The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this Organization, which was created in 1948, the health professions of over 190 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world of a level of health that will permit them to lead a socially and economically productive life.
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Environmental health services in Europe 2
Policy options
WHO Library Cataloguing in Publication Data
MacArthur, Ian Environmental health services in Europe 2 / by Ian MacArthur and Xavier Bonnefoy
(WHO regional publications. European series ; No. 77)
1.Environmental health 2.Health services – organization 3.Europe I.Bonnefoy, Xavier II.Title III.Series
ISBN 92 890 1341 9 (NLM Classification: WA 30) ISSN 0378-2255
Text editing: Frank Theakston Cover design: Axiom Design, London, United Kingdom
World Health Organization Regional Office for Europe
Copenhagen
Environmental health services in
Europe 2
Policy options
Ian MacArthur and Xavier Bonnefoy
WHO Regional Publications, European Series, No. 77
ISBN 92 890 1341 9 ISSN 0378-2255
The Regional Office for Europe of the World Health Organization wel- comes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Publications unit, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark, which will be glad to provide the latest information on any changes made to the text, plans for new edi- tions, and reprints and translations already available.
© World Health Organization 1998
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The mention of specific companies or of certain manufacturers’ prod- ucts does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
The views expressed in this publication are those of the authors and do not necessarily represent the decisions or the stated policy of the World Health Organization.
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Contents
Page
Foreword .......................................................................................... vii
Acknowledgements ......................................................................... ix
Introduction ..................................................................................... 1
1. The concepts of environmental health ....................................... 7
2. Strategies for environmental health services ............................. 25
3. Institutional development ........................................................... 45
4. Functions of environmental health services .............................. 69
5. Capacity building ....................................................................... 101
6. Evaluation of environmental health services ............................. 117
References ....................................................................................... 131
Annex 1. Countries surveyed, March 1993 to March 1994 ........... 135
Annex 2. Participants in steering group meetings, 1992–1994....................................................................... 137
Foreword
After the Rio, Cairo and Copenhagen summits, it is absolutely clear that countries need to analyse carefully whether they are developing in a sustainable way, with demographic trends compatible with that develop- ment and in line with the basic prerequisites for a harmonious society. The Second European Conference on Environment and Health, in Hel- sinki in 1994, provided the Member States of the WHO European Region with the framework for environmentally friendly and healthy develop- ment.
In publishing this series of books on environment and health ser- vices, we at the WHO Regional Office for Europe hope and intend to provide Member States with authoritative documentation on the ways and means at their disposal for managing their services. This second volume aims at providing policy guidance and options in the area of environment and health management. It has been produced as an aid to the process of reorganization and to initiate debate within countries on the best structures and policies for effective environmental health ser- vices. We hope that these books will encourage countries and cities to analyse and restructure their environmental health services in a way that will allow them to pursue a health policy compatible with health for all and the Helsinki Declaration.
This volume is the result of a joint effort by many partners, among whom the Chartered Institute of Environmental Health in London played a very important role. The advice of all experts involved was invaluable,
vii
and has been instrumental in providing the Regional Office and the Char- tered Institute with recommendations that will allow them to pave the way for developing environmental health services in line with the best available knowledge.
J.E. Asvall WHO Regional Director for Europe
viii ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Acknowledgements
The following advisers gave of their valuable time and experience in guiding the development of the first two books in the series: Maria Haralanova, Director, Department of Health Promotion and State Sani- tary Control, Ministry of Health, Sofia, Bulgaria; Michael Jacob, Con- sultant in Food Safety and Environmental Health, Rickmansworth, United Kingdom; Antonio Lobato de Faria, National School of Public Health, Lisbon, Portugal; Andreas Kappos, Behörde für Arbeit, Geshundheit und Soziales, Abteilung Gesundheit und Umwelt, Hamburg, Germany; Jean- Luc Potelon, Sanitary Engineer, Grenoble, France; Julius Ptashekas, Di- rector, Environmental Medicine Centre, Vilnius, Lithuania; and Linda Smith, Head of Environment and Health, Department of the Environ- ment, London, United Kingdom.
The convening of the follow-up working groups, the missions to the countries and the convening of the final review group meeting were made possible by the financial support of the German, Swiss and United King- dom governments. The hospitality of Bulgaria, France, Lithuania and the United Kingdom, which agreed to host the major meetings in Sofia, Salindres, Vilnius and London, respectively, is gratefully acknowledged.
The Chartered Institute of Environmental Health in London seconded Ian MacArthur to the Regional Office for two years. This secondment made the whole project possible, and both Ian MacArthur and the Insti- tute are warmly thanked.
* * * *
ix
The 27 individual country reports have not been published by WHO. They are, however, available as unpublished documents on request to the Regional Office. Although each report has been reviewed by experts in the country concerned, it does not necessarily represent the true posi- tion or policy of that country.
The technical language used when discussing environmental health and associated topics is particularly difficult, owing to many historical, social and cultural factors. In an effort to aid the understanding of a common language and terminology, readers are requested to refer to the glossary of terms produced for the Second European Conference on Environment and Health, held in Helsinki in June 1994.
x ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Introduction
The concept that environmental conditions can affect health is relatively new, yet it has become clear in recent years that health is central to the pressing concerns of environment and development. In 1984, the Euro- pean Member States of WHO adopted the strategy for health for all (1), setting out a common set of health targets for all countries in the Re- gion. Among those targets were several relating to environmental health conditions and management. In 1989, the WHO Regional Office for Europe organized the First European Conference on Environment and Health in Frankfurt-am-Main, when the European Charter on Environ- ment and Health was adopted (2). The Charter was seen as the first ma- jor step towards the creation of national policies on environmental health.
Other international actions have also had a significant impact on this area of work. The United Nations Conference on Environment and De- velopment, held in Rio de Janeiro in 1992, endorsed “Agenda 21”, a vision for ensuring that development is carried out in a sustainable man- ner (3). The principles that underlie the concept of sustainability also serve to mould the way in which environmental health issues must be addressed. The WHO Global Strategy for Environment and Health, as endorsed in 1993 in World Health Assembly resolution WHA46.20 (4), reflects the importance of the Rio Conference in dealing with environ- mental health.
Concerns for European environmental problems have also received attention from the international community. The United Nations
1
2 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Economic Commission for Europe and the Organisation for Economic Co-operation and Development have together undertaken a process to produce a broad strategy that serves as an environmental action pro- gramme for central and eastern Europe, requiring the development of individual national plans. The most recent international event relating to environment and health was in June 1994, when the Regional Office organized the Second European Conference on Environment and Health in Helsinki (5). The Conference sought to bring together some of the existing initiatives and reflect on how best to progress with the various actions required. The Conference called for the creation by 1997 of na- tional environmental health action plans, which would integrate the work already undertaken in the fields of environmental protection and sus- tainable development with those components that relate to health. The Environmental Health Action Plan for Europe (6), adopted at the Hel- sinki Conference, recognized the need for improved environmental health services in countries as a fundamental starting point from which effec- tive environmental health policies could be delivered.
This is the second in a series of publications relating to environmen- tal health services in the WHO European Region. It serves to comple- ment closely the first book (7), which provides factual descriptions and partial analysis of the existing provision of environmental health ser- vices in the Region, and is based on the same format and principles. The information for both of these publications was collected through a series of 27 country reviews carried out by international consultants between March 1993 and March 1994 (Annexes 1 and 2).
The reforms that swept central and eastern Europe and the former USSR in the late 1980s and early 1990s, and the economic changes now taking place in this part of the Region, have inevitably led to changes in government structures and institutions. In several countries it was the “green movement” and the environmental lobby that were at the fore- front of the pressure to change the former regimes. In only a few years, however, it has been realized that the new reforms will not solve the environmental damage that has been bequeathed to these countries. Even the many internationally funded capital investment programmes, aimed at producing specific solutions for particular problems, have not been sufficient to make a significant impact on the environmental health prob- lems inherited by the new governments throughout the eastern half of the European Region. It has become apparent that long-term investment
INTRODUCTION 3
in the capacities and structures in countries will be required before last- ing changes can be brought about in the management of the environ- ment. Many countries are therefore currently reviewing their entire le- gal and institutional structures in relation to environmental health serv- ices. In many countries, a new environmental protection system is being developed. The existing capacities and management traditions, however, do not always allow for radical reforms in the strategies and policies of national, regional and local authorities, and inevitably some environ- mental protection measures will have to wait.
