findings (World Bank 2005). PPAs are flexible quality of life. it has been calculated that the project could generate $394,000 in savings to the health system and in terms methods that combine mapping, matrices, diagrams, open- of lost productivity associated with child death (Borghi ended interviews, and discussion groups, all of which et al. 2002) emphasize exercises that facilitate information sharing, analysis, and action (Chambers 1997). PPAs need to be linked with policy making and not be used as a tool to extract Source: Cairncross et al. 2003. Source: Cairncross et al. 2003. information--although some issues highlighted by PPAs 34 Box 7. Seasonality is Important in Tanzania: Findings from the PPA in many PPas, seasonality analysis highlighted great differences in poverty, vulnerability, and coping strategies throughout the year. a household survey in tanzania concluded that 22 percent of the poor had access to safe water from protected sources, indoor plumbing, standpipes, and covered wells with hand pumps. But the survey overlooked the seasonal dimension of access to safe water and therefore overestimated the access. the PPa, which collected information from the same villages, revealed that in two-thirds of the villages thought to have access to safe water, water was actually a major problem. in the dry season, as water tables fell, people were forced to walk further for water or switch to unsafe alternatives such as uncovered dug wells, ponds, streams, and rivers. Source: Robb 1998. Photo: Arne Hoel "Poor people cannot improve their can be effectively applied to identify environmental health Assessments combining analytical and status because they live day by day, concerns that communities face, as they have the capacity to participatory approaches analyze the cause of their vulnerability and rank their priorities Other key tools that combine both analytical and participatory (Box 7). In PPAs carried out in Ghana, Mali, and Nigeria, and if they get sick then they are in approaches, and often feature in national legislation, for example, the poor said that physical isolation and lack of include strategic environmental assessments (SEAs) and access to water were their main problems (Robb 1998). PPAs health impact assessments (HIAs). Good-practice guidance trouble because they have to borrow may be used to complement quantitative data and provide a on strategic environmental assessment has recently been deeper understanding of the complexity of poverty, health, published by the OECD Development Assistance Committee money and pay interest" and service provision. (OECD 2006). Another important approach is the joint WHO/UNEP Health and Environment Linkages Initiative (HELI), which has developed a tool kit of health and ­ a woman in Tra Vinh, Vietnam environmentassessmentapproaches.BoththeHELIapproach (Crying out for change, World Bank) 35 and SEA can accommodate both economic assessment as prioritize efforts on the basis of risk reduction potential. Box 8. Incorporating Environment well as qualitative analysis (including institutional analysis), As a result, the Hawaii CRA resulted in the establishment and Health into Poverty Reduction and also emphasize involvement of both expert and broad of an indoor air program, a program to test blood levels in Strategies in Tanzania stakeholder consultations. children, new legislation to implement the recommendations, and a cabinet-level committee to oversee progress (Ijjasz and the "Programme on integrating environment into Comparative Risk Assessments (CRA) Tlaiye 1999). PrSP," which began in 2003 and is now in a second Another example is CRA, which provides a systematic phase called mkUkUta, is led by the vice-President's framework for evaluating different environmental problems One of the lessons learned from prioritization exercises is office/ Department of environment in partnership with that pose different types and degrees of risks to human health that it is important that countries build their own capacity other ministries that include the ministry of Planning, and the environment. CRAs also consist of both analytical to conduct such exercises through universities and think economy and empowerment and the ministry of and participatory components; however, some CRAs have tanks. The process of capacity building should be recognized Finance, among others. used expert groups rather than more broad-based groups as a slow process. Similarly, prioritization of environmental to rank different environmental problems (Morgenstern health issues would benefit from cross-sectoral and to mainstream environment into the PrSP, several 2008). The biggest impact of CRAs has been to help broaden multistakeholder dialogue. One result is that benefits that activities took place. these included: thinking in the policy community regarding the need to may be hard to value in economic terms but are important ˇ Production of guidelines for mainstreaming environ- ment into the PrS process, including budget guide- lines and a public expenditure review on environment ˇ Development of environmental indicators Box 9. Changing the Policy Approach: Lessons from Yunnan Province ˇ Establishment of an Environmental Working Group ˇ Training of state and non-state agencies. yunnan is a poor and remote province in China dependent on economic activities that include the unsustainable the following were some of the outcomes of exploitation of mineral or forest resources. traditionally, government agencies in the province have formulated supply- those efforts: led, top-down poverty reduction projects, where policies have not adequately reflected the needs and requirements ˇ The environment was expressed as a challenge of the poor. a change in national policy, however, has given local governments more flexibility in the preparation of to livelihoods, health, and economic growth local development programs. as a consequence, the institutional framework has changed to give local government ˇ Environmental concerns were incorporated into the responsibility for village-level infrastructure and agricultural resources. it has also encouraged the participation 16 of 96 development targets and integrated into the of community organizations. Within this institutional change, the yunnan environment Development Program (yeDP) monitoring process began with the support of the Uk Department for international Development. yeDP has not only instituted a bottom-up ˇ Different stakeholders were brought together to approach to service delivery, but has also attempted to change how its partners--from veterinary workers to water lay the foundation for future cooperation supply engineers--work together. integrated work is difficult because (a) each agency has its own mandate, (b) ˇ The budgetary allocation for the environment agencies compete for financial resources, and (c) the incentive and reward system are associated with the agency was increased rather than with the yeDP. this was solved by having a key actor lead the initiative, which is not tied to a given agency ˇ Increased awareness of poverty-environment linkages. in terms of budgeting and reporting lines. in this case, it was the township vice-mayor who assisted the process. Source: UNDP-UNEP Poverty Environment Initiative (n.d). Source: Spencer et al. 2006. 36 Box 10. Philippines: A Need to Rediscover the Sanitation Code although environmental health practice is well-established in the Philippines and has a long tradition dating back to the colonial era, it had been neglected for a while, and more recently has been rediscovered as an important feature of health protection. Under-5 mortality has been dropping in the Philippines thanks to current child survival efforts, but it remains high, especially among the poor in both urban and rural settings. twenty-five million people in the Philippines live in households without sanitary toilets. Diseases typically related to the inadequate provision of water and sanitation, as well as improper hygienic practices, dominate the disease burden. For example, diarrhea is the leading cause of hospitalization, and 40 percent of Filipino children are infected with soil-transmitted helminths that are largely attributable to inadequate sanitation practices. the Code on Sanitation (1975) is the centerpiece of health protection legislation in the Philippines. as a cross-cutting theme, environmental health is governed by this and several other laws in other sectors that seek to protect citizen's health from environmental hazards. at the national level, environmental health is within the mandate of the ministry of Health, which coordinates activities and interventions through the interagency Committee on environmental Health. the functions of this committee include (a) formulating policies and guidelines and developing programs, (b) coordinating, monitoring, and evaluating environmental health programs and projects, (c) disseminating and coordinating education campaigns, and (d) coordinating research and relevant activities for environmental maintenance and protection. this committee has established similar regional interagency committees for implementation at the regional level. Photo: Ray Witlin in 1991 the devolution of many health and environment functions put local governments in control of many environmental-health-related functions, making