Articles > Dr Yasmin von Schirnding
Integrated Strategies for Improving Health and Environment Conditions in Low Income Urban Areas
Dr Yasmin von Schirnding, World Health Organisation
This article briefly highlights current trends in environmental health conditions in urban areas, emphasising issues of global relevance to the health of the poor in the context of changing health and environment concerns at the turn of the millennium. The role of the health authority in environmental health is highlighted, issues regarding administration of environmental health services discussed, and intersectoral approaches for environmental health advocacy and promotion highlighted. Implications for implementation of strategies and capacity building are discussed.
With massive urbanisation occurring on a global scale, international interest and concern has centered increasingly on the state of the environment and human health in cities. Worldwide, cities are growing fast - the scale and pace of current urbanisation is unlike that of any other time in history. The urban population will continue to grow, with most of the growth occurring in developing countries (WHO 1997). Currently Africa and Asia have the lowest levels of urbanization, but are experiencing the most explosive urban growth rates. It is estimated that by the year 2025, over 5 billion people will live in cities. Already, in the developing countries of the world, there are more than 200 cities with populations of one million people or more (Dowdeswell 1996).
Whilst age-old public health hazards such as inadequate and unsafe food and water, microbiological contamination of the environment, and overall poor sanitation and environmental hygiene are still prevalent in urban (and rural) areas, in addition, new environment and development problems have emerged, some of which appear to threaten the entire ecosystem. High population density and the concentration of industry in the rapidly growing cities of the world is leading to significant increases in problems such as air pollution from households, industry, power stations, and transportation.Water pollution, inadequate sanitation, crowding, and poor quality housing are other concerns for many cities. Around 30 to 60 % of the urban population in low-income countries is believed to live in poor quality housing (WHO 1997).
Cities have a very significant impact also on the broader hinterland and global environment. Whilst the lines that separate a city, country or region are becoming increasingly blurred, it is also clear that the fate of cities will have a major influence on the fate of nations, and of the planet (Dowdeswell 1996).
It has become evident that whilst cities are associated with numerous positive benefits, related for example to the provision of increased job opportunities and essential services and facilities, many environment, health and development problems have reached near crisis dimensions in cities around the world. Urban growth has exposed populations to serious environmental hazards and has outstripped the capacity of municipal and local governments to provide even basic health services. There is the potential for serious health problems to escalate, and for many of the profound gains in health status which have been achieved over the past years, to be reversed. For example over the past 50 years, in many countries, the incidence of infectious diseases has declined dramatically. Childhood mortality and morbidity has been greatly reduced by better control and prevention of infectious diseases. In many places reduced levels of pollution have contributed to health gains.
Not all regions of the world have shared equally in improvements to health however. In many instances the health gaps between countries and within countries, are widening. Despite unprecedented wealth creation worldwide in the past two decades, the number of people living in absolute poverty (between one quarter and one fifth of the world's population) is growing steadily (WHO 1997). Poverty and inequity is not only a concern for developing countries. The trend in recent years for an increasing gap in most countries between the economic resources available for the top 20% of earners and the bottom 20%, has highlighted that poverty and its associated poor living and working environments is still an important problem in developed countries (UNDP 1996). Even within rich countries, the poor suffer much worse health than do the better off.
The worlds poorest people live predominantly at the margins of expanding urban areas and in remote and often ecologically fragile rural areas. The former is the concern of this article, nevertheless it should be emphasised that some of the health and environment problems faced by people in rural areas are not dissimilar to those faced by people living on the fringes of major cities. Indeed in some instances there is a process of "ruralisation" of urban areas underway, and of "urbanisation" of rural areas. The adverse environmental conditions in both settings expose poor populations to health risks from inadequate water and fuel supplies, waterborne diseases, ambient and indoor air pollution, and to natural and technological disasters (WHO 1997). Those living in poverty include a high proportion of women, children, refugees and other displaced persons who lack access to education, employment, healthcare and other basic resources.