This volume on policy options has been produced as an aid to the processes of reorganization, and to initiate debate within countries on the best structures and policies for effective environmental health ser- vices. It will also serve as an extremely valuable and supportive tool in the development of national environmental health action plans, which are to be produced by 1997 under the terms of the Helsinki Declaration.
This book comprises six chapters that closely mirror those of its com- panion volume (7), which provides an overview of current European practice. By this means, the reader can compare how existing services operate against the policy options for reforming particular aspects of the delivery of environmental health services. The overview also provides examples of the principles set out in this publication. There is, therefore, much benefit to be gained by referring to both volumes when looking at the future work of environmental health services. Both publications are intended to be used as reference works, providing a complete overview of a subject area within each chapter. Inevitably, therefore, there will be an element of duplication between the chapters of essential information common to more than one subject area.
As its title suggests, this publication is intended to offer options for development. It is not intended to provide a prescriptive model for re- form. It is essential that each country uses the information provided and adapts it to its own unique situation, reflecting the various historical and cultural differences that enrich the European Region.
There are, however, some principles in the delivery of environmental health services that cannot and should not be compromised. Chapter 1 addresses many of these essential building blocks in exploring the con- cepts of environmental health. It shows why environmental health is
4 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
important, and why it is a function that requires commitment at the highest level.
Chapter 2 deals with the implementation of strategies by the environ- mental health services, provides methodologies through which the vari- ous sectoral policies that influence environmental health can be inte- grated, and demonstrates how environmental health agencies can go about their tasks.
Chapter 3 relates to the institutional development required for the delivery of effective environmental health services, and the level of gov- ernment best suited to deliver them. Obviously, the institutional infra- structures in a country have been created against the background of the political and social development of that country. The principles explored in Chapter 3 do, nevertheless, attempt to highlight some of the princi- ples of governance that can be used and adapted to national traditions and existing structures.
Chapter 4 concentrates on what environmental health services do. It discusses their functions, and provides options on additional areas of responsibility beyond their traditional roles.
There is clearly little point in identifying policies, devising strategies and providing suitable institutions to deliver environmental health ser- vices if there is insufficient capacity to deliver what is required. Chapter 5 considers how capacities can be developed according to four different frameworks: economic, legislative, professional and informational.
Finally, Chapter 6 raises the issue of the evaluation of environmental health services. This is a particularly difficult area, which is certainly worthy of further research. This chapter sets out the problem, but in truth offers little in the way of solutions. Clearly, services must be evalu- ated if effective management is to be achieved, but the complex mix of policies, actions and effects involved in environmental health make such evaluations fraught with difficulties.
The WHO European Region comprises 51 countries of immense di- versity. Although this volume does not provide solutions to every prob- lem in the development of environmental health services, it does attempt to give a “shopping list” that can be used to create unique solutions for
INTRODUCTION 5
individual needs. Undoubtedly some will disagree with these concepts and principles – it would be hard to imagine the completion of such a work without a contrary view. The Regional Office would therefore be grateful to receive comments on the content or style of this publication, as these will be very useful in any future revision.
1
The countries of the WHO European Region are enormously diverse. Their diversity relates not only to their geographical and cultural differences but also, and perhaps more impor- tantly, to the range of social and economic conditions that currently prevail in these countries. As a result, the perspec- tive taken on environmental health issues, and particularly on how these services are delivered, reflects this wide degree of variation throughout the Region. Some countries have well established environmental health services that can trace their origins back 100 years or more, while others are only now developing services for environmental health work.
Before setting out the various policy options for the estab- lishment, development and management of environmental health services, it is necessary to establish a clear and common understanding of some key terms and concepts. This is essential in the light of the many different perceptions and understandings in the field of environmental health.
This first chapter therefore defines the basic foundations of environmental health and environmental health services, outlines their objectives and, among other things, describes the concepts of intersectoral working, sustainable develop- ment and health for all.
7
The Concepts of Environmental Health
8 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Definitions are of fundamental importance. They set out the precise scope of and the restrictions placed on the activities of environmental health institutions and professionals. Any definition of environmental health must therefore encompass both its present and future needs. In this chap- ter, an amended definition of environmental health is proposed and, for the first time, a separate definition of environmental health services is suggested. Changes to the existing definition were required to specify the types of environmental factor that affect health. The definitions also aim to highlight the work of environmental health services in address- ing the problems of the past, present and future. Quality of life and the concept of sustainability are also incorporated.
WHO (2) has defined the term “environmental health” as compris- ing those aspects of human health and disease that are determined by factors in the environment. It also refers to the theory and practice of assessing and controlling factors in the environment that can potentially affect health. Although some may find this definition a little old for the problems facing environmental health professionals today, it does serve as a strong basis for development.
Environmental health problems clearly relate to areas beyond the mere physical interaction of environmental and health factors. More and more, there is an indication that the social and psychosocial factors in the en- vironments in which we live also have an effect on health. It is clear, then, that environmental health as a discipline must now encompass these areas as well as those traditionally associated with the term. It can be difficult to prove a direct correlation between some of these social fac- tors and health. Some may be precursors of other, more tangible effects, while others may have a synergistic effect. This should not make them any less important in the consideration of environmental health priori- ties.
Such factors can relate directly to quality of life, which is now be- coming the major area of concern in countries where mechanisms for the control of the main physical factors influencing health are well es- tablished. Environmental health must therefore reflect these changes in perspective and they must be added to the current definition.
The following new definition of environmental health is therefore proposed (8):
THE CONCEPTS OF ENVIRONMENTAL HEALTH 9
Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting and preventing those factors in the envi- ronment that can potentially affect adversely the health of present and fu- ture generations.
It is natural that countries adopt policies to deal with environmental health issues that reflect their various social and economic needs. These are formed by a mixture of historical, social, regulatory, economic and public control policies. All policies require to be implemented and/or monitored, however, and in this respect environmental health services are vital to the strategies that aim to address environmental health issues. They are not, however, limited to these areas alone; envi- ronmental health agencies can also make a considerable contribution to formulating and promoting environmental health concepts for the pur- poses of decision-making, and to delivering public education and infor- mation.
Environmental health services are the direct interface between policy- makers and those who are subject to that policy control. They also have a direct relationship with the general public, in dealing with their com- plaints and concerns relating to environmental health issues. There is a need for such services to be appropriately targeted and sympathetic to public needs, while at the same time representing the views of the rel- evant authorities, be they local, regional or national.
Thus, environmental health services can be defined as those services implementing environmental health policies through monitoring and control activities. They carry out that role by promoting the improve- ment of environmental parameters and by encouraging the use of envi- ronmentally friendly and healthy technologies and behaviour. They also have a leading role in developing and suggesting new areas of policy.
There are several stages in the formulation and implementation of environmental health policy in any country. When environmental health priorities within a country, region or district have been identified, con- sideration must be given to how those priorities can be dealt with. This can be achieved through a number of intervention mechanisms, and it is the role of environmental health agencies to carry out that intervention work. Any policy must, however, enjoy legislative support, since this
10 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
demonstrates government commitment to the issues and provides those who implement the policy with legal guidance and authority.
Environmental health services originated from the movement to im- prove sanitation and public health during the Industrial Revolution in western Europe of the late eighteenth and early nineteenth centuries. Increased urbanization and poor standards of city housing, together with intolerable working conditions, created an environment in which maim- ing, death and disease were commonplace among the relatively young. Some enlightened industrialists and others expressed concern about and resolved to act against these conditions. Through their work, which linked environmental conditions to health problems and disease, the public health movement and services were born (9).
Today, environmental health services are still founded on the princi- ples of public health, and indeed many of the problems faced by western Europe in the last century are reflected in some of the eastern countries of the European Region. Nevertheless, many of the areas that the services are now expected to address, such as quality of life, are more diverse and complex and need to be dealt with in a multidisciplinary manner.
Many of the prevailing systems of environmental health control in eastern countries were developed in the mid-1950s, largely on a two-tier system of local administration. The upper tier was the main (district) level formed by the larger cities, towns and rural areas. The second tier comprised the authorities of villages and the smaller urban settlements. Both levels had extensive legal powers, including the supervision of the economic plan for the area as well as the administration of a variety of services, including that of health. There was nevertheless a lack of real autonomy, primarily caused by the principle of “democratic centralism” that referred all decisions to the next higher level, and so on up to the national level.
In practice, the upper tier was almost always the dominant force. It represented the lowest level of central control – a form of direct central rule at local level. The lower tier was thus devoid of all real power. Hav- ing inherited such an infrastructure, the new democracies are struggling to match the needs of local people to the mechanisms required to pro- vide appropriate local services.
THE CONCEPTS OF ENVIRONMENTAL HEALTH 11
The range of subjects dealt with under the banner of environmental health varies from country to country, and are so diverse that no single profession or institution has the capacity to deal with them all. Some individual professions or agencies may deal with many aspects of envi- ronmental health, yet they may have to seek additional technical assist- ance from elsewhere. On the other hand, they may deal with just one dimension of environmental health control, such as law enforcement, rather than providing services directly to the public or industry.
Environmental health agencies also have an important intermediary role in the formulation of policy. Through their work, they are able to identify potential problem areas and bring them to the attention of the policy-makers. They can then monitor policy and report on its effectiveness to the policy-makers, so that it can be amended as appropriate.
HEALTH FOR ALL PRINCIPLES
The health for all policy for Europe, as expressed in the targets for health for all (10), unites 860 million people in the WHO European Region, an area stretching from Greenland in the north and the Mediterranean in the south to the Pacific shores of the Russian Federation. The policy sets out the improvements in the health of Europeans that are expected by the year 2000. It also describes the strategies for achieving them through healthier lifestyles, improvements in the environment and the provision of high-quality services for prevention, treatment, care and rehabilitation. The targets are intended to fuel debate on the formation of national health policies and their implementation in WHO Member States.
Targets 18–25 are concerned with the contribution of the environment to health. They link together the emerging commitment of the environmental policies that lead to ecologically sustainable development, the prevention and control of risks, and equitable access to healthy environ- ments. Their aim is to provide opportunities for people to live in communities with socially and physically supportive environments.
12 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Health for all target 1, relating to equity in health, states (10):
By the year 2000, the difference in health status between countries and between groups within countries should be reduced by at least 25%, by improving the level of health of disadvantaged nations and groups.
This target is of particular importance for environmental health services. Disadvantaged groups within a country are often those who live in the worst housing with poor sanitation and water supplies, who work in the most dangerous occupations, and who have limited access to a whole- some and varied food supply. In short, they are often those people who live and work in the worst environments.
To reduce such inequalities, people must have equal access to envi- ronmental health services and there must be an uptake of services that relates to need. The geographical distribution of service resources should also reflect the needs of the entire population. The provision of advanced medical technology should not be restricted by social or economic dis- advantage, and services should be sensitive to the needs of minority groups. To achieve this, the disadvantaged within the population will require special assistance and attention.
The transboundary nature of many of the environmental factors that contribute to such inequalities means that cooperation at the international level is essential. This is obvious in areas such as the control of air and water pollution, but such collaboration is also important wherever specific assistance is offered, either directly or through an international agency such as WHO.
Health for all target 18 states (10):
By the year 2000, all Member States should have developed, and be imple- menting, policies on the environment and health that ensure ecologically sustainable development, effective prevention and control of environmen- tal health risks and equitable access to healthy environments.
The target goes on to state that Member States should:
• review, adapt and develop their environment and health policies in the light of the European Charter on Environment and Health, as an essential component of health for all policy;
THE CONCEPTS OF ENVIRONMENTAL HEALTH 13
• formulate and implement country, regional and/or local laws, regu- lations, incentives and practices accordingly; [and]
• establish country, regional and local mechanisms for involving people in policy development and implementation.
Sustainable development is dealt with in more detail later in this chap- ter, but it is worth stating here that all references to ecological protection in this book pertain to those ecosystems that are required to sustain hu- man environments.
Target 19 states (10): “By the year 2000, there should be effective management systems and resources in all Member States for putting policies on environment and health into practice”. This target is a key indication of the need for effective and appropriate environmental health services. It goes on to state that the target can be achieved if Member States:
• establish systems for environmental monitoring and impact assess- ment, linking environment and health information;
• use country, regional and local mechanisms to involve government, industry, primary producers and community groups in environmen- tal health action based on full sharing of information;
• consider the impact on environment and health of policies and strat- egies in sectors such as urban planning, energy, transport, industrial development and agriculture;
• mobilize adequate resources from all sectors to achieve environmental health targets; [and]
• develop management systems, operational methods, appropriate tech- nology, research and training to support environmental health man- agement.
OBJECTIVES OF ENVIRONMENTAL HEALTH SERVICES
At their most basic, the objectives of environmental health services are to protect and promote environmental health. Their primary aim is to ensure improvements in living conditions in order to promote human health. Several secondary objectives can be identified as contributing to the whole. These include developing and enforcing legislation, promoting public participation and involvement, influencing the development of government responsibility at all levels, and supporting practical and academic research.
14 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Whichever of the definitions of environmental health given above is used, it will serve to set out the basic mission of the environmental health services. Nevertheless, intermediate, practical objectives should not be overlooked. Environmental health services are primarily concerned with environments supportive of human health, and with ensuring improve- ments in health in all environments where people live.
The population of the WHO European Region enjoy a wide diversity of such environments, but their quality varies immensely. It therefore follows that people’s aspirations will differ from country to country, from region to region, and even from city to city. One of the objectives of environmental health services, therefore, should be actively to promote and develop public aspirations for a continual improvement in local, national and international environments, within a framework of realistic targets (11).
Environmental health agencies and institutions are at the forefront of changes in environmental health policies, conditions and problems. They can act as the “eyes and ears” of policy- and decision-makers. They should therefore see as one of their objectives the creation and develop- ment of government responsibility, at all levels, to respond to the pub- lic’s wishes.
In setting their objectives, environmental health services must not only address the current problems. They must recognize that they are also required to work to correct previous environmental health problems and to promote good practices in the future. This requires them continu- ally to evaluate their effectiveness within their available resources, and to address new issues once existing problems no longer present an unac- ceptable risk and are adequately under control.
One of the basic functions of environmental health agencies is to enforce legislation. Many laws in the field of environmental health rely on the principle of self-regulation, and environmental health services must control and monitor this process. A further objective is to promote the use of healthy technologies and the “cradle to grave” considerations in production processes.
To ensure continued development in their work, environmental health services must also support and suggest practical and academic research in areas where they have identified a lack of information or knowledge.
THE CONCEPTS OF ENVIRONMENTAL HEALTH 15
SOCIAL ASPECTS
The environmental factors that influence human health can be categorized as physical, biological or social. Traditionally, environmental health services have concentrated on physical and biological factors, which can be readily measured and whose effect on human health can be directly quantified (12). As many countries come to terms with such factors and bring them within acceptable limits, however, the environmental health services are being presented with problems that are rooted in complex social issues. Although they can be meas- ured, such problems are difficult to correlate directly with human health.
The existing WHO definition of environmental health concentrates on factors in the environment and their impact on health. Within the Euro- pean Region today, however, it is clear that, although some of these “fac- tors” cannot be effectively measured or quantified, they still contribute to major public concerns. Economic, aesthetic and social factors all have a significant effect on the level or state of environmental health. Issues such as housing, urban development, transport and occupational stress all have direct or indirect effects on the health of the exposed populations. Environmental health services will have to turn their attention, in col- laboration with other professions, to the environmentally related social and psychosocial factors that affect health.
Of primary concern in terms of these social aspects are urban growth and development. Increased urbanization has led to inadequate incomes, diets, housing and services, and it has often left such municipal services as waste collection and disposal unable to respond.
Of the many social and cultural factors with an impact on health, the most important, in both urban and rural areas, is poverty. Unem- ployment, as well as reducing income, creates stress and insecurity that may lessen resistance to disease. Education, health and other social services may also be less accessible to the urban poor, thereby increasing their vulnerability. Education is of primary importance to the improvement of environmental health, in that it creates the op- portunity for people to increase their incomes and thus to afford healthier lifestyles.