implementation capacity a key issue at the local level. a sanitary inspector is part of the local health team and is responsible for most environmental health functions, including water supply, foods safety, sewage and excreta collection and refuse disposal, vermin control, and industrial hygiene. During the past decade or so, there have been efforts to improve coordination of multisectoral health activities at the national level, but more is needed to guarantee crucial horizontal coordination at the local level. Source: World Bank 2007c. 37 from a cultural perspective are also determined, and broader place in the context of sectoral specialization and distinct Code also illustrates the importance of ensuring that there is support amongst different groups is built. Finally, priority responsibilities working in "silos" with little communication capacity at the local level for horizontal coordination. setting processes should ideally take place periodically in between agencies. Supra-national initiatives, such as those order to detect environmental health problems at an early implemented by WHO (European Environment and Health Many aspects of environmental health depend on improved stage rather than when they impose a significant cost to Process)ortheEuropeanCommission(EuropeanEnvironment governance, both in delivery of essential environmental health society (World Bank 2005). and Health Action Plan 2004­10) can have a positive impact services and in regulation and legislation. Laws on health and on policy coordination. For example, in the European context, environmental quality, as well as environmental standards for the WHO-led National Environmental Health Action Plan clean air and water, are an important first step in safeguarding aSSeSSinG anD StrenGtHeninG (NEHAP)hasbeenapowerfultooltoincreasecollaborationand the country's public health. A mix of approaches--including inStitUtional CaPaCity anD facilitate integration of the policy domains of the environment economic instruments, inspection and enforcement, and GovernanCe on environmental and health sectors. NEHAP has played an important role in penalties and fines--can be used to ensure compliance with HealtH iSSUeS increasing awareness of environmental health and promoting regulations. Regulations linked with disposal of wastes, use ministerial coordination and decision making (Ivanov et of pesticides, housing construction, and food hygiene are Researchondevelopmenthasfoundthatthestateofinstitutional al. 2004, OECD 2006b, Perlstadt 2003). Similarly at a also important examples of the regulatory framework for development is the single most important variable in explaining national level, coordination across sectors, appropriate budget environmental health and further demonstrate the importance a country's overall level of development (World Bank 2002). allocation, and results monitoring by finance and planning of cross-sectoral collaboration as they are often developed and Poor governance at the national and local level and within other ministry officials can help to marshal individual efforts by enforced by different agencies. governing bodies is a key cause of poor environmental health. different sectoral agencies toward better environmental health. Governance can be undermined by a range of factors, including Box 8 demonstrates the power of an approach in Tanzania that Regulatory frameworks also need to be revisited every few lack of transparency, weak accountability, poor organization and takes a multistakeholder perspective. At a city level, the mayor's years to keep up with new studies on the effects of pollut- lack of technical capacity, inefficiency, and poor motivation. office often plays such a role. ants on people's health. Constant reevaluation of priorities Within the institutional assessment, informal institutions such and sharing this information with stakeholders is also impor- as traditions, customs, and practices also need to be assessed Inadditiontobettercross-sectoralcollaboration,thesuccessful tant. In the 1970s, for example, the conventional wisdom was as they can be a constraint or a facilitator for reform. For implementation of environmental health interventions often that high ambient concentrations of total suspended particles environmental health, this means examining the institutional relies on both horizontal and vertical partnerships across and (TSP) represented a serious health problem. More recently, and governance underpinnings, identifying strengths and between local and state levels, as well as with NGOs and the with improvements in measurement technologies and analyti- weaknesses, and making recommendations to enhance policies private sector. The latter is discussed further in chapter 4. cal techniques, fine particles with diameters of 2.5 microns or on better environmental health (Lovei and Pillai 2003). However, within government, it is particularly important that less appear to be the real culprits. This finding has led to sig- local governments convey the environmental health priorities nificant changes in air pollution control strategies in the U.S. Environmental health by definition is cross-sectoral, and of their constituents upwards to national-level authorities and other countries. requires the participation of many ministries in the policy as they formulate policies and assign budgets, and similarly process. However, the implementation of specific interventions that national agencies can work with state and local levels The basis for establishing health-based national or local needs to be carried out by an individual agency with clearly to implement these policies. Box 9 provides an example of a environmental regulation is provided by WHO guidelines. delineated responsibilities (OECD 2006b). Existing shift from a top-down approach to a bottom-up approach to These are science-based and are available, for example, for coordination of environmental and health policies often takes service delivery in China. Box 10 on the Philippines Sanitation drinking water quality, safe use of wastewater in agriculture 38 and aquaculture, safe use of excreta and greywater, and air quality (valid for indoor and ambient air pollution). These Box 12. How Peru Incorporated Environmental Health into National Plans and Policies guidelines are regularly updated on the basis of emerging evidence of links to health (WHO 2005c). Peru began the process of developing a Country environmental analysis (Cea) through a participatory process to build consensus on the identification of environmental priorities for poverty alleviation and on the design Some of these changes in environmental standards can also be and implementation of related environmental policies. Several workshops were held in which various sectors a product of globalization or international commitments to participated, including the ministries of environment, health, finance, agriculture, and energy and mines; international agreements, such as the Stockholm Convention regional environmental authorities; the private sector; nGos; indigenous communities; civil society; and governing the use of persistent organic pollutants. For international organizations. through a media campaign, the Cea also helped generate national consensus, create example, trade regulations in industrialized countries can awareness, and build constituencies. as a result, environmental health issues were incorporated into this analysis as affect developing countries and smaller-scale producers by environmental health currently represents Peru's most important environmental problem. First, the Cea helped identify the linkages between environmental health issues and poverty. the poor in general Box 11. Successful Adjustment to were exposed to greater environmental risks than higher-income groups and lacked the resources to mitigate those Environmental Health Standards risks. For example, the analysis found that the impact of urban air pollution relative to income is more severe for the poor than for the nonpoor. Health impact relative to income is a useful indicator, because illness and premature in 1989, Germany--the leading export market mortality result in medical treatment costs and lost income, in addition to pain, suffering, and restriction of activity. for indian leather products--banned the import Based on this indicator, health impacts are between 75 and 300 percent higher among the poor. of consumer goods containing PCPs and a large number of dyes, citing concerns over health impacts Second, the Cea helped prioritize environmental health issues by identifying which issues had the most on consumers. these chemicals were routinely used significant economic costs. the analysis shows that the most costly problems associated with environmental in leather tanning in india. it came as a shock to degradation are, in decreasing order, inadequate water supply, sanitation, and hygiene; urban air pollution; this important export industry, which ranked fourth natural disasters; lead pollution; indoor air pollution; and agricultural soil degradation. the study found that in export revenue in india at the time. these issues cost Peru 3.9 percent of GDP each year. the export ban prompted a quick regulatory action third, the Cea helped choose environmental health interventions by conducting an analysis that estimated the by the indian