The urban poor live in unsafe and over crowded housing, which lacks access to safe water, or to excreta disposal. They are much more likely than the wealthy to be exposed to pollution (both indoors and outdoors), traffic, industry (associated with both the formal and informal sector), and other risks at home, work, and in their communities. They are more likely to consume insufficient food, or food of poor quality, making them even more vulnerable to the ill-health effects from environmental exposures.
Poor children are particularly affected by adverse environmental conditions. Not only are they more exposed to health threats in the environment, they are also more vulnerable to the ill-health effects stemming from problems such as a lack of clean air and water. In the US and parts of Europe, lead poisoning illustrates the unequal burden of risk borne among poor urban children, who are not only more exposed to sources of lead in and around the home environment, but who also are more affected by the toxicity of lead.
The urban poor frequently suffer from a double burden of disease, with problems related to poverty and a lack of basic services, as well as with the impact on health of large scale and rapid industrialisation, urbanisation and technological development. Indeed, it is often difficult to distinguish traditional risks from new and emerging risks associated with industrialisation. For example pesticides and faeces may contaminate the same water supplies. Air pollution may stem simultaneously from burning dirty household fuels and industrial use of fossil fuels. Nowhere is this duality of health and environmental burdens more evident than in low-income areas on the peripheries of cities.
It is well documented that exposures related to inadequate water and sanitation, excreta disposal, polluted air, particularly indoors from cooking and heating fuels used, are associated with a wide range of diseases, both infectious (ARI, diarrhoea, vector-borne diseases) and non infectious. Diarrhoeal diseases are 5 to 6 times more common in developing countries than in developed countries (WHO 1997). Such diseases are closely related to poor sanitation and hygiene, and the resultant contamination of food and water. It is estimated that upwards of 1100 million people lack adequate and safe drinking water, and around three times this many people lack adequate sanitation (WHO 1997).
People may be exposed to especially high levels of air pollution in developing countries, where biomass burning and use of fuels such as coal and kerosene for cooking and heating still prevails, both in urban and rural areas. This is particularly prevalent in India, China and sub-Saharan Africa. It has been estimated that about 3 million deaths occur globally each year (comprising around 6% of the 50 million deaths that occur annually) (WHO 1997), due mainly to suspended particulate matter.
Acute respiratory infections are a leading cause of death in children under the age of five, killing more than four million people per year, and accounting for over 8% of the global burden of disease (WHO 1997). The indoor environment is an important risk factor in this regard, particularly pollution from domestic fuel burning, and overcrowding. Indeed, the overwhelming proportion of deaths from air pollution occurs in developing countries, mainly from indoor air pollution associated with domestic fuel use. Widespread exposure of children in all countries to environmental tobacco smoke adds additional risks to child health.
In the next millennium clearly one of the major challenges will be poverty alleviation, both urban poverty and rural poverty. With gaps between rich and poor increasing, it is likely that there will be more social disruption, violence, and psycho-social stress, manifested most profoundly in urban areas. Rapid urbanisation and migration will contribute to the development of megacities and peri-urban settlements, as well as to the growth of secondary cities. This will result in a range of physical and social ill-health conditions, including depression, anxiety, and the breakdown of physical and social support systems.
There are also significant epidemiological changes underway, with a continuing high incidence of infectious diseases, increasing incidence of non-communicable diseases, injuries and violence.With populations living much longer, and with more elderly, it is probable that there will be an increase in non-communicable diseases, such as cancer, heart disease and tobacco related disorders, as well as disability and mental ill-health disorders. The determinants of rising cancer and heart disease death rates in cities, tobacco, high fat diets and decreased physical activity, are closely related to profound changes in lifestyle in large part marketed and actively encouraged by the tobacco and fast-food industries. Increasing levels of trauma and violence in cities are related to increased social class inequities, widespread access to weapons and the greater use of alcohol.