16 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Urban living brings about urban stress that can manifest itself in de- pression, anxiety, suicide, alcohol dependence, drug abuse and mental illness. Mental disorders have increased among older people living in cities, as have juvenile delinquency, violence and other problems stem- ming from psychosocial factors.
All of these issues are determined to an extent by public policies and programmes. They affect not only access to social services but also the economic sector. They determine the ground rules for social living, pre- scribe basic rights and entitlements, and provide a framework for socio- economic development. The challenge in formulating such policies is to find a balance between economic growth and the maintenance of a se- cure social environment.
DEMOCRATIC PRINCIPLES
The adoption of democratic principles of government is the cornerstone of the establishment of effective environmental health services. The European Charter on Environment and Health (2) sets out the basic entitlements of individuals, including the rights of full information, active consultation and genuine participation in environmental health decisions. Democratic principles, however, also imply responsibilities. Every individual also has a duty to act responsibly in an effort to contribute to the protection of the environment. To achieve this partnership, environmental health services must adopt a role of promoting environmental health and be responsive and answerable to the needs and desires of the communities they serve.
Democratic principles of government are now familiar to all Member States of the WHO European Region. Such principles are the key to the establishment of effective environmental health services.
The European Charter on Environment and Health (2) states that every individual is entitled to:
• an environment conducive to the highest attainable level of health and wellbeing;
THE CONCEPTS OF ENVIRONMENTAL HEALTH 17
• information and consultation on the state of the environment, and on plans, decisions and activities likely to affect both the environment and health; [and]
• participation in the decision-making process.
Every individual also has a responsibility to contribute to the protec- tion of the environment, and government agencies and public and pri- vate corporations must play a full role in protecting the environment and promoting human health through environmental health management. In this respect, environmental health services should actively and regularly provide the public with the information and tools necessary to facilitate this process. Furthermore, private industry should recognize the right of the general public to timely, accurate and comprehensible information on any impact on the environment.
SUSTAINABLE DEVELOPMENT
Sustainable development is more than environmental protection. The Rio Declaration on Environment and Development laid out the following guiding principles in relation to sustainable development that are particularly relevant to the delivery of environmental health services (3).
• Human beings are at the centre of concern for sustainable development.
• To achieve sustainable development, environmental protection must remain an integral part of the development process.
• Equity in the delivery of services is an essential part of sustainable development.
• Environmental issues are best handled with the participation of all concerned citizens at all levels.
• Effective environmental legislation should be enacted. • Both the precautionary approach and environmental
impact assessment should be widely applied as tools in competent decision-making.
Sustainable development was defined in Our common future (13) as “development that meets the needs of the present without compromising
18 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
the ability of future generations to meet their own needs”. It was further defined in the 1991 report of the World Conservation Union, the United Nations Environment Programme (UNEP) and the World Wide Fund for Nature, Caring for the earth (14), as “improving the quality of life while living within the carrying capacity of supporting ecosystems”.
There is no longer any justification for the claim that sustainable development is such an all-embracing term that it is effectively mean- ingless. There is now considerable agreement on the meaning of sus- tainable development and even, in the broad sense, on its implications for policy. Sustainable development goes beyond the idea of environ- mental protection as it has traditionally been conceived (15).
Environmental health has always included the concept of quality of life, though initial priorities rightly focus on matters deemed to present the greatest risk to health. Priorities constantly change, however, and environmental health services must adapt to those changes. As one group of hazards is eradicated or controlled, the services must turn their atten- tion to the next problem while continuing to monitor the first.
This can be demonstrated by the work carried out through the environmental health services in some countries of western Europe. Diseases related to known environmental factors have, apart from sporadic cases, been largely controlled. Surveillance as part of control programmes is still maintained, but attention is increasingly being paid to lifestyle conditions and diseases related to environmental factors. A great deal of progress has already been achieved in these areas and the services are now beginning to address quality of life. It is worth noting that, although environmental health services should concern themselves with all three aspects at once, only in the relatively wealthy countries is quality of life actively discussed and a part of the normal work of these services.
Not only does sustainable development encompass certain issues, but it requires particular ways of managing them. There are three par- ticularly important principles for the policy-making processes relating to environmental health services: policy integration, partnership and appropriate scale (16).
Policy integration involves introducing environmental considerations into all other areas of policy and the integration of different policy fields
THE CONCEPTS OF ENVIRONMENTAL HEALTH 19
and different levels of government. Partnership implies consulting with and the participation of all groups in society in the planning and imple- mentation of sustainable development policies. Appropriate scale means handling policy at the level of government (from local to international) at which an environmental issue itself occurs, with emphasis on the prin- ciple of subsidiarity.
Environmental health services have an important role to play in the planning and management of sustainable development, as part of an in- tegrated national and local structure. They are already involved in sev- eral aspects of sustainability and in policy management work such as environmental monitoring, education and enforcement. Their practical experience of working with business and the general public allows them to contribute to the implementation of policy by assisting and informing government, local industry and the general public.
Local issues of environmental quality, which have been considered the core work of environmental protection in the past, are related to sustainability in a number of ways. For example, motor transport is a contributor both to local air pollution and health problems and to global warming. Industries causing local pollution also use energy and pro- duce solid waste. Policy towards such issues as food safety has implica- tions for sustainability in relation to packaging and energy consumption during refrigeration. The relationship between sustainability and local environmental quality can be complex, and it is important that solutions to local problems also contribute to global sustainability, or at least avoid contributing to unsustainability.
INTERSECTORALITY
Many sectors of society must collaborate in order to achieve health for all. Intersectoral participation is needed to ensure health and protection from risks in the physical, economic and social environments. Such action implies cooperation among government agencies at national, regional and local levels and with other sectors such as business and industry, nongovernmental organizations (NGOs) and professional groups. It also implies a constant search for quality and cost–effectiveness. In terms of the establishment and
20 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
development of environmental health services, the ministries concerned with both health and the environment must play leading roles in promoting intersectoral cooperation (10).
WHO’s European health for all policy (10) suggests that all sectors of society, including every individual, group and organization, have a duty to exercise care for a healthy environment when going about their busi- ness. Unless special care is taken, each person, group and organization – often without realizing it – tends to degrade the environment, to deplete the earth’s resources and to infringe the entitlements of others. As with individual health, therefore, environmental health is the responsibility of all sectors of society.
Potential hazards to health are caused by agents from many sources that reach humans by complex routes. The most effective protection from these hazards requires the cooperation of all sectors involved, and opti- mal progress depends on collaboration among all those responsible. When working in this manner, the individual professions or agencies involved must clearly recognize their responsibilities and limitations and respect those of others. Environmental health impact assessment can be used as a tool to promote this intersectoral approach (6).
Isolated decisions cannot usually solve problems of environmental health; lack of cooperation among authorities has in the past created or aggravated many problems. Mechanisms for intersectoral cooperation are the basis of policies on strategic and operational planning and for individual projects. Such cooperation must therefore work in particular at local level, where such decisions are made. Environment and health considerations must be addressed at the earliest possible stage in ac- cordance with the principle of prevention.
Individual European countries vary considerably in the way they del- egate responsibility for environmental issues as a whole, and for the health aspects of the environment, among government departments and agencies. This is true regardless of the system of government. The many possibilities for interaction between the policies of the health and envi- ronment sectors and those of others require both effective collaboration and very clear mutual objectives.
An important question is whether the political responsibility for ma- jor socioeconomic development should lie in the same hands as that for
THE CONCEPTS OF ENVIRONMENTAL HEALTH 21
protecting human health and the environment. The choice of structure, however, is probably less important than having clear overall objectives. Short-term clashes of interest between environmental health and eco- nomic objectives should be openly acknowledged, and there should be intersectoral links with clearly delegated responsibilities and public ac- countability to make sure that these links are effective.
Fig. 1 provides an example of intersectoral and multisectoral work. It shows that an intersectoral approach brings together the various differ- ent interests in delivering services, while the multisectoral approach deals individually with each component of environmental health. The intersectoral approach should function at both policy-making and serv- ice delivery stages, and at both national and local levels.