government to prohibit manufacturing of costs and benefits of four interventions: (a) handwashing by mothers or caretakers of young children in rural the banned chemicals. the application standardized and urban areas, (b) improved water supply in rural areas, (c) safe sanitation facilities in rural areas, and (d) methods for testing so as to ensure compliance, drinking water disinfection at point-of-use in urban and rural areas. and provided for rapid development of low-cost substitutes. Surprisingly, this example shows that even Without an enabling environment, such interventions could not be implemented. Given the severity of environmental highly dispersed, traditional small-firm clusters can health risks, the Cea recommended the establishment of an autonomous environmental Health agency responsible meet strict environmental standards successfully in a for developing and enforcing health-related parameters, such as WHo water-quality parameters that have health relatively short time and stay competitive. implications such as pathogens, volatile organic compounds, and persistent organics. Such parameters contribute to the monitoring process of the chosen interventions, and contribute to reducing health risks associated with poor health. Source: Pillai 2000. Source: World Bank 2007b. 39 requiring them to adhere to stronger environmental and Figure 7. Multiple Inputs and Outcomes in Environmental Health health standards than prevalent in their own countries. In order to remain competitive, small and medium enterprises will conform to higher environment/health standards to meet Some Interventions Outcomes international requirements effectively, turning them into a and Examples market advantage rather than an obstacle (Box 11). It is essential that responsibilities for tackling environmental Behavior change health priorities are clearly defined and budgets are Health promotion Improved health appropriately allocated. Since this role of approving budgets Advocacy often lies with finance or planning departments at a national Governance Saving time and drudgery or state level, or with a mayor's office, it is essential that these Air pollution codes institutions use tools--such as periodic reviews of legislation-- EH legislation to ensure that mandates and responsibilities are clearly Environmental Health Improved quality of life defined both horizontally and vertically among government Service delivery GLOBAL departments, as well as public expenditure reviews to assess Water supply whether priority issues are receiving adequate funding within Refuse disposal NATIONAL Empowering women sectoral departments. LOCAL Infrastructure HOUSEHOLD Public expenditure reviews Water supplies Increased attendance Public expenditure reviews are tools that systematically assess Drainage and better performance the equity, efficiency, and effectiveness of public spending. Improved housing at school By incorporating specific questions on environmental health expenditures (such as spending on water supply, sanitation and Finance and social marketing hygiene,andimprovedcookstoveprograms),theseexistingtools Promotion More sustainable can also be used to provide additional information on whether Credit livelihoods priority issues are receiving adequate funding (Hamilton et al. Subsidy, if suitable 2006). Sector reviews (based on annual performance), value- for-money, and public expenditure tracking studies (PETS) are also good tools to use. Source: Cairncross et al. 2003. 40 Box 13. The Ecohealth Approach: CHooSinG aPProPriate for the integrated management of childhood illness. At first, incorporating environmental health issues within Combating Malaria through Agricultural environmental HealtH interventionS conventional health sector interventions may be a challenge. Practices in Kenya Using the information from the previous steps, government However, it can also be seen as an opportunity to significantly impact health outcomes by complementing or supplementing in kenya, a project supported by the international departments will be better placed to choose specific health system activities. Mexico, for example, complemented Development research Centre is examining the linkag- environmental health interventions. Box 12 illustrates such child survival interventions--generally managed using a es between agriculture and malaria through the ecosys- an example in the context of Peru, where ranking of the more "health-systems" perspective, and thus restricted to tem approach. the goal is to reduce the incidence of country's priorities, an assessment of costs and benefits linked vaccinations, micronutrient supplementation, and promotion malaria through agricultural interventions. through re- to individual investments, combined with information about of breastfeeding--with a clean water program. As a result. it search and capacity-building, communities can adopt the enabling environment (institutions, laws, budgets) helped is now one of seven countries on track with meeting MDG-4 numerous agricultural practices to reduce and prevent to guide the choice of intervention. (reduction of child mortality) by 2015 (World Bank 2008). malaria, improve nutrition, and benefit their economic outlook. these practices include the following: In many cases environmental health interventions can complement or supplement the activities of the health Additional considerations that need to be taken into account while choosing environmental health interventions include ˇ Using cattle as "bait" to divert mosquitoes away from sector and do not need to compete for resources. There the level of social acceptability, political will, and level humans. research has shown that certain species of are several areas where case management through health of poverty impact. In rolling out programs on improved malaria-bearing mosquitoes prefer the blood of cattle systems is falling short--for example, childhood illnesses cookstoves, it is imperative to undertake formative research to that of humans. such as diarrhea, ARI, and helminth infections--suggesting on whether local communities will adopt and use these stoves ˇ Reduce mosquito-breeding habitats by limiting the the need for better primary prevention of environmental appropriately. Involving communities in identifying and amount of water used for rice cultivation. risks. Environmental health interventions, for example, choosing interventions is essential to identify locally relevant ˇ Reduce the amount of time that paddies are wet, can complement child survival, nutrition, and programs solutions. In Kenya, Box 13 illustrates an approach that is either by changing flooding schedules or alternating both multisectoral and informed by community involvement. rice cultivation with dryland crops such as soya. in addition to limiting the mosquitoes' habitat, planting Since there are multiple outcomes linked with environmental soya could boost income and improve nutrition. health issues (Figure 7), bringing different stakeholders ˇ Introduce naturally occurring bacteria into stagnant together and identifying how some of these outcomes are also water to kill mosquito larvae during the peak synergistic with other priority development goals is important. breeding season. Furthermore, fostering an environment that encourages the creation, sharing, and effective application of knowledge the heart of the ecosystem approach is to include to improve health outcomes will help to better bridge the active participation of community members in the knowledge gap of "what needs to be done" and "how to do research process, and therefore help researchers it," thus helping governments to continuously adapt policies understand people's perceptions of the health and and interventions to changing circumstances in the enabling development problems in the area. the ecosystem ap- environment through a dynamic learning process. proach also seeks interventions and solutions that are transdisciplinary. Source: IDRC 2003. Photo: Dominic Sansoni 41 Table 4. Key Environmental Health Indicators monitorinG ProCeSS anD oUtCome inDiCatorS environment- intermeDiate inDiCator imPaCt oF inDiCator In order to measure progress of the impact of environmental relateD illneSS health interventions, a system is required to systematically monitor exposure and health improvements. In most Diarrhea ˇ Access to safe water (private or public) ˇ Incidence of diarrhea developing countries, health surveillance systems need ˇ Access to sanitation (private or public) ˇ Diarrhea mortality further enhancement and exposure monitoring data is largely ˇ Hours/days of available piped water ˇ Malnutrition (weight for age, height ˇ Quantity of water used per capita per day for age, weight for height) unavailable. Furthermore, measurable and appropriate ˇ Time taken/distance involved in collecting indicators are often not tracked. water ˇ Disposal practices of children's feces Household surveys are often a key source of national data. ˇ Percentage of child caregivers and food However, national-level surveys (such as the DHS and preparers with appropriate hand-washing LSMS) often ask very few questions on environmental- behavior health-related issues. For example, a study in Guatemala ˇ Coliforms/100 ml of water consumed by residents by both source and tap found that DHS lacks information on household income, ˇ Persons per room of housing ARI symptoms, and women's respiratory illness. Meanwhile, the LSMS lacks clarity on ARI symptoms and the relative use respiratory infections* ˇ Availability of ventilation in home ˇ Incidence of ARI/ chronic ˇ Children sleeping in cooking area respiratory diseases of fuels in households that use more than one fuel (Ahmed ˇ Percentage of households using cleaner fuel ˇ Incidence of bronchitis et al. 2005). New modules on specific environmental health ˇ Persons per room of housing ˇ ALRI issues such as indoor air pollution should be considered for ˇ Percentage of households using improved ˇ Death rate of children under five incorporation into these surveys (see Sullivan and Barnes stoves years of age 2007). In other cases, efforts have been made to encourage malaria ˇ Proportion of households having at least ˇ Malaria death rate (probable and the use of harmonized questions in national surveys as a tool one treated bednet confirmed) among target groups to help countries gain more systematic information on the ˇ Percentage of health facilities reporting no (under 5 and other) water supply and sanitation needs within their population. disruption of stock of anti-malarial drugs ˇ Number of malaria cases, severe Such efforts also seek to make data across international and (as specified by national health policy) for and uncomplicated (probable and national survey programs more comparable so that more more than one week during the previous confirmed) among target groups accurate water supply and sanitation coverage estimates can three months ˇ Percentage of malaria patients getting treatment be made (WHO, UNICEF et al. 2004). Broad indicators ˇ Public health expenditures ˇ Under 5 mortality rate Furthermore, vital registration systems in most developing ˇ Lost disability-adjusted life years (DALys) countries are very poor; less than 50 percent of births are recorded, and less than 30 percent of deaths recorded. Work *Notes: The intermediate indicators in this category pertain mainly to indoor air pollution. However, for countries such as China where urban air pollution is likely to grow in magnitude, it would be important to identify intermediate and impact indicators related to outdoor air pollution. Blood-lead levels among children are a good indicator of urban pollution, but bio-monitoring is very expensive. 42 needstobecarriedoutonstrengtheningdatacollectionsystems. quintile, as well as address the statistical needs of several An ideal setting would be for data collected to reflect health stakeholders, including donors, NGOs, local governments, Box 14. Global Initiative on Children's outcomes rather than inputs or outputs. However, this is a national planning commissions, and interested ministries, Environment and Health Indicators difficult task. Process indicators--for example, the percentage among others. of the rural population with access to a water supply--may a Global initiative on Children's environmental Health be easier and more reliable to measure, and progress is more In any given country, the measurement system to monitor indicators was launched at the World Summit on easily attributable to interventions and has greater diagnostic environmental health outcomes will depend on (a) data, Sustainable Development in September 2002. this power. For this, collaboration is needed across sectors. The (b) cost and ease of measurement and monitoring, (c) represents an independent effort that contributes to measurement of these indicators will provide opportunities for stakeholder perceptions on what is important to monitor achieving the objectives of the Healthy environments multisectoral collaboration. and acceptance of indicators, and (d) the final purpose for Children alliance, in particular to inform and for which the information is used (Shyamsundar 2002). influence policy makers and to judge the effectiveness National, subnational and household-level indicators are Finally, even though there are challenges associated with of programs to improve children's environmental health. important. National-level data may only tell half the story, so measuring and using environmental health indicators, this setting up surveys and monitoring systems at the local level is is clearly an area that can yield massive benefits in reducing the objectives of the initiative are to: vital. Disaggregated data at the subnational level helps to better poverty compared with the associated costs.16 Box 14 shows 1. Develop and promote the use of children's identify vulnerable groups and geographic priorities, while an example of how several international organizations are environmental health indicators household-level data will provide the necessary information to working together to develop common indicators to monitor 2. mprove the assessment of children's environmental facilitate community-level interventions. children's environmental health. health and monitor the success or failure of interventions Indicators are essential for raising the importance of environ- This chapter has highlighted some of the entry points in de- 3. Facilitate the ability of policy makers to improve mental health issues to high-level decision makers. For example, velopment planning and related tools to better integrate en- environmental conditions for children. a recent study of Vietnam, Lao PDR, and Cambodia developed vironmental health issues into development agendas. It has a spatial analysis to determine in which districts the poverty-en- focused on the role that an umbrella coordinating agency can the implementation of this initiative is being led by vironment nexus was worst. The variables used included poverty play, such as a ministry of finance or planning, similar depart- the World Health organization. it builds on existing incidence, deforestation rate, steepness of slope as an indicator of ments at the state or provincial level, or a mayor's office. The international, regional, and national work on child health soil vulnerability, wood/charcoal use, unsafe water sources, and next chapter discusses in more detail how governments and and environmental indicators by initiating a series of prevalence of childhood diarrhea. Such an analysis can help tar- other stakeholders, such as NGOs and the private sector, can regional pilots to develop, collect, and report children's get interventions to specific areas. Instead of using a particular work together to build long-term constituencies in order to environmental health indicators. the initiative aims to indicator for environmental health, a basket of different sector continually place environmental health issues on the devel- ensure equal relevance of the indicators for the health and indicators that may already be collected could be useful. These in- opment and poverty reduction agenda. environment sectors so that both can monitor their efforts dicators also need to capture issues of access by income or wealth toward realizing healthy environments for healthy children. WHo regional and country offices, as well as their UniCeF counterparts, are working with countries and partners actively involved at the regional and country level to design and implement pilot projects in north america, latin america and the Caribbean, europe, the middle east, and africa. Source: WHO Program on Children's Environment and Health (www.who.int/ceh/en/). 43 Environment and health assessment tools: Decision-making tools: For additional information on available environmental burden of disease (eBD): www.who.int/ Comparative risk assessment (Cra) publications by WHo: resources: quantifying_ehimpacts/national/en/index.html http://who.int/healthinfo/boddocscra/en/index.html Country profiles on environmental Burden of Disease: Poverty mapping: http://go.worldbank.org/r00QivF2a0 Sources for data: www.who.int/quantifying_ehimpants/countryprofiles Scenario analysis: http://go worldbank.org/GltQa9DHW0 Demographic and Health Surveys (DHS): Health impact assessment (Hia): www.who.int/hia//en/ http://www.measuredhs.com/ Country environmental analysis (Cea): http://www. worldbank.org/ceatoolkit living Standard measurement Surveys (lSmS): Other Tools: http://www.worldbank.org/lSmS/ Strategic environmental assessment (Sea): http://www.worldbank.org/seatoolkit Public expenditure reviews (Pers) are a key tool for Country data sheets on health indicators, determinants analyzing public-sector issues by systematically assess the and finance: http://go.worldbank.org/n2n84rDv00 environmental impact assessment (eia): http://ec.europa. equity, efficiency, and effectiveness of public environmental eu/environment/eia/ spending. See: http://go.worldbank.org/W98PDjFyC0 environmental health indicators: www.euro.who.int/ eHindicators Heli: Health and environment assessment: Public expenditure tracking survey (PetS) is a technique www.who.int/heli for tracking the effect of public expenditure on growth Children environment and health indicators: and/or social outcomes. For more information: http://www.who.int/ceh/indicators/en/ http://go.worldbank.org/kQQS1BDG90 Tools for developing environmental and Quantitative service delivery survey (QSDS) evaluates health norms and standards: efficiency of public spending and incentives by collecting Economic assessment tools: data on inputs, outputs, quality, pricing, and oversight, air quality