Infectious diseases like AIDS, malaria and TB will remain important threats to global ill-health in urban and rural areas alike. There is likely to occur also the simultaneous emergence of unknown, new pathogens. And ARI, diarrhoea and other traditional diseases of childhood will continue to prevail. The divide between urban and rural, and between global and local, is becoming increasingly blurred, nevertheless all of these ill-health conditions will impact increasingly on the urban poor, and in many, if not all instances, urban living conditions are expected to make a significant contribution, both indirectly as well as directly, to the incidence of these ill-health conditions.
What can be done, and what sort of strategies are needed to improve health and environment conditions in low income urban areas? Certainly, there will be a need, more than ever, to form partnerships between the public and private sectors, to work across sectors such as environment, health, housing, transport, energy, to better involve communities in decision-making, and to devolve decision-making to the lowest level feasible, along with resources. Intersectoral efforts are particularly important in order to address such complex, inter-related, cross-cutting problems, whose determinants or solutions lie outside the direct control of the health sector. It is necessary to make optimum use of limited resources and to draw on the expertise, knowledge and experience of all relevant sectors of society in order to develop solutions which are sustainable and implementable.
In this context, intersectoral action is no longer a "nice to have" add-on factor to a long list of health and environment strategies, it is necessary and indeed may be the only way in which there is a chance of successfully solving health and environment problems facing us today and in the future. Intersectoral action is needed to address the driving forces (for example of economic development) which ultimately influence health and environmental conditions (through policy development and implementation), the pressures placed on the environment (for example through adequate housing and services provision, cleaner production methods and emissions reduction), the state (quality) of the environment (through pollution control devices for example),human exposures (through legislation, behaviour modification, personal protection), and the resultant health effects (through medical care of those who become ill) (WHO 1997)
It is important to recognise that health cannot be considered in isolation from human and social development. The purpose of human development is to permit people to lead economically productive and socially satisfying lives. This requires progressive improvements in the living conditions and quality of life enjoyed by all members of a society. On the one hand, healthy people and the energy they expend in intellectual and physical labour are vital for successful development. On the other hand health is an important outcome of development because it depends first and foremost on such factors as availability of safe and nutritious food, uncontaminated water, a clean environment, decent shelter and an effective health care system which places emphasis on prevention (Kreisel 1988).
Good health is therefore both a resource for, and an aim of, sustainable human development. Indeed, the health of people, particularly the most vulnerable, is an indicator of the soundness of development policies. Without good health, individuals, families, communities and nations cannot hope to achieve their social and economic goals. Thus, economic and technological progress needs to be compatible with the protection and promotion of the quality of life for all.(WHO 1998). Promoting economic growth, alleviating poverty, reducing population pressures, achieving satisfactory levels of education and health, and protecting the environment, are mutually supporting objectives in the long run.
Whilst there are shared global and transnational problems, each country, region and community also faces its own unique problems, the solutions to which will be influenced by factors such as their resources, customs, institutions and values (WHO 1993). This implies that a combination of global, national and local strategies need to be developed, which must be harmonised. Strategies need to be created that address underlying systemic problems rather than symptoms, which factor in economic, social and environmental factors, and which fully engage all relevant interest groups and service users.
In order for intersectoral strategies to succeed, it is vital that there is a clear recognition of the respective responsibilities and roles of the key sectors and actors.One of the key factors to address in developing integrated strategies to improve health and environment conditions in urban areas, is the delineation of responsibilities in terms of environmental health. WHO defines environmental health broadly as being concerned with those factors in the environment which have an impact on health. This includes the direct pathological effects of specific chemical, physical and microbiological agents, and also the effects of the broad physical and social environment, such as housing, urban and rural development, land use and transportation. The definition is significant in that it encourages not only a narrow agent-specific focus in dealing with environmental health hazards, but stresses the need also to look at the broad impacts of various development sectors in general, and how social issues such as poverty impact on the physical environment.