Fig. 1. Intersectorality versus multisectorality
Cabinet level
Ministry level
Public
Intersectoral services
Cabinet level
Ministry level
Public
Multisectoral services
22 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
PROMOTION OF ENVIRONMENTAL HEALTH
The promotion of environmental health involves advocacy, education and lobbying. Environmental health services are normally located where they are best able to work for better management of the environment through environmental promotion activities. Promotion requires a proactive approach to defend environmental resources. Through the techniques of promotion, issues are placed in the public arena for debate and policy revision. Promotional activities are best under- taken at the level at which local communities can understand the issues and have a direct influence on their immediate environments. Environmental health promotion relies on the use of different techniques, including those of the mass media, education, petitioning, publicity, research and lobbying.
Promotional and publicity strategies encourage and maintain awareness about the environment and the related health issues. Such strategies can, however, place undue emphasis on certain issues purely because the publicity itself is good rather than the actual issue being publicized. For this reason, it is important that environmental health promotion is car- ried out in a planned and strategic manner.
Environmental health services must identify clear objectives and the target audience before embarking on publicity campaigns. Because these services are normally based at the local level, they are usually in an ideal position to educate, advise and persuade local communities on environmental issues.
The promotion of and education in environmental health issues cre- ate not only a sense of ownership of environmental problems among communities, but also involvement in potential solutions and decision- making processes. Once communities are better informed, they are more able and willing to participate in providing solutions (17).
Environmental health services must promote environmental health issues in all areas. They must ensure that these issues are included and re- main on the agendas of local and national political, industrial, academic and community groups. Through such promotion they can advocate a coordinated and intersectoral approach to solving environmental health problems.
THE CONCEPTS OF ENVIRONMENTAL HEALTH 23
INTERNATIONAL COOPERATION AND COMMUNICATION
An increasing number of environmental health problems transcend national frontiers. Strong international cooperation makes it possible to ensure protection from transboundary pollution, access to adequate resources for healthy living, and the provision of services that are of high quality and take advantage of current knowledge and technology.
Many important international initiatives have been taken in the field of environmental protection. Many United Nations agencies have environ- mental programmes, and mechanisms are in place for regularly exchang- ing information and for taking joint action (18). In particular, the WHO Regional Office for Europe has carried out many environmental health activities with other United Nations agencies, the European Union (EU) (19) and its own Member States.
The ramifications for health of global disturbances to the environ- ment will require further international attention in the future. Many of the current priorities in environmental health go beyond national bor- ders and most require international, especially pan-European, coopera- tion if they are to be satisfactorily resolved. Well coordinated joint ef- forts in education, research and development should facilitate the most effective utilization of available resources.
International environmental health problems fall into different classes, and the services that must address these issues should also reflect their differing features. Some problems cannot be solved by a single country, and international assistance, aid and/or cooperation will thus be required to develop a solution. Other problems are by their very nature interna- tional, such as pollution of the Danube or the Aral Sea. Finally, some problems are created locally but affect much wider areas, such as transboundary air pollution and acid rain.
International cooperation is one of the principles of health for all (10). In the field of environmental health, it has been shown to have clear advantages for the solution of both international and national prob- lems.
Chapter 1 sets out the concepts of environmental health. These are the foundations for the operational development of environmental health services. The question now is how these concepts can be translated into action. Strategies for environmental health set the structure and interrelation- ships among the various partners for the delivery of appro- priate services. Several elements must be taken into con- sideration during this process, including policy formulation, situation assessment, priority setting, planning, public participation and management. This chapter outlines these components and the various options for their development and implementation, and discusses the advantages and disadvantages of certain strategies that can be adopted.
POLICY FORMULATION
The process of policy formulation as a function of environmental health services is dealt with in depth in Chapter 4. Nevertheless, policy formu- lation needs to be considered in the framework of strategy development and implementation. The policy set on a particular issue is the starting point from which strategies are developed. Policies establish ground rules and determine the aims and objectives; the strategies then adopted must reflect the intent of the policy.
Strategies for Environmental Health Services
2
25
26 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Strategies, however, will often have to take account of more than one policy. For example, an environmental health service may have a clear policy on the protection of foodstuffs. It may also have a policy on en- forcement. When it comes to devising a strategy on food safety, there- fore, both of these policies will have to be incorporated and reflected in the actions taken. Strategies must take account of a mix of policies, which may affect one another. Policy-makers must therefore be aware that their work has to be translated into strategic action, and they should make every effort to avoid drawing up policies that may conflict. Such diffi- culties will leave those who have to develop and implement strategies in an untenable position. Consideration must also be given to relevant poli- cies developed elsewhere.
At its most simple, policy formulation can consist of three review stages. These are an internal review, where policy is considered and ad- vocated by services or departments themselves; an external review, where the proposal receives comment from other administrative departments and the general public; and finally a political review, where a final deci- sion is made. The policy development process may not always be in that sequence, but the final stage before implementation is always the politi- cal review. For environmental health services, policy is normally set at government level. Ideally, this will establish a long-term overview of environmental health and will allow strategies to be developed that pre- vent the unacceptable and promote the desirable. The essential aim of any government’s long-term strategy will be to put in place the services, incentives and controls that encourage individuals, households, com- munities, businesses and bureaucracies to promote health and the sustain- able use of resources and to protect the natural and human environments.
Once a policy is in place, a general structure will be developed as part of the implementation strategy. The institutions within this struc- ture can then be given freedom to generate their own policies. It is from here that service strategies can be developed, creating suitable struc- tures, management systems, programmes and targets.
Environmental health services will therefore have little to say in the overall objectives, but the so-called horizontal policies – relating to how strategies can be implemented to achieve the specific objectives – can present several different options. Table 1 briefly describes some of these approach poli- cies and outlines their perceived advantages and disadvantages.
STRATEGIES 27
Table 1. Advantages and disadvantages of various policies
Type of policy Description Advantages Disadvantages
Proactive Services actively Has a positive effect Can lead to more measure, monitor on environmental demands being and inspect. health. made on the service.
Programmes of Control of environ- Can be expensive work are formulated mental health and to operate. and targets are set. standards lies with
the environmental Attempts are made health services. to create standards even better than those set out in legislation.
Reactive Complaints and Concentrates on Deals only with emergency situations areas of greatest extreme situations. are responded to. need.
Is less expensive in Cannot lead to a the short term. strategic and con-
trolling overview.
Is very expensive in the long term.
Specialist Staff skills and In-depth knowledge Concentrates on resources are used and well founded one area only, thus to deal with individual solutions are no holistic view sector-specific issues. available. possible.
Is resource-intensive.
Lacks intersectorality.
Generalist Staff skills and Allows a general Lacks specialist resources are used overview. knowledge, although to deal with issues in this can be obtained an integrated manner. Allows good through centres of
identification and excellence. assessment of the complete problem.
Self-regulating Those who have to Can reduce monitor- Is open to abuse. comply with legis- ing workload. lation monitor and Is initially resource- control themselves Allows resources to intensive. internally. be devoted to priority
problems. Improvements beyond Inspectorates minimum standards “monitor Is cost-effective. are difficult to make. the monitoring”.
Can lead to better understanding by industry and commerce.
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The policy approaches described in Table 1 can be used in conjunction with one another, adopted at different times within an overall strategy, or used on their own. They can be used either for individual subject areas or across all areas of environmental health concern. The mixture of policies adopted will form the overall strategic or enforcement policy for a particular service. Such a policy will serve as the basis for subsequent activity, so it should be written down and made familiar to all involved in the environ- mental health services and to the general public.
For example, a strategy for safeguarding a wholesome and safe food supply may initially adopt an educative and proactive approach, whereby the environmental health services attempt to educate those in the food trade on the reasons for good hygienic practice. An enforcement approach could follow if standards have not improved. Obviously, such policies cannot cover every eventuality, and an element of flexibility should be considered. The adoption of the most appropriate strategy will depend not only on the stated policies but on other factors, including the relative priorities and available re- sources within the environmental health services. The following sections con- sider how these can be assessed and built into the strategy-formulating processes.
ASSESSMENT OF THE EXISTING SITUATION
Before strategies can be developed, it is necessary to establish exactly which problems require to be addressed.
Table 1. (contd)
Type of policy Description Advantages Disadvantages
Active Full and immediate Is efficient and Can lead to difficult enforcement use is made of effective. relationships.
legislative powers. Treats everyone Can be expensive. equally.
Will achieve only minimum standards.
Educative Educative and Develops cooperation Is open to abuse. persuasive means and understanding. are used to achieve Relies on cooperation. compliance and Is good in conjunction standards. with self-regulation.