guidelines: etc. For more information see: http://go.worldbank.org/ Cost-benefit analysis (CBa): Peru Cea that used CBa http://www.who.int/phe/health_topics/outdoorair_aqg/en/ mB54Fmt3e0 analysis: http://go.worldbank.org/lDDPjn2tU0, cost benefit analysis of interventions on indoor air pollution: Wastewater reuse and excreta in agriculture and knowledge management: http://www.who.int/kms/en/ http://who.int/indoorair/interventions/cost_benefit/ aquaculture guidelines: http://www.who.int/water_ en/index.html sanitation_health/wastewater/wasteuse/en/index.html environmental valuation including cost-of-degradation: Drinking water quality guidelines: http://www.who.int/ http://go.worldbank.org/XBSSSHXD30 water_sanitation_health/dwq/gdwq3rev/en/index.html Consideration in evaluating cost-effectiveness of on-site sanitation guidelines: http://www.who.int/water_ environmental health interventions: http://www.who.int/ sanitation_health/hygiene/envsan/onsitesan/en/index.html quantifying_ehimpacts/publications/en/wsh00-10.pdf other water and sanitation guidance: http://www.who.int/ water_sanitation_health/publications/en/index.html 16. This section highlights some of the conclusions reached by the participants of the Workshop on Environmental Health Indicators: Cure or Placebo? June 2006. World Bank, Washington D.C. 44 Photo: Prabir Mallik Francis Dobbs 45 4. BUILDING LoNGER-TERM CoNSTITUENCIES To SUPPoRT PoVERTy-ENVIRoNMENT-HEALTH ISSUES Thepreviouschapteroutlinedseveralstagesinthedevelopment matters are highlighted in Principle 10 of the Rio Declaration on transparency laws enacted by governments; (b) government planning process where environmental health inputs could Environment and Development and more recently in the Aarhus reports and websites that share monitored information on be incorporated by government officials from finance and Convention on Access to Information, Public Participation in poverty-environment-health indicators; and (c) voluntary and planning or by a mayor's office. This chapter discusses a Decision-Making and Access to Justice in Environmental Matters mandatory public disclosure schemes supported by the private topic that cuts across the entire development planning and (www.unece.org/env/pp/documents/cep43e.pdf). implementation cycle, namely the creation of long-term constituencies within a country to help continually focus The remainder of this chapter discusses each of these three attention on environment-health-poverty issues and promote themes in more detail and in an environmental health context. Box 15. Building Constituencies in social accountability among public officials for effective It also describes the role of different stakeholders in facilitating Colombia to Reduce Urban Air Pollution action on these issues (Ahmed and Sánchez-Triana 2008). the formation of constituencies for supporting environmental Such constituencies are also important for facilitating results health and poverty issues. Clearly the government, at both the in 2005, the Colombian government requested the World on this agenda, as environmental health often requires both national and local levels, has an important role to play here. Bank to carry out a Country environmental analysis for technology change as well as behavioral change to achieve However, the role of civil society organizations (CSOs) and Colombia. this included a study focused on calculating improved environmental health outcomes. NGOs, as well as the private sector, is equally important. the cost of environmental degradation. this study esti- mated that there were close to 6,000 premature deaths In order to build constituencies, the first step is making as a result of outdoor air pollution in the country, reflecting information on poverty-environment-health issues available in aWareneSS-raiSinG anD the shift from a rural economy to a highly urbanized one order to raise awareness, both in terms of holding the government CommUniCation StrateGieS in the last four decades. Wide media coverage of these accountable but also to promote behavioral change among the findings resulted in a broad public debate, which was population. Effective means of communicating this information Within the development planning process, monitoring poverty also taken up by politicians during the recent reelection and making people aware of how they can access the information and environmental health indicators are clearly important campaign. one candidate placed white blankets in the is equally important. A second important step is involving the from the perspective both of understanding the baseline open air in Bogota and then widely disseminated to his public in decision making. Encouraging the participation of situation, and of monitoring the future impact of policy constituency the change in color of these same blankets, weak and vulnerable stakeholders is particularly important, so changes and additional investment. Equally important is comparing it to the effect on their lungs and quality of life. that all views are taken into account, rather than the views of making this information available to the general public so that this open public debate has resulted in increasing the the more powerful and vocal stakeholders only. A third stage is its implications are understood by them and they can use it as number of champions in the authorities to revise air quality providing access to justice for all citizens in order to promote a mechanism to hold public officials accountable in the longer standards. in 2007, the first air Pollution Control bill was social accountability among public officials. These three aspects, term. Box 15 illustrates such an example from Colombia. There discussed in the national Congress. namely public disclosure of information, public participation are many other examples of policies or programs that facilitate in decision making, and access to justice on environmental the dissemination of information to the public, including (a) Source: Ahmed and Sánchez-Triana 2008. 46 sector together with governments, such as the Pollution Box 16. Environmental Health in the Media Box 17. The Global Public-Private Reduction and Transfer Registry for industry in Mexico, the Partnership for Handwashing with European Blue Flag Scheme for clean beaches, or the PROPER the media is a powerful tool for spreading messages industry disclosure program in Indonesia. regarding environmental health. reports from developing Soap in Ghana countries show that the very first information many Communication strategies are crucial in making sure this people receive about a health hazard is through their in 2004, the national Handwashing Campaign information is accessed and understood by the public and newspaper or radio/tv program, followed by a reaction launched an intensive media campaign through to help stimulate a two-way flow of information. The media by the formal establishment, either the government or three television networks and 17 radio stations can play an important role and efforts to train journalists to the private sector. newspapers in particular help create throughout the 10 regions of Ghana. these public understand and report accurately on environmental issues. public awareness. in zambia, a newspaper reporter, service announcements were complemented Box 16 examines some ways in which the media has covered when asked what was newsworthy stated: "it is health- by a number of radio and television discussion environmental health, with big one-time stories getting more related stories such as pollution in cities and their effect programs, with interviews held throughout the coverage than the long-term environmental health issues that on people's lives." country on national media and district-specific Fm radio stations. the communication program was affect millions of people everyday. Some examples of the issues covered in developing supplemented by district-level handwashing action Communication is also crucial from the perspective of raising countries include: plans for implementation. after six months, reported rates of handwashing with soap among mothers and social awareness and promoting behavioral change to improve ˇ In Brazil, the mass media appears to concentrate schoolchildren showed a marked improvement over environmental-health outcomes. Approaches to marketing more attention on oil spills near rio de janeiro than baseline rates. exposure to all campaign materials the links between environment, health, and behavior include epidemics affecting the favelas of the city or the was also very high, with over 80 percent of children television, radio, and street theater. For example, the Mexican epidemics in amazonia. and adults reporting positive behavior change since television producer Miguel Sabido deftly weaves health and other socially responsible information into "traditional" soap ˇ Issues of the Montreal Protocol gets regular coverage the campaign launch. operas to raise consciousness about issues such as diseases that in the southern part of Chile, which is near the Source: Kristensen 2005. arepreventableorreadilytreatable.Theplotsoftelevisionshows antarctic ozone hole and greatly affected by climate and theater are innovative ways to incorporate environmental change. in contrast, Chile's national media takes less health issues, thus both entertaining and educating the general interest in the issue and coverage is superficial. Box 18. Worm Control: An Opportunity public. Box 17 illustrates how a media campaign in Ghana for the School System helped increase handwashing with soap. ˇ A media taboo is lack of sanitation, which has a direct bearing (with hygiene) on people's health. recent studies in a number of african countries have Awareness may also be promoted in collaboration with primary ˇ There is an overwhelming need to train shown that primary school teachers can play a key and secondary schools. Linking health program delivery into environmental health journalists, given the increasing role in the treatment of children with parasitic worm the education system has also proven to be cost-effective. complexity of the issues, whether they are global, infections. teachers can also play a part in mobilizing Collaboration between the health and education ministry, national, or local. pupils and their parents to prevent environmental teachers and health workers, schools and community groups transmission of worms (and not just to treat the infection) can be fostered. Experience has shown that school-age children ˇ How the environment impacts people's health is of by building latrines, and clearing vegetation from direct relevance to those affected. bathing places infected with schistosomiasis. Source: D'Monte 2005. Source: Cairncross and Kolsky 2003. 