At a time when health and environment issues are receiving more attention than they have in the past (Doll 1992), it is ironic that the health sector in particular has been slow to embrace developments in the field There has in fact been a trend in many parts of the world for the health sector to abdicate much of its responsibility for environmental health. There are many examples of environmental health responsibilities having been gradually eroded from under the control of health authorities, for example food safety, chemical safety, waste management and pollution control. Privatisation of many essential environmental health services has contributed to this process. The health sector has lost organisational responsibility for many environmental health activities at the national, regional and local levels (Gordon 1992).
One reason that some health authorities have chosen to remove themselves from responsibility for environmental health is that environmental health is perceived as being associated with problems which are unmanageable, the roots of which frequently lie outside of the health sectors direct responsibility. Environmental health is broad and difficult to define in terms of its boundaries and its complexity, and it straddles the broad areas of environment and health, not falling into the mainstream activities of either the health or environment sectors. Thus, neither sector has taken clear responsibility for it. Environmental health is intrinsically part of environmental management, in which many development sectors and agencies have important roles to play. It is also an intrinsic part of public health, and the health system at large. The challenges inherent in environmental health today however have become so complex and diverse that the health sector has found itself increasingly unable to define coherently specific responsibilities in this area. The result has been that the public health basis of environmental control is being gradually eroded.
Given the increasing pressures and responsibilities of health authorities to deal with all manner of pressing urban health problems and diseases, the question that needs to be asked is, what attention should they be giving to environmental health? Is the health sector in the business of environmental management, and if so in what way? Environmental health should be part of the responsibility of all development sectors, however the health sector , it is argued, has these key responsibilities at least:
• monitoring of overall (urban) environmental health status, including ensuring that environmental health status is monitored at the level of the city, neighbourhood or district level, and intra-urban and intra-district differences are detected (this is important in terms of shifting the focus of regulatory control in many countries from low risks which affect often only relatively small percentages of the population);
• estimating the contribution that various social and environmental factors are making to urban health problems;
• analysing urban environmental health needs and requirements in various development sectors that are significant for health, such as housing, local government, transport, industry and so on, with consideration of the health opportunities offered by each sector;
• formulating specific urban environmental health policies, health-related legislation and standards, and targets, in partnership with each sector (such as for water, sanitation, local government, education, industry, labour; advocating, facilitating and enabling urban environmental health issues to be addressed in the work of competent agencies, and promoting environmental health generally;
• evaluating preventive and curative urban environmental health services, and their implementation at various tiers of government;
• supporting regional and local environmental health service delivery and providing such services as are not feasible to provide at other tiers of government;
• supporting the development of research which may be necessary in order to better understand, assess and manage urban environmental health risks.
Administration of Environmental Health Services
The nature and complexity of urban environmental health problems and the strategies needed to address these within various local contexts will differ, and will determine to some extent where environmental health services are best placed. In some contexts, prime responsibility for environmental health might be best placed within the health department, in others not. In the case of peri-urban areas, environmental health service delivery frequently falls under the responsibility of a provincial, regional or national authority, rather than under the authority of local government. In the case of very large urban metropolises falling under local government this may include responsibility for environmental health service delivery in peri-urban areas. Frequently however, there are no clear lines of responsibility delineated when it comes to environmental health service delivery, particularly in cases of "illegal" settlements, where services may not be provided by the government.
In the case of the development of district health systems in many countries, and the parallel development outside of the health sector of environmental management systems, the placement of environmental health functions is a fundamental issue which needs to be urgently addressed.
There is an increasing recognition occurring of the interdependence of ecosystems and health systems (Lancet 1991). Indeed, many basic principles of environmental management and ecology, such as working within natural systems, maintaining diversity and variety, ensuring recycling and using renewable resources, balancing population and resources, are applicable to new environmental health thinking (Ashton 1991). It is also clear that advocates of personal health and health care are very different from environmental health advocates (Gordon 1992). Ultimately it may well be the case that one will see an increasing trend at the local level towards the clustering of personal health and health care services with related community services, and that of environmental health services with environmental protection and planning/development departments.