Enforcement is used Self-improvement is as a last resort. possible.
STRATEGIES 29
It may also be necessary to establish the urgency that should be attached to each issue in order to make the best use of the available resources. Several methodologies can be used to obtain this information, depending on the detail required and the various constraints imposed on data collection or recording systems. This section looks at the concepts of hazard and risk, and at how risk assessment and environmental health impact assessment can serve as useful tools in identifying and formulating strategies. It also identifies other matters to be considered when assessing needs.
Hazard identification Hazards and risks are encountered throughout everyday life. The two terms are often confused and can become interchangeable in normal conversation. Technically, however, they deal with different though re- lated concepts. The hazard associated with a situation relates purely to its potential to cause harm. Hazard analysis will reveal the extent of that potential. It will determine the worst-case scenario, the number of peo- ple or the extent of the area that may be affected, and the severity of injury or damage that could occur.
Environmental health services can identify a number of significant environmental health hazards through the process of hazard analysis. Hazards can be identified in several ways, but epidemiology, scientific research and toxicological information and analysis are all basic require- ments. Without proven relationships between various factors and their effect on human health and the environment, the environmental health services cannot make informed decisions when identifying and analys- ing hazards.
Environmental health services can occasionally identify hazards that were previously unrecognized. Their main role in the formulation of strategies, however, is the recognition of existing hazards that may dam- age the environment or lead to increased ill health among the local popu- lation. Methods of identifying hazards include:
• investigating complaints from the public and other agencies; • evaluating the results of monitoring and testing undertaken by
other agencies;
30 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
• conducting specific surveys, and sending suspected hazardous materials for testing and analysis;
• routinely sampling and/or monitoring when this is not undertaken by other agencies;
• identifying sources of contamination; and • keeping an open mind.
Physical surveys and archive searches can be used to supplement the above data, and could result in the creation of a complete register of hazards within the remit and geographical area of the environmental health services. It is important that all significant hazards within the area be identified, and that they include those hazards that, although perhaps transitory, can be predicted to be present from time to time. This is particularly important where an area is crossed by major roads and/or railways that may occasionally carry hazardous materials.
Risk assessment and environmental health impact assessment Hazards relate to the potential of an item or situation to cause harm. The risk related to that hazard is the probability that or the frequency with which the predicted result of the hazard will occur. The risk associated with an identified hazard is therefore the major factor in determining the actions and strategies taken by environmental health services. The potential of a hazard may be great, but if it is effec- tively controlled and managed the likelihood of that hazard present- ing a risk to a population will be reduced. Risk-based strategies for environmental health services allow precious resources to be directed to those areas that present the greatest probability of causing harm. To develop such strategies, risk assessment has to be carried out over the range of hazards identified.
Risk assessment in fact consists of two separate elements that have to be considered in stages. The first of these is risk estimation, which is the result of hazard analysis (i.e. the worst scenario, the size of the population or area likely to be affected, and the potential severity of the injury or damage) compared with the analysis of the risk. Risk estimation can be carried out by assigning numerical values to the different categories of hazard and risk. The resulting product of the two can be used as a very crude way of comparing the relative serious- ness of risks.
STRATEGIES 31
This is not, however, the complete process, since risk evaluation must also be carried out. From the estimation of risk, a scale of relative priori- ties can be made based purely on hard data that can be proved and tested. Risk evaluation, however, also places a human significance or value on the estimation. Many risks are taken because those who are exposed find the benefits outweigh the disadvantages, and this dimension has to be incorporated into the risk assessment.
The ability to live with a risk has to be publicly tested unless the acceptance is implicit, such as in the case of motor transport. The ben- efits and disadvantages can be a trade-off involving many different as- pects, depending on the issue at hand. It should be borne in mind, how- ever, that the site of any benefits may not be the same as that of the disadvantages. Subnational, national or international considerations may have to be weighed. For example, a high-risk industry may bring direct local benefits, such as employment and an improved economy, but the risks may be much more widespread, either within the locality or further afield.
Risk evaluation can have one of three possible outcomes. It may be considered that a risk is unacceptable, that the disadvantages outweigh the advantages. In such circumstances, the environmental health ser- vices would need to take prompt action either to minimize or to elimi- nate the risk. On the other hand, it may be decided that the risk is accept- able, and that society can live with it without further precautions other than monitoring and surveillance. Third, it is possible to classify a risk as tolerable. This means that, while the risk can be lived with, all efforts and precautions must be taken to control it. Tolerable risks are often those related to nuclear power stations. The precautionary principle is applied, whereby a substance or activity is afforded all possible safe- guards until the true risk has been quantified. This approach can only be adopted where there is a strong economy to support such a policy.
Through the full process of risk assessment, environmental health services can determine where their efforts can be directed most effectively. Routine inspection and monitoring schedules, although cov- ering all identified sites of interest, can be heavily weighted towards those areas that present the greatest risk to the population or to the envi- ronment. The services can monitor and inspect more frequently those sites that present the greatest risk, and service managers can plan capital- intensive programmes more effectively.
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Risk assessment can be made into an extremely complex science. It need not be, however; to well trained environmental health profes- sionals, risk assessment for day-to-day purposes can become second nature.
Linked to risk assessment is environmental health impact assessment. This is another science that can be made to appear extremely difficult and complex, and expertise is certainly needed depending on the depth of assessment required. Environmental health impact assessment is now becoming generally accepted as an important tool in planning new de- velopments. The potential effects on human health must be fully taken into account in such work, and staff in environmental health and other disciplines involved in the development process may require training. This process could easily be built into legislation. To have optimum prac- tical value, the reports of such assessments should contain appropriate recommendations for follow-up studies during the construction, opera- tion and, where applicable, closing down of facilities. These might in- clude monitoring and epidemiological studies, and the results should be used as a continuing basis for decision-making.
Social factors While the environmental health situation within a certain geographical area is being assessed, information on the population of that area must also be gathered and analysed. Real and perceived needs can vary widely across different social, educational and age groups, and it is the task of the environmental health services to ensure that their work is tailored to the needs of those groups (20). Following the principle of equity, all members of society should receive a level of service appropriate to their needs. It therefore follows that environmental health services will have to concentrate their efforts in areas that are socially and educationally deprived, and to focus on the more vulnerable populations.
Information on and representation of vulnerable groups may be more easily obtained when a municipality is responsible for its environmental health services. Elected representatives of different areas within the municipality will carry with them the needs and desires of their con- stituents. It will thus be possible for policy and strategy to be directly formulated by those people, leading to more responsive and equitable services.
STRATEGIES 33
Data and information sources During the process of assessing the current situation, environmental health services should make full use of the various information and data sources available. Monitoring data, records of ill health, results of toxi- cological and epidemiological studies and academic research, data from geographical information systems and other statistical data all provide valuable sources of information on which value judgements can be made for the needs of the particular locality being dealt with. If the appropri- ate baseline information does not exist, then the environmental health services should consider either carrying out the necessary studies them- selves or commissioning others to carry them out on their behalf. Such baseline information can be pooled nationally or regionally to assist in strategy formulation elsewhere. Comparative data will assist in deter- mining reference points, which can then be used to measure the effec- tiveness of the various strategies developed.
PLANNING AND PRIORITY SETTING
Planning is the process of determining in advance an ordered methodology. For environmental health services, such a process is normally carried out within a framework of constraints. These include the policies that have been made and the prevailing conditions in the field of environmental health. Resources are also a limiting factor.
The mix of policies that environmental health services have to work with will provide the objectives of any strategy, and these need to be considered at the beginning of the planning process. Fig. 2 sets out the way in which various types of policy and information can interact to influence the development of strategic plans and ultimately the targets set.
Many factors, including the results of comprehensive analysis, need to be taken into account when planning an environmental health service. Fig. 2 shows that, as a government responsibility, the initiative for environmental health policy lies initially at national level. This is a broad statement of intent, providing a general commitment to protect the natural environment and to promote healthy living conditions. Addressing the various areas at national level may result in a framework of policies on the various sector-specific topics such as safe and wholesome food and
34 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
clean air. Moreover, an overall enforcement policy will be formulated at national level, which will establish some of the methodologies for dealing with environmental health problems. It is at this stage that choices can be made between national and local inspectorates and institutions or the operation of a two-tier system.