47 can carry messages home to their families, including younger 10 percent at baseline to over 50 percent three years later. This siblings, and connect with the wider community in conveying was further associated with a 27 percent increase in child sur- messages on personal hygiene, handwashing, and promoting vival among children from 1 month to 4 years old (Schellenberg improved sanitation. For example, for the overall promotion et al. 2001). While in Zambia, the Safe Water Systems social and control of malaria in the community, schools have been marketing program has shown a similar success, with the use successful partners through helping to promote a community- of chlorine for household drinking water treatment rising from wide understanding of disease and health issues with particular 13.5 percent in 2001 to 42 percent in 2004 (Scott 2005). emphasis on the need for community-based control measures, such as the use of impregnated bednets for malaria. Schools can serve as a focus for synchronized impregnation of bednets and PartiCiPation anD StakeHolDer distribution (Hunt and Peralta 2003). Another example is in the involvement treatment of parasitic worm infections (Box 18). Participation of stakeholders can facilitate prioritization, Awareness-raising may also be built into the curriculum for help set the agenda, collaborate with implementation, and professional qualifications. However, less formal education can contribute to monitoring. Often both the poor and local also play a key part by showing those working on their own governments are left out of participating in development how they can help achieve wider benefits, as the Farmer Fields planning. For this reason, both legal and informal mechanisms School work on malaria shows (Box 19). that bring together different viewpoints during the policy formulation and implementation process (particularly of In some cases, improvements to environmental health require those that are most vulnerable) are important (Feldman and interventions that change behaviors. Social marketing builds on Khademian 2008). For example, focus groups with women Photo: Curt Carnemark traditional marketing approach of the four Ps: product, price, in Guatemala showed a lack of awareness of the link between place, and promotion. It is often applied to service provision indoor air pollution (environmental health issue) and acute and use, the development and acceptance of products, or the respiratory infections (health outcome), which was the single "We have nobody to talk to when we adoption of new behavior. Social marketing begins with a sys- most important cause of morbidity and mortality in the tematic use of data collection to find out what consumers know, country (Ahmed et al. 2005). Indoor air pollution, however, face problems. We become reluctant do and want (LSHTM/EDC 1998). The results are used to de- was a lower priority for Guatemala than urban air pollution. velop positive messages that address specific health problems. Important environmental health issues for the poor may Often it is behavior-focused through for example, hygiene pro- not make it to the policy agenda without an active effort by to talk because village leaders ignore motion. Over six months of hygiene promotion with a pilot public officials to involve and hear the voices of these groups. group in Lucknow, India, the proportion of mothers washing Sometimes NGOs step in to amplify the voices of these our complaints especially if they touch their hands with soap after defecation went from under a quar- vulnerable groups, as was the case in Ukraine (Box 20). ter to over half (LSHTM/EDC 1998). Large-scale social mar- [governance] issues" keting of treated bed nets in rural Tanzania showed an increase Involving local constituents and civil society organizations in the number of infants sleeping under bed nets from under (CSOs) can also help in the implementation of environmen- ­ Women's Dignity Project 2003 48 Box 19. Tackling Malaria through Work with Farmers -- the Farmer Field School Approach the Farmer Field School uses experiential learning methods to build farmers' expertise. it has an impressive track record in participatory community approaches to agricultural issues. over 2 million farmers have studied integrated pest management (iPm) during the past 15 years, mainly in asia, but more recently also in africa, the middle east, and latin america. malaria has strong linkages with agriculture, and farmers in regions with malaria have a central position in creating or controlling the conditions that favor disease transmission. an interdisciplinary approach is needed to involve farmers with other sectors in control efforts. malaria control can benefit from a complementary intervention in rural development, such as in the combined health-agriculture curriculum known as integrated pest and vector management (iPvm) developed in Sri lanka. agricultural practice will influence malaria epidemiology if income and living standards are raised (by improving people's access to health care) and if agro-pesticide use is reduced (by lowering the risk of insecticide resistance in malaria vectors). institutional ownership and support for iPvm could potentially be spread over several public sectors, requiring a process for institutional learning and reform. Source: van den Berg and Knols 2006. Photo: Eric Miller 49 Box 20. Women take a Lead in Tackling Environmental Health Problems Box 21. A Hood Solution for a Maasai Community in Rural Kenya luzanivka--a district of odessa in the Ukraine--suffered for many years from two major environmental problems that had direct and serious health impacts. Due to inadequate sewage-pumping capacity in the district, in kenya, 96 percent of the population lacks residential houses were often affected by sewage spills. in addition, a nearby chemical plant had a facility for access to grid electricity and more than 80 cleaning railway oil tanks in the open air. this problem led to a severe environmental disaster in 1996, when percent of the population relies on solid fuels. six people died. masai women in the kajiado region cook and this resulted in a rapid increase in community activity led by a group of low-income women. they initially heat with wood, cattle dung, and crop residues. focused their activities at the grass-roots level, working with people who were most severely affected. they Fires are often kept smoldering throughout the approached the local authorities several times, but were told that there were no funds to address the sewage day and night, leading to very high levels of and air pollution problems. indoor smoke. the intermediate technology Group/Practical action (itDG/Practical action) they responded by working harder and built up their own expertise. they worked with other residents to worked with local women to solve this problem. document the full extent and impact of the environmental problems. then, with the help of a lawyer, they got 80 residents to sue the local authority for failure to act on air and sewerage problems. this was backed up Participatory approaches accompanied the by protests and media work and was supported by the nGo mama 86. after some discussion, the national solution from beginning to end. repeated government finally agreed to fund construction of a new sewage facility. the local authority also allocated funds talks with the masai community revealed the for environmental works in the district. many health and social problems associated with indoor smoke. From a range of options, this participatory action was a new experience for many people in Ukraine. the women led the way in the women cooks decided on a simple and demanding improvements to environmental health systems. While they started with protests, they are now working affordable smoke hood as the solution that best in cooperation with the state government and local authorities. luzanivka is still a poor community, but the sewage suited