What is needed is a precise delineation of sectoral responsibilities at different tiers of government, based on integrated, intersectoral policies and plans. Regardless of the administrative setup for environmental health services in any one setting, the involvement of all tiers of government and all sectors of the community is regarded as being fundamental to ensuring that programs reflect local priorities, have widespread support, and are sustainable. Whilst government has the main responsibility for ensuring healthy living environments, it can only do so by working in collaboration and partnership with other stakeholders. Indeed A21, the Global Programme of Action on Sustainable Development called on governments to enter into a dialogue with citizens, local organisations and private enterprises and adopt A21 plans of action. This underscores the fact that the traditional service roles of government, the private sector, community organisations and trade unions have all rapidly changed in recent years. This is a result of factors such as fiscal constraints, constitutional and legal reforms, resource scarcity, globalization of economies and liberalization of markets (ICLEI 1996). Government has thus seen the need to adopt a partnership approach to service provision and planning.
New participatory approaches and strategies all recognise the fundamental importance and central role that local communities must play in bringing about change. This implies starting a process of decentralisation. Indeed one has now seen a global trend towards decentralised government services and more emphasis on environmental and health actions by non-governmental organisations and the community itself.
INTERSECTORAL APPROACHES FOR ENVIRONMENTAL HEALTH ADVOCACY AND PROMOTION
This is an area in which a health authority should play a leading role. This would include support to local governments in undertaking local agenda 21, "sustainable cities", healthy city and healthy village type projects, in order to put health on the agenda of decision?makers, to build support for local public health action, and develop local participatory approaches for addressing health and environmental issues.
Since 1992, more than 1300 local authorities from 31 countries have responded to the local Agenda 21 mandate by developing their own Agenda 21 action plans (Strong 1996). Many of these feature health- and health- related objectives and activities. A number of international, regional and local initiatives and networks to improve conditions in cities have emerged, which involve WHO as well as other UN agencies such as UNCHS/UNEP, UNDP and the World Bank. Examples include the WHO Healthy Cities Project (WHO 1995,1996), the LIFE programme of UNDP, UNDP/World Bank/UNCHS urban management programme, the Sustainable Cities programme of UNCHS/UNEP, CITYNET / Asia Pacific 2000 programme of ESCAP/UNDP, the Megacities programme, the former Model Communities programme of ICLEI, and many others. In Europe, in 1994, the "European Sustainable Cities and Towns Campaign" was created to assist local governments to establish Local Agenda 21 processes in their cities.
There is an attempt now to bring these various movements together - this is reflected in growing trends of international meetings addressing issues of healthy and sustainable cities, environmentally sound and healthy cities and so on. The idea is to attempt to better integrate environmental, social, economic, health and land-use planning at the local level.
The UN Center for Human Settlements (UNCHS or Habitat) has been administering a "Sustainable Cities" program since 1989, in collaboration with the UN Development Program (UNDP) and the UN Environment Program (UNEP). The main goal of this project is the implementation of Agenda 21 at the local level. It is currently working with local governments in Asia, Africa, Latin America and Eastern Europe. The ultimate aim is to develop participatory environmental management and planning practices, encourage sound natural resource management and reduce environmental hazards that threaten the sustainability of urban growth and development.
The first global meeting on implementing the urban environment agenda took place on the eve of the HABITAT 2 conference, and strategies for improvement of environmental information and technical expertise, better implementation of policies and strategies, enhanced institutional and participatory capacities and the more effective use of scarce resources for effecting change were recommended. The meeting resulted in the adoption of the "Istanbul Manifesto", which will help cities and programmes in the follow-up and implementation of the Global and National Plans of Action. It is also seen as an important step in the process of city-driven global support activities which will define local efforts and international cooperation in matters concerning the urban environment.