At local level, information on hazards and risks that the environmen- tal health services have gathered in assessing the existing situation can be placed in order of priority and cross-referenced to national sector- specific objectives. By comparing the local and national policies and reaching, where possible, a position of compromise, local sector-specific objectives can be developed. Such a procedure allows the local author- ity flexibility in the planning of its services.
National level
Overall environmental health policy
Individual subject policies (water, food, air, etc.)
Overall enforcement policy and
legislative framework (formed by national controls
and local flexibility)
Local level
Assessment and prioritization of
existing situation
Enforcement approach
Existing resources and
capabilities
Outcome
Outcome
Local subject objectives
Targets and time scales
Local strategic plans
Outcome
Points of policy integration
Local enforcement approach
Fig. 2. Planning processes for environmental health services
STRATEGIES 35
Once the local objectives are in place, the way in which they are to be achieved has to be determined by considering both national and local policies. National legislation will normally stipulate various requirements, and may provide enforcement tools and options. Oc- casionally, these may be statutory and the local environmental health services will therefore be obliged to use them. This may occur where a matter is of national importance, or where consistency in approach is desirable. Objectives may well be the same at both national and local levels, or even between different local services, but the meth- ods adopted to achieve them need not be. As stated earlier, there are several ways of implementing environmental health policy. Consid- eration of national legislation together with the local approach to enforcement will result in the formulation of a local enforcement policy.
Once this policy has been integrated with the local sector-specific objectives, a local strategic plan can be developed that integrates the various objectives with the means of approach adopted. This may, for example, result in an educative approach to food control or strict en- forcement for polluting emissions. Various mixes and hybrid plans can also be developed.
The ultimate constraint on the planning of local services is their re- sources and capabilities. If resources are particularly scarce or vulner- able, they may have to be considered earlier when determining enforce- ment approaches. They should also be considered, however, once the strategic plans have been drawn up. The level of resources in terms of funds, personnel and equipment will determine the feasibility of the plan and thereby the practical targets that can be set and the time scales for their achievement. Mechanisms can be developed that allow the national level to gain information on and an understanding of the local situation, thus allowing realistic planning.
The description given here of the planning process is rather simplis- tic. Various contributing factors such as public involvement and other external pressures have also to be considered, and mechanisms set up to take them into account. Some of these matters are discussed later in this chapter. In general, however, the constraints and processes of policy in- tegration outlined here can serve as an extremely valuable model for the strategic planning of environmental health services.
36 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
Priority Setting Priority setting is basically the process of ranking future actions in such a way that they will achieve the greatest gain relative to objectives and available resources. There are many methods of establishing priorities and several factors influence the process of determining them. In terms of priority setting for environmental health, work carried out to assess basic risks in a certain area can serve as the starting point. Risk assessment is not, however, the only factor that needs to be considered; political, social and financial benefits can all be incorporated into the process (20). A particular problem may, for example, present a significantly high risk to a small population group but have a low impact in terms of cost. On the other hand, a minor risk may affect a large population and thus be extremely costly. It might be decided, therefore, that in such circumstances greater attention should be paid to the latter situation.
Priorities constantly change, and work will move from one topic to an- other. Nevertheless, once a particular problem has been controlled to an acceptable level, efforts must be made to maintain what has already been achieved. This requires a re-evaluation of strategies and plans to assess the resources required to monitor and maintain that level of achievement, and the resources that will remain for addressing the next priorities. A balance is needed between new priorities and the work necessary to maintain existing baselines, so as to ensure that resources are used efficiently while at the same time the health of the population continues to improve.
Planning There are several elements that can be considered in the development of a local strategic environmental health plan. At this stage, the baseline information will have been collected and the priority setting completed. The planning process will determine how the problems already identi- fied are to be dealt with.
First, key supporters of particular local objectives should be identified. These may be local or regional authorities, NGOs or even sectors of private industry. Environmental health services, in developing their strategic plans, should liaise closely with such groups to facilitate teamwork and to identify complementary roles. Working groups and liaison committees can be established to monitor progress on specific issues, and to coordinate the technical input to the decision-making process.
STRATEGIES 37
The main opponents and barriers to the achievement of objectives should also be clearly identified. Depending on the problem, opposing groups can either be singled out for action or education programmes or they can be avoided altogether. Barriers do not, however, necessarily take the form of institutions or groups. Legislation, or the lack of it, can also act as a barrier to the achievement of objectives. In such circum- stances, the first action under the local plan will be to lobby for a change in or introduction of legislation to deal with the problem in the most appropriate manner. The level of resources available to the environmen- tal health services may also prevent the achievement of a particular ob- jective. It is important that the full extent of such barriers is known at the outset, so that the appropriate measures can be built into the plan- ning process (17).
From the process of policy integration between national and local concerns (Fig. 2), a local intervention plan can be developed. This plan can set out measurable targets to be achieved in a set time. Targets can be based on risk assessment principles, mortality and morbidity data and potentially high-risk scenarios. Targets can also be set that do not necessarily relate to measurements of health improvement but reflect the level of activity of the environmental health services. These can in- clude the number of inspections carried out, the number of complaints dealt with, the amount of taxes or fines collected or the number of legal notices issued. These, however, as indicators of activity rather than per- formance, cannot be relied on to indicate the effectiveness of the ser- vices provided. For example, an increase in the number of complaints could be an indication that standards in the service have dropped and that the problem has reached an unacceptable level. On the other hand, it could be viewed as a success in raising public awareness. Such dual interpretations can prove to be misleading, and services should take care not to rely too heavily on such indicators of performance. The WHO health for all and Healthy Cities indicators can also be used as barometers of change (10,21).
Once the various interventions have been agreed on and adopted, various protocols can be developed to ensure that policies are effectively translated into practice. Documentation could be produced on a wide range of subjects such as risk assessment, routine investigation and moni- toring. Contingency plans, educational programmes, enforcement activities and risk communication guidelines could all be produced for professional
38 ENVIRONMENTAL HEALTH SERVICES IN EUROPE 2
staff. Such guidance will ensure not only that the strategies are carried out as intended, but that they are also completed in a consistent manner.
The implementation of the strategic plan will of course depend on the available resources, and any limitations must be fully recognized. There are, however, areas of expenditure that are essential for a workable strategy. Staff training, for example, may be required to provide a workforce that is able to respond effectively to the demands placed upon it, and the planning of any strategy should include an element of staff training. Similarly, a strategy can be very effective if it is supported by a programme of communication. Communication of objectives and strat- egies will assist in the development of links with other interested part- ners, and may encourage other service providers to support environ- mental health programmes.
PUBLIC PARTICIPATION
Public participation is crucial for both strategy and action. The right to participate in the political process is one of the most fundamental of human rights. Participation also serves to promote health and environmental quality in two other re- spects: first as a means of stimulating action and motivating individuals and communities to contribute to the improvement of health and a good environment; and second as a check on abuse of the environment. Citizens with clear rights and knowledge, and who have access to a legal system that makes speedy redress possible, are a powerful constraint on the contravention of health and environmental regulations.
Communications A communications strategy should form an integral and fundamental part of the programme of work of any environmental health service. Declared intentions regarding the transparency of policy formulation and the availability of collected data should be supported with actual mechanisms to ensure that these intentions are fulfilled.
The communication of environmental health information to the public brings many benefits. Information and education allow members of the public to participate more confidently in policy-making. They also allow
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those who are already involved in the various processes to distinguish among relative risks, and to sort through the often conflicting claims of the different actors in the field of environmental health.
Environmental health policies, issues and laws can be complex. The full impact of environmental health actions can sometimes spread wider than intended, and occasionally action has to be taken in one sector in order to have an effect on another. The dissemination of such concepts requires time and a considered approach if the public is fully to understand the intentions behind the actions. A communications strategy demands careful planning.
Public participation is required to ensure the success of any envi- ronmental health programme. Not only does it allow people to under- stand the issues that the services are attempting to deal with, but it gives them an opportunity to promote social change through their own ac- tions. Public interest in environmental and associated concepts has in- creased greatly in recent years. Although this interest has somewhat de- clined in the eastern countries of the European Region of late, owing to the greater attention being paid to economic reforms, it will not disap- pear altogether. Environmental health services, in designing their strat- egies, need to be fully aware of this interest and to nurture, develop and manage it. Recognizing the value of public participation is not enough; environmental health services must actively communicate with the pub- lic to encourage that participation (15,17,20).