their needs. together with local artisans, facility has been built, the hazardous waste facility has been closed, and the wetlands polluted by the oil have itDG/Practical action developed and tested a been cleaned up. hood that draws smoke straight from the fire and out through the roof. once installed, this smoke hood cut down concentrations of respirable Source: ANPED 2005. particles by up to 80 percent, from more than 4300 mg/m3 to about 1000 mg/m3. Source: WHO 2006c. 50 tal health interventions. In rural Kenya, for example, women Involving stakeholders early in the process of decision making the results. This may require building some research capacity collaborated with an international NGO to design a low-cost may also help implement politically difficult policies with in developing countries. For example, Danida has successfully solution--a smoke hood--that not only reduced their expo- minimal social unrest (Box 23). If the general public is given provided budget support for a program of comprehensive sure to indoor air pollution but also helped the local economy information about how a particular practice or environmental capacity building on intersectoral and intercountry Health by having local artisans build them (Box 21). risk is affecting their health and they are brought into the Impact Assessments (HIA) in the Mekong Basin. consultationprocess,theywillnotonlysupporttheintervention, Local governments are in a particularly strong position to but will most likely demand it. International as well as national partnerships can help mobilize facilitate stakeholder involvement and participation at the concern and commitment for environmental health actions to grass-roots level. Box 22 illustrates how local governments-- Involvement of research institutes and local universities is achieve the MDGs. Such partnerships include, for example, working directly with affected communities in partnership important as they can support research on linkages between the Water, Sanitation and Hygiene (WASH) initiative, led by with NGOs--have successfully improved slum sanitation environmental health and poverty, help analyze data to make the Water Supply and Sanitation Collaborative Council; the in India. decisions,designnewinnovativeprojects,andhelpinmonitoring Global Handwashing Initiative, and the Water and Sanitation Box 22. Slum Sanitation in Mumbai, India: Building Sustainable Partnerships approximately 55 percent of the population of mumbai lives in slums. Surveys show that 80 percent of the 9,700 "We don't have influence public toilet blocks were not functioning and hardly meet 50 percent of the total demand. over the hospital because they the Slum Sanitation Program (SSP) decided to tackle the issue by implementing a framework based on a demand-driven and participatory approach. it adopted a learning-by-doing capacity-building strategy. at the end of the pilot phase, the program moved toward an innovative partnership between the municipality and communities. the municipality provided don't take our advice" initial capital to build community toilet blocks, while the community would take full charge of operation and management. the municipality also provided slum dwellers with information packages on hygiene, program implementation and ­ Poor people in Mtamba, Malawi management, the construction of the community toilet block, and the provision of complementary utilities such as water and electricity. nGos also participated by building the toilet blocks with community inputs. the first lesson learned from this case study is that stakeholder partnerships are the key to success. Second, ensuring that local communities take charge of management is key to the sustainability of the program. third, to facilitate and speed up implementation, it is important to work across complementary government institutions/departments to guarantee the mainstreaming of all the necessary bureaucratic procedures. Fourth, an integrated approach to the provision of a wider set of environmental services (including water and electricity) is needed. last, a solid mechanism for initial assessment and ongoing monitoring and evaluation is important to support the implementation process, evaluate the impact on the ground, and provide lessons for scaling up. Source: Nitti and Sarkar 2003. 51 Box 23. Dhaka Two-Stroke Three-Wheelers Phaseout three-wheelers with gas-fueled two-stroke engines, nicknamed "baby taxis," provided useful point-to-point transportation for passengers but were a major source of particulate and hydrocarbon air pollution in Dhaka, Bangladesh. numbering around 50,000, their emis- sions were exacerbated by the excessive use of inferi- or-quality lubricant (called straight mineral oil). While technical solutions to reduce and even eliminate this pollution could be designed, implementing such a solu- tion was considered nearly impossible, as made clear at an initial stakeholder's consultation meeting. a five- year multipronged approach was launched to better understand the issues and agree on possible solutions. the plan was to learn and share all information with stakeholders in a transparent manner. media coverage of activities assisted in raising awareness of Citizens of Dhaka; without this nGo's support, an eventual phase- out would not have occurred. as a result of the actions mentioned above, a complete ban on all two-stroke baby taxis began in Dhaka on january 1, 2003. Because of prior consultation in prepa- ration for the ban, there was minimal social unrest, even Photo: Curt Carnemark though some of the drivers were displaced. the public response as reported in the media and polls has been overwhelmingly positive, citing much cleaner air along traffic corridors in Dhaka. the weekly average before and after removal of baby taxis shows a 40 percent drop in the average Pm2.5 level. this reduced the health impact for the public, in particular the baby-taxi drivers, who were breathing the pollution over 16 hours a day. Source: World Bank. 52 the state accountable; examples include citizen monitoring Box 24. Sri Lanka: Collaboration for Box 25. Reinforcing Social Accountability of public services, participatory expenditure tracking, social Urban Air Quality Management for Improved Environmental Governance auditing,independentbudgetanalysis,civilsocietymonitoring in India of the impact of policies, and so on (Malena et al. 2005). The in response to deteriorating air quality in Colombo, social accountability initiatives regularly rely on actions on the the World Bank supported the government of Sri in recent years, india has made progress in part of government, the media, and other societal actors that lanka through a grant for institutional development accessing the judiciary to address environmental increase transparency, improve access to public information, that helped to build cross-sectoral capabilities not only pollution issues. a landmark case on air quality or enhance the enabling environment for civil engagement in government agencies, but also in the private sector in Delhi firmly brought this issue to the attention of (Malena et al. 2005). Through allowing legal recourse to and civil society. a key achievement was to facilitate government policymakers and emphasized their justice, governments can lay the ultimate foundation for social national consensus to move the target date for eliminat- accountability to the general public. in the early accountability. Box 25 illustrates an example from India of ing leaded gasoline from 2010 to mid-2002. the grant 1990s, an indian nGo asked the Supreme Court how civil society organizations (CSO) can put pressure on also supported the establishment of the air resource to compel the Delhi government to enforce the clean local governments to enforce its regulations by appealing to management Center, which has had considerable suc- air laws that had been passed some 15 years earlier. the judicial system and sustaining a media campaign on the cess in achieving cross-sectoral coordination, leading after a long and sustained campaign--which used effects of air pollution, thereby increasing people's awareness. to development of a program of measures to improve quantitative information on health damage effects, urban air quality, including the Clean air 2005 Plan, including estimated mortality rates, as well as an InEurope,civilsocietyorganizationsfoughttogetlawschanged and the introduction of initiatives to control vehicular effective public awareness campaign through the so that they could have information and legal rights when their pollution through emissions standards, regulation, fuel press--the Supreme Court in 1998 issued its first environment and health was damaged (Stephens and Bullock pricing, import policies, and public awareness. comprehensive mandate for tackling air pollution. 