The concept of addressing issues at the local level in partnership with key stakeholders is reflected also in the Healthy Cities Movement initiated over a decade ago by the WHO. Healthy cities-type approaches are diverse, with some addressing comprehensive community development initiatives on a city-wide basis, incorporating a planning component, and others addressing the implementation of more specific community-based projects. The project as a whole is purposively political and process-oriented in approach, promoting political committment and advocating fundamental change in local government and its relationship with communities. The approach is of particular relevance in countries where health is not a local government function. Indeed, healthy communities and healthy cities-type initiatives have been particularly successful in Canada and the UK, both examples of countries where public health functions were taken away from local municipalities and placed with regional authorities.
Networks of cities in all regions of the world have been formed. City "twinning" initiatives have also become commonplace, and are based on relationships between cities that have particular ties based on language, culture, level of development, political history and so forth. An approach used in Europe has been to develop "Multi-City Action Plans", where networks of cities address simultaneously a particular issue such as water quality or air pollution for example. The Healthy Cities programme and approach has also been applied to a number of rural areas as "Healthy Villages" projects.
These sort of participatory planning initiatives typically involve a wide variety of stakeholders who are increasingly becoming involved in all stages of policy making and implementation, from the initial definition and prioritisation of issues, to the collection and analysis of information, to the development and implementation of plans. In order to ensure long standing committments, it is important that stakeholders are properly involved in the definition of problems, as well as in problem resolution.The concerns, needs and preferences of all relevant interested and affected parties, including the service users need to be articulated. Local partners bring their knowledge, expertise and perceptions of the problem, and can also frequently benefit by gaining a better understanding of the technical and financial constraints which might have a bearing on subsequent plans developed.
The nature of any partnership set up involving different stakeholder groups normally depends on the scope of the planning initiative, its goals and objectives. The initiating institution (for example the local municipality), in consultation with potential stakeholders might form a preliminary stakeholder group, which could be broadened and formalised following a more formal consultation process. This might proceed through a series of workshops with identified target groups. What is important is that the membership be broad- based, in order to facilitate the involvement of as many relevant sectors as possible. It is essential that there is a clear mandate and authorisation from the government authority so that there is democratic accountability, and also a link with the planning activities of government.
The structure of the partnership has been found to be critical in terms of providing political links and direction, and the form for facilitating intersectoral coordination and community participation. Adapting committee structures to facilitate links to existing political and community structures has been found to be important. Stakeholder groups can range from round tables and forums which have relatively short-term mandates, to more formal statutory committees and councils with long-term mandates. They can be formed from within an existing government structure, or from outside.
Once the formal stakeholder group has been formed, it has been found useful for more specialised working groups to be established. They could deal with particular issues, or they could be structured along district or neighbourhood boundaries, or they could be divided according to responsibility for different elements of the planning process (such as issue identification, action planning, or evaluation). This is often an important component of the intersectoral effort, as frequently it is difficult to sustain the interest and involvement of groups with such diverse interests and backgrounds. Specialised working groups can help to focus the interests and energies of disparate groups. At the national and local level, many countries have established intersectoral committees for follow-up to Agenda 21. Through these fora, including the task forces and working groups set up to address specific issues, the health sector has had the opportunity to exert a significant influence.
It is important to engage stakeholders early on in the planning process. The process of indicator development has proved to be a very effective way of ensuring public participation in sustainable development issues. The process is often as important as the indicators themselves. Communities and non-governmental organisations (NGOs) often have a major stake in developing indicators, not only for their own activities, but also to monitor the activities of government, and of other parties, ensuring that policies are implemented, that governments (and other partners) meet their obligations, and remain accountable. This is normally most productive where communities and governments plan in partnership. Many community-based organisations (CBOs) and NGOs have used indicators in funding applications, for example in establishing their bona fides, in demonstrating their monitoring and analytical capabilities, their organisational success, responsiveness and accountability (UNCHS 1995).