Both the quantity and the quality of the information communicated to the public must be analysed. The method of communication also needs to be considered, so that the most cost-effective strategy can be devel- oped. The target audience may largely determine the way in which infor- mation is delivered.
Journalists and other media professionals are important partners in the development of communication strategies. They should be singled out by environmental health services to receive information and educa- tional programmes with a view to encouraging good relationships and providing them with a better understanding of the issues and constraints involved (17).
Finally, the role of NGOs should not be forgotten. Environmental health services have to work together with appropriate responsible NGOs
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to increase public understanding. NGOs will often have access to a know- ledge base and information networks that the environmental health ser- vices have not yet developed. The services should attempt to tap those resources and work in partnership with NGOs to promote their mutual interests.
STRATEGY MANAGEMENT
Once a strategy has been formulated and is ready for implementation, certain management structures will need to be in place. The roles and procedures in the management process can be built into legislative frameworks. These systems rely mainly on recording levels of activity and other basic indicators that reflect the work of environmental health services rather than their impact. In terms of day-to-day management, and in setting and reaching targets, such systems of recording can be extremely useful.
Monitoring and quality assurance Monitoring of environmental parameters is a fundamental task of environmental health services. Equipment and laboratories are used extensively in determining pollution levels and the toxicity of sub- stances and in epidemiological studies. The result of such monitor- ing will often determine the action subsequently taken, and may serve to indicate whether or not a legal standard has been contravened. It is therefore vital that such work is carried out consistently, not only within the service itself but also at national and international levels. Standards or guidelines for pollution levels are very often set at in- ternational level, and it therefore follows that procedures for moni- toring those levels must follow international protocols where they exist. Where national standards are used, the accompanying protocols also need to be produced.
Equipment used to measure environmental parameters can be expen- sive and complex. When planning strategies that make use of such equip- ment, it will be necessary to budget for quality control, calibration and maintenance. If such considerations are not built into the strategy, the results may be at worst valueless and at best unreliable. Management systems that ensure quality of performance are also needed. Managers
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of services should monitor the activities of their staff by such means as reference laboratories and validation inspections. Either a local or a cen- tral reference authority or laboratory could be used to confirm the qual- ity of results or interventions.
Audits of performance can be carried out within the service, though external audits, either by a ministry department or by a central auditing body, will prove more effective. If environmental health services utilize private companies to carry out some of their functions, they will natu- rally set up an audit procedure to ensure that the terms of the contract are fulfilled. These principles should also apply to the work of the envi- ronmental health services themselves.
Complaint management Complaints by the general public can, in some cases, generate most of the work of environmental health services, and as a public service they need to respond effectively to such complaints. Service managers need to develop protocols for this work, developing clear reporting structures and identifying the responsible personnel. Recording systems, response times and the outcome of the complaint should all be considered. The public should be aware of these protocols, and the appeals procedure if a complaint has not been effectively dealt with.
Contingency management Environmental health problems cannot always be predicted. The fre- quency with which various types of natural and man-made disaster oc- cur demands that systems be provided to cope with such eventualities and to ensure that the threat to public health is reduced. Most major accidents have their most significant impact at local level, and the local services must therefore be prepared for such eventualities.
In an emergency, the services will have to adopt roles in addition to their normal everyday functions. This will involve three phases: prepa- ration of plans, dealing with the emergency and returning to normality. The objective throughout will be to protect the public and the environment from any additional risk caused by the intervention of other emergency services. Environmental health services will already have a comprehen- sive database of information relating to potentially hazardous sites and likely eventualities, and will have close links with other public and emer- gency services. They are thus well placed to develop and coordinate the
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emergency plan for their particular administrative area. Disasters do not, however, respect lines on a map, and therefore good coordination will be needed with neighbouring services and even with other countries.
In drawing up emergency plans, the services need to appreciate fully the roles and interrelationships of the various agencies at central, regional and local levels. Five principles can form the basis of any plan; a plan:
1. should be in writing and simple to read; 2. should ensure that all those responsible for putting it into effect
have been notified and understand their role; 3. should be comprehensive; 4. must make advance arrangements for effective operational con-
trol; and 5. should make provision for the use of facilities during an emer-
gency.
These principles should be applied to each of the following essential components common to all plans.
The plan must identify the key personnel in each department and the roles they undertake. It should provide information on contacting these personnel both during and after office hours, and on contacting back-up staff if they are not available. The plan should identify those responsible for maintaining and keeping it up to date.
The plan must lay down a management structure that will be in op- eration during the incident. It must identify who can make decisions and at what levels the various decisions will be made. It must identify lines of communication and the ways in which requests for information and assistance will be handled. If the plan fails to do this, chaos and confu- sion will severely hamper the operation.
The plan should identify all available resources that may be of use during an incident, and should provide daytime and out-of-hours con- tact names and telephone numbers, along with information on any re- strictions on availability.
The plan should provide for regular liaison among the key personnel. It is essential that this includes personnel from other agencies involved
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in the plan, so that effective working relationships are established before any incident occurs.
The plan must be written concisely and simply, so that, if necessary, someone unfamiliar with the plan can put it into action.
Once the plan has been written, it should be tested theoretically against a number of different scenarios. It should also be regularly tested by means of full-scale exercises to ensure that it is effective in dealing with a real incident.
These exercises, together with the regular liaison between the key personnel, will lead to review and revision of the plan. The date of the latest update should be clearly shown at the beginning of the plan.
In 1993, the Lucerne Conference on an Environmental Action Programme for Central and Eastern Europe (22) suggested that the greatest contribution to improved environmental management is likely to come from the strengthening of local and regional institutions within countries and, in particular, from improving their capacities for financial and economic management.
Once an environmental health policy has been established, a country has to set about implementing it. This will undoubtedly involve the utiliza- tion of environmental health services. These services are normally formed around institutional structures suitably located, both geographically and governmentally, for the level of service required.
Very often, the location of these institutions will have been deter- mined historically in an unplanned organic manner, though occasionally direct intervention and planning will have resulted in the creation of service delivery bodies.
The institutional development of environmental health services re- lies on a number of different factors, all of which are interconnected. The nature of environmental health as a subject depends on an intersectoral approach, as described in Chapter 1. This chapter explores the organizational structures of service institutions, both internal and external.
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Institutional Development
3
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Environmental health service institutions do not work purely within government networks. The use of private services and links with private enterprise, the general public and communities also determines the institutional development of these services. All of these aspects are examined in this chapter and various options for development are suggested.
Finally, this chapter considers the various support mechanisms re- quired for the effective operation of environmental health service insti- tutions. This includes an examination of the necessary legislative bases, the financial mechanisms and the information support required to en- sure such institutions can operate adequately and develop further.
ORGANIZATIONAL STRUCTURES
National level It has already been demonstrated that the primary respon- sibility for environmental health policy and therefore for the operation of the environmental health services in any country lies with the national government. When this role is estab- lished, its precise nature and the institutional framework and infrastructures needed to carry it out must be developed.
One of the essential functions of national governments in the implemen- tation of any strategy is systematic and effective planning. They must take the responsibility for coordination and the setting of priorities. It has clearly been shown that environmental health is a widely diverse field whose effective management requires an intersectoral approach. It is therefore essential that national institutions and structures are created in such a way that they can operate in an intersectoral manner. The na- tional level also plays a role in providing scientific advice and dissemi- nating the results of research, information that should be available both within and outside the environmental health services.
In many of the eastern countries of the European Region, the move from a centrally controlled economy to one led by market forces has resulted in significant changes in the system of government. This is es- pecially true in the field of environmental health. Rather than dictating through decrees, governments now find themselves having to achieve
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effective control through a range of softer tools such as incentives, per- suasion, negotiation and compromise. They can no longer plan centrally, but must set parameters within which market and social forces can de- termine what is acceptable or unacceptable.
In addition to the economic reforms currently taking place in eastern countries, countries throughout the Region are going through a process of decentralization. The transfer of decision-making from the centre to the regions and districts of a country is fundamental to the success of a democratic society, and as such must be encouraged. The delegation of power from national to