More health for your buck: health sector functions to secure environmental health

880 Bull World Health Organ 2009;87:880–882 | doi:10.2471/BLT.08.059865 More health for your buck: health sector functions to secure environmental health Eva A Rehfuess,a Nigel Bruceb & Jamie K Bartramc a Department of Medical Informatics, Biometry and Epidemiology, University of Munich, Marchioninistrasse 15, 81377, Munich, Germany. b Division of Public Health, University of Liverpool, Whelan Building Quadrangle, Liverpool, L69 3GB, England. c Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America. Correspondence to: Eva A Rehfuess (e-mail: rehfuess@ibe.med.uni-muenchen.de). (Submitted: 2 October 2008 – Revised version received: 11 March 2009 – Accepted:24 March 2009 – Published online: 14 October 2009 ) Introduction Modifiable environmental risk factors are responsible for approximately one quarter of the global burden of disease. This environmental burden of disease is distributed extremely unequally: in developing countries 15 times more healthy life years are lost per capita than in developed countries, with di- arrhoea and acute lower respiratory infections among children being the largest contributors. The two principal environmental risk complexes for these diseases – drinking-water/sanitation/ hygiene and indoor air pollution from solid fuel use – cause more than 2 mil- lion deaths annually.1 Known effective solutions include: ensuring that households have access to and use safe drinking-water and im- proved sanitation facilities; encouraging household water treatment; promoting the use of cleaner-burning stoves and switching from traditional solid fuels to cleaner modern fuels.2,3 They are good value for money, yielding health-care savings, health-related productivity gains, time savings and environmental benefits that far exceed costs. Delivery of environmental health interventions is, however, rarely ad- ministered or controlled directly by the health sector. Uncertainty about leadership and responsibilities across many public and private actors contrib- utes to overall underperformance and inefficiency. This raises important ques- tions about the most appropriate and effective roles for the health sector in environmental health policy develop- ment and implementation. We believe that, to date, attempts to answer these questions, conceptually or in practice, have been limited but will be essential if we want to make use of a significant opportunity to reduce the disease bur- den attributable to the environment, especially in developing countries. Defining a health system Some would assert that, given the multitude of health problems and the health workforce crisis in developing countries, the health system should focus solely on the provision of health care and preventative services such as vaccination. They might argue that economic development – through a better infrastructure, higher incomes and greater purchasing power – would eventually take care of the “unfinished agenda” of access to basic environmen- tal health services and healthy living environments. This restricted view contradicts WHO’s definition of a health system: “A health system consists of all orga- nizations, people and actions whose primary intent is to promote, restore or maintain health. This includes efforts to influence determinants of health as well as more direct health-improving activi- ties. A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. … It includes inter-sectoral action by health staff …”4 Here, we argue that six specific health sector functions are critical in secur- ing environmental health gains – both through direct health sector action and through working with other sectors (Fig. 1). These functions are: (i) ensur- ing that environmental health issues are adequately reflected in inter-sectoral policy development and implementa- tion; (ii) setting and overseeing the implementation of health-protecting norms and regulations; (iii) incor- porating environmental health in disease-specific and integrated health programmes; (iv) practising environ- mental health in health-care facilities; (v) preparing for and responding to outbreaks of environment-mediated diseases; and (vi) identifying and re- sponding to emerging threats and op- portunities for health. It is evident from the WHO defi- nition and historical experience, in- cluding the 19th century sanitary revo- lution, that the health system must be involved to accelerate the scaling-up and improved delivery of environmen- tal health interventions.5 Multisectoral collaboration is com- plex and requires leadership and a clear consensus on and assignment of roles. Some of the critical health sector func- tions require direct action and leader- ship by that sector, while others can only be achieved in cooperation with other sectors. The execution of these functions can vary widely depending on the specific environmental health issue and between developing and de- veloped countries. Inter-sectoral policy Altering traditional household energy practices and extending use of safe drinking-water and sanitation involves energy, water, development, environ- ment and finance sectors. The “voice” of health – advocating through ministries of health, health professionals and non- governmental organizations – in argu- ing for improved policy, practice and financing, may secure substantial health investment outside health sector budget lines. For example, WHO involvement in the East African Community strategy to improve access to energy provided an opportunity to identify health concerns associated with energy alternatives pre- emptively and to ensure that chosen approaches actually deliver health gains in practice.6 Health sector roles include 881Bull World Health Organ 2009;87:880–882 | doi:10.2471/BLT.08.059865 Perspectives Environmental healthEva A Rehfuess et al. building and maintaining expertise to track and influence major policies that impact on health; employing formal mechanisms for health impact assess- ment; and establishing effective multi- disciplinary collaboration. Norms and regulations Experience shows that regulation and certification have a strong influence on the delivery of safe services, technolo- gies and products in homes, workplaces, schools and public places. Water safety plans, as promoted in WHO guide- lines,7 are being progressively applied in countries as diverse as Nigeria, the Philippines and the United Kingdom. In Iceland, for example, drinking-water quality improved markedly following regulations introduced in 1995 that require water suppliers to implement water safety plans. Various WHO normative guidelines on environment and health provide a consistent basis for protecting public health from the harmful effects of pollutants, based on best available evidence and scientific consensus. Health sector roles include developing health-protecting standards and regulations appropriate to a coun- try’s social, economic and environmental circumstances, as well as monitoring their implementation and contribution to achieving population health gains. Disease-specific and integrated programmes Health professionals – generalists or specialists – are influential in raising awareness about health determinants, influencing attitudes and behaviours and generating demand for solutions. Un- der Indonesia’s community Integrated Management of Childhood Illness pro- gramme, for example, every pregnant woman receives guidance on preventing coughs and diarrhoea by measures such as keeping children away from kitchen smoke, boiling water, hand-washing and using a toilet.8 The local implemen- tation of cross-cutting primary health care initiatives and of vertical disease programmes involves primary and community health workers, as well as social marketing campaigns through the media, schools and community organi- zations. Specific population groups may also be targeted, for example, HIV/ AIDS programmes should reflect that HIV-positive individuals are more sus- ceptible to environment-related disease Fig. 1. Health sector functions to secure environmental health Outbreaks of environment-mediated diseases Response to emerging threats and opportunities Environmental health in health-care facilities Health- protecting norms and regulations Environmental health in health programmes Health in inter-sectoral policies Primary leadership and direct action Primary coordination and cooperation with other sectors yet may be denied access to latrines or water access points for fear of infection. Health sector roles include integrating environmental determinants into cur- ricula for health professionals; incorpo- rating environmental health messages and actions in health programmes; and working with partners in raising aware- ness in countries. Health facilities “First do no harm” is a long-recognized maxim in health care. Nevertheless, health-care facilities cause many pre- ventable infections through inadequate management of water, waste, hygiene and ventilation.9 This imposes a high cost on the health system and attracts political and media criticism. In Lima, Peru, better air exchange achieved through improvements in the natural ventilation in tuberculosis wards re- duced the risk of disease transmission between patients, visitors and hospital staff.10 Health sector roles include set- ting standards for health-care facilities; budgeting for structural improvements and capacity-building to encourage behavioural changes among staff; and enforcing compliance through an inde- pendent oversight function. Outbreaks Outbreaks of environment-mediated disease, such as diarrhoea, occur in de- veloped and developing countries. An adequate response is critical for both disease containment and future preven- tion. The impact of an evolving under- standing of the underlying determinants 882 Bull World Health Organ 2009;87:880–882 | doi:10.2471/BLT.08.059865 Perspectives Environmental health Eva A Rehfuess et al. References 1. Prüss-Üstün A, Corvalan CF. Preventing disease through healthy environments: towards an estimate of the environmental burden of disease. Geneva: World Health Organization; 2006. 2. Bruce N, Rehfuess EA, Mehta S, Hutton G, Smith KR. Indoor air pollution. In: Jamison DT, ed. Disease control priorities in developing countries. 2nd edn. New York, NY: Oxford University Press; 2006. 3. Cairncross S, Valdmanis V. Water supply, sanitation, and hygiene promotion. In: Jamison DT, ed. Disease control priorities in developing countries. 2nd edn. New York, NY: Oxford University Press; 2006. 4. Everybody’s business: strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva: World Health Organization; 2007. 5. Bartram J. Flowing away: water and health opportunities. Bull World Health Organ 2008;86:2-3. PMID:18235877 doi:10.2471/BLT.07.049619 6. Strategy on scaling up access to modern energy services in order to achieve the Millennium Development Goals. Arusha: East African Community; 2007. 7. Guidelines for drinking-water quality, 3rd edn, Vol 1: recommendations. Geneva: World Health Organization; 2004. 8. Buku KIA. The maternal and child health handbook. Jakarta: Department of Health, Indonesia/Japan International Development Agency; 2003. 9. Prevention of hospital-acquired infections: a practical guide. 2nd edn. Geneva: World Health Organization; 2002. 10. Escombe AR, Oeser CC, Gilman RH, Navincopa M, Ticona E, Pan W,et al. Natural ventilation for the prevention of airborne contagion. PLoS Med 2007;4:e68. PMID:17326709 doi:10.1371/journal.pmed.0040068 11. Nichols G, Chalmers R, Lake I