Environmental Health Surveillance and Risk Management
There is frequently inadequate information available to support decision-making and action, based on the systematic identification of urban issues, problems and assessment of needs and priorities. Problems and issues should normally be defined in qualitative as well as in quantitative terms, and indicate sector responsibilities. The analysis of needs and the priority-setting process thus involves both the views of the communities involved (that expresses fully the local perception of the problems and issues), and a technical assessment based, for example, on available urban health statistics and known epidemiological linkages between health status and environmental and social conditions. A variety of methods and techniques can be used to engage partners in the identification of issues, and in data collection.
Priority urban health and environment issues will naturally differ from place to place, and will depend in part on the particular priorities and capacity in respect of data collection and analysis that may exist in any one setting. Priorities may also change over time, particularly as different stakeholders get involved in the process, whose perceptions of problems may change over time.
One of the main functions of a health authority is to contribute to the proper identification, assessment and management of health risks in the environment. It is a prime function of the health authority to obtain the necessary information relating to health status and its determinants. The collection of routinely available data relating to health status would be done predominantly at the local level. In addition, there will normally be a need for a national surveillance system to be set up, at least for selected priority diseases which are environmentally- related, or where the environment plays the major role in etiology.
Health-related environmental monitoring would normally be done at the regional or local level, with a health authority playing a key role in the design of monitoring systems to ensure that the exposure information is of relevance from a health point of view, and not merely from a point of view of environmental control. This would entail, for example, ensuring that air monitoring strategies take into account where people are most likely to be exposed, and focuses on high risk groups, such as young children, who are likely to be most influenced (for example) by the indoor environment, which is poorly regulated.
A key role of the health authority in respect of risk assessment and management would be in linking any information available on urban exposures to health outcomes, so that risks can be better understood and managed. Risk assessment is clearly of vital importance in order to form the basis for deciding to what extent various sectors might be responsible for identified risks, and in order to more appropriately assist in the development of appropriate health policies for various sectors. Commonly it is found that there is no mechanism in place to ensure coordination at the national, regional and local levels in respect to the evaluation of environmental health effects of hazards, or the development of adequate national reporting systems. Equally, mechanisms are frequently not in place to ensure that such information once obtained is transmitted to the various sectors for action.
Policy and Plans Development,and Evaluation
The creation of stakeholder groups, and the identification and analysis of priority issues, form the basis for the subsequent development of policies and strategic plans of action. Many countries around the world have been relatively slow to develop coherent urban environmental health policies. This has been due in part to the fact that there are often gaps in knowledge, and the perception that there is insufficient evidence on which to act (Lancet 1996), as well as to the fact that policies are increasingly needed outside of the health sector to deal with the new and emerging problems. The health authority has a key role to help ensure that the policies and activities of various sectors and organizations contribute positively to health protection and promotion. This requires it to help develop health policies for various sectors outside of health.
Of equal importance is that implementation strategies - and not only the agenda - are developed in partnership with relevent agencies (Walker 1994). Of importance from the point of view of facilitating broad action, is that action strategies and committments of the different stakeholders are identified, so that they can work as partners in achieving the various goals, objectives and targets (measureable committments to be realised in a specific time frame) of policies and plans developed. If stakeholders have not been properly involved in the development of the policy or plan, the plan may not be properly implemented, competing plans may be developed and the whole process of implementation many be undermined. Examples abound where community problems have been studied with great thoroughness, but stakeholders have not been involved in the policy formulation phase (Rider and Flynn 1992). Normally, stakeholders are not only able to define and identify problems, they contribute also to finding workable solutions, adequate funding, and techniques for implementation.
Implementing agreements in plans should include programme committments of all relevant partners, and agreements among stakeholders to undertake relevant work. They may also be useful for mobilizing resources to deal with the problems.The plan should not however be considered a "one-off" exercise that will generate all the necessary actions to solve all the problems once and for all; rather it should be seen as an on-going process of consultation, data gathering and analysis, and resource mobilization to undertake priority actions.
The final step is to implement and monitor the implementation of the plan. Often it is known what to do, but not how to do it. Ideally, monitoring should begin before project implementation, and continue during, as well as after, the implementation phase. Failure to implement plans is a common problem and one of the biggest stumbling blocks to achieving desired goals. However if the practical requirements of implementation are addressed, the plan stands a better chance of success.
Evaluation is important in terms of maintaining accountability among stakeholders and providing feedback to communities. It is important also in terms of providing information to service users and providers. Systems need to be developed whereby stakeholders report to each other on progress, and methods and tools such as indicators need to be developed to measure performance in achieving goals and targets. Two aspects in respect of the development of indicators for reporting on performance need to be evaluated - the performance of stakeholders in achieving goals and targets in the action plan, and progress in improving the actual health and environmental conditions. In order to measure real progress in improving health and environmental conditions, one would normally need to do a comprehensive audit every few years (Brugmann 1996)
Whilst intersectoral plans developed have indeed varied in scope, content and quality, the process has nevertheless been successful in promoting collaboration between various sectors such as health and environment, and in developing mechanisms for the formation of partnerships. In many instances however, strategies have proved inadequate to involve planning and finance ministries in particular, or NGOs, in the process. There is nevertheless a greater awareness of urban health and environmental problems in government, non-government bodies and in communities. There is also better recognition of the need to focus more on prevention, and broader approaches generally are being used to address environment, health and development problems.
Institutional mechanisms may need to be reorganised and strengthened, and mechanisms for inter-jurisdictional cooperation developed in implementing urban policies and plans. Decentralization of structures may be needed to facilitate community involvement and involvement of sectors, and better coordination within and between government structures and other bodies. Substantial reform of services may be needed to facilitate the implementation of intersectoral plans.
Capacity development needs to be oriented to a wide array of many different allied professions, so that they can better contribute to urban planning, policy formulation and implementation. Training needs to be multidisciplinary in nature and addressed to a wide variety of professionals, be they environmental scientists, environmental health officers, nurses, medical doctors, sanitary engineers, planners or teachers. In general, there is a need for multi-skilling in order to address the cross-cutting, multifactorial nature of environment and health problems.
In- service training at the local level is particularly important in light of decentralisation occurring worldwide, where powers and functions have been transferred to the local level, but where insufficient capacity often exists to implement activities. Training of health inspectors (or environmental health officers), needs to be re-orientated in order to address the changing priorities of urban environmental health in particular. What is needed is a fundamental rethink of the prime role of environmental health officers. Health authorities need to play a leadership role in defining the changing role of environmental health officers, and to specify what types of other environmental health professionals and ancillary support staff are needed for what types of work, in what numbers, and where.
The role of the health inspector/ environmental health officer in the context of sprawling urban metropolises needs to be looked at in relation to that of competing professionals such as pollution control officers, sanitary engineers, building inspectors, chemists, and so on. Unlike a century ago, the universal, all-encompassing role of the environmental health officer may no longer be realistic (Fulton and Sutherland 1991). What is clear is the need for better education (Sexton and Perlin 1990), and for more and better qualified environmental health personnel (Foskett 1993). There is a need for multi-skilling in order to address the cross-cutting, multifactorial nature of environmental health, as well as specialisation (Foskett 1993). According to Ashton (1991), the work of environmental health officers has become "defined and codified, frozen in relation to another era and another way of looking at the world. Its practice now seems to have become reactive and bureaucratic, rather than proactive and innovative".
The challenges for urban environmental health in the 1990s are truly formidable. The attainment of the goal of sustainable development which meets the health needs of future generations requires that we put environmental health at the top of the health and environment agenda and move from rhetoric to action.
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