2000). The Aarhus Convention on Access to Information, Public Participation in Decision-making and Access to Justice in Environmental Matters is the first international agreement Source: Martin 2004. Source: World Bank 2005b, Blair 2008. that takes forward both participation in decision making and social accountability (Stephens 2007). The United Nations Program. The new Global Water Challenge, supported for intersectoral collaboration through their projects and Economic Commission for Europe (UNECE) describes the by the United Nations Foundation, is a network of local programs. Pressure to improve environmental health issues convention in the following terms: "The Convention adopts and international nongovernmental organizations, private may also come from NGOs and civil society, as in the case of a rights-based approach. Article 1, setting out the objective of sector companies, government officials, and community Mumbai (Box 22) or from the international community, as in the Convention, requires Parties to guarantee rights of access representatives that support national programs and has already the Sri Lanka example (Box 24). to information, public participation in decision making, and begun to reap the fruits of effective collaboration. access to justice in environmental matters. It also refers to the goal of protecting the right of every person of present and The impetus for improved collaboration and strengthened aCCeSS to jUStiCe future generations to live in an environment adequate to health partnerships can come from within country governments, but and well-being, which represents a significant step forward in may also come from other voices in society as well as external Social accountability refers to the broad range of actions international law. These rights underlie the various procedural actors. Multilateral and bilateral donors can provide incentives (beyond voting) that citizens themselves can use to hold requirements in the Convention." (United Nations Economic 53 Commission for Europe 1999). The convention entered into force on October 30, 2001 and was hailed as a milestone of environmental democracy. Other resources: This chapter has outlined the importance of how to build Participatory poverty assessment (PPa) collects poor stronger constituencies for environmental health issues people's views regarding their own analysis of through provision of information, public participation in poverty and the survival strategies that they use. decision making, and access to justice on environmental See: http://go.worldbank.org/QaaSG4tk80 matters. In the longer term, these constituencies are crucial to more effectively raise the profile of environmental health the access initiative: http://www.accessinitiative.org issues and ensure their integration into national development Partnership for Principle 10: http://www.pp10.org/ plans and poverty reduction strategies. aarhus Convention: http://www.unece.org/env/ pp/contentofaarhus.htm Water Supply and Sanitation Collaborative Council: http://www.wsscc.org/ Global Water Challenge: http://www.globalwaterchallenge.org/ Global Handwashing initiative: http://www.globalhandwashing.org/ Water and Sanitation Program: http://www.wsp.org 54 Photo: Prabir Mallik Ray Witlin 55 5. moving towArd Action The previous two chapters have discussed how national and countries is frequently financed by multilateral and bilateral capacity relating to environmental health for cross-sectoral local government actions can facilitate the integration of agencies. Officials may wish to draw upon this support as they policy integration. This means supporting the development environmental health issues in development planning and prepare their development agendas. More broadly, resources of a country's national policy formulation, resource allocation poverty reduction strategies processes as well as to help build applied to programmatic budget support and technical mechanisms, and systems and procedures to set targets, and long-term constituencies for environmental health issues faced assistance for institutional capacity building can also be then monitoring the results (Shine and Paris 2007). by the poor. Given the nature of the interventions and their utilized by countries to strengthen institutions and governance impact on improving the well-being of the poor, this chapter mechanisms linked with poverty-environment-health issues. Specific reference is also made in the Paris Declaration to the briefly discusses how government officials can also draw upon The Paris Declaration on Aid Effectiveness establishes global need for specific capacity in areas such as environmental eco- the support of other actors, namely NGOs and CSOs and commitments for donor and partner countries to support nomic analysis to (a) better quantify the economic and financial multilateral and bilateral institutions, to support their efforts. reforms intended to "increase the impact of aid in reducing value of improved environmental health issues, and (b) make a poverty and inequality, increasing growth, building capacity stronger case for environmental health management in negotia- "When food was in abundance, and accelerating achievement of the MDGs" (Paris Declaration tions with economic, finance, and planning ministries. Another 2005). In particular, the Paris Declaration recognized the challenge is to support CSOs and multistakeholder forums relatives used to share it. In importance of strengthening institutions for development. involved in informing and influencing policy debates that bring environmental health to the forefront (Shine and Paris 2007). these days of hunger not even The Paris Declaration's main principles are (a) ownership, so that partner countries exercise effective leadership over their development policies and strategies and coordinate develop- relatives would help you by ment actions; (b) alignment, so that donors base their overall support on countries' national development strategies and pro- giving you some food." cedures; (c) harmonization, so that donor's actions are more harmonized, transparent, and collectively effective; (d) manag- ­ A young man, Nchimishi, Zambia ing development results, which emphasizes the need for results- (Dying for Change 2002) oriented policies and programs and the need to regularly moni- tor actual outcomes to identify corrective measures as needed; and (e) mutual accountability, so that both donors and partners are accountable for developments (Shine and Paris 2007). HoW DonorS anD nGoS Can SUPPort There are several key future directions highlighted by the Paris Government eFFortS Declaration to support action on cross-cutting issues such as environmental health. The shift toward program-based ap- Many of the tools described in Chapter 3--such as cost-benefit proaches offers potential when accompanied by other develop- analysis, cost-effectiveness analysis, cost of degradation, and ment cooperation instruments that build institutional capacity. public expenditure reviews--are tools whose use in developing Development agencies can help by strengthening institutional Photo: Tran Thi Hoa 56 The involvement of NGOs and CSOs to support the building Despite this, the institutional problems associated with work- "At least my daughter's of longer-term constituencies is also crucial. This suggests that ing across disciplines--including environment, health, educa- activities (often by other NGOs)--such as through The Ac- tion, energy, water, sanitation, and hygiene--mean that a ho- cess Initiative--that aim to strengthen NGO capacity within listic approach to poverty and environmental health remains a education will ensure that she a developing country to be better advocates for these issues is challenge. Making progress in reducing environmental health also important. risks that work toward poverty reduction and sustainable de- will get a groom who comes velopment requires changes in the array of policies, tools, and The Poverty Environment Partnership (PEP), as a network of institutional priorities. Government departments--such as from a home with a toilet." multilateral and bilateral development partners as well as major finance or planning or a mayor's office--are particularly well- NGOs, is well-positioned to help support governments in such suited to playing a coordination role to address the environ- ­ Manjulaben, age 38, a daily wage efforts. At a broad level, PEP can (a) make the case for link- mental health agenda. ing environmental health to poverty reduction by highlighting laborer from Nagalpur village, its economic importance; and (b) incorporate environmental Thisreporthasoutlinedtwostrategiesfortacklingthisenormous Gujarat state, India (Dying for health into existing tools, programs, and investments by PEP and important agenda for the world's poor. This two-pronged members to enhance the quality of life of the poor. approach focuses on (a) identifying the entry points and tools Change 2002) that public officials can use to integrate environmental health ConClUSion issues important for the poor into development plans and poverty reduction strategies, and (b) discussing the elements There is an immediate need to tackle environmental health that are important to help build longer-term constituencies issues as part of any strategy to reduce poverty. Problems such to continually raise the importance of these issues on the as unsafe water, sanitation and hygiene, and air pollution development agenda. Governments, NGOs, and the private are major contributors to the worldwide disease burden. sector can play a role in facilitating these processes. Poorer communities are disproportionately affected by these issues, which seem likely to worsen with climate variability National action by governments supported by other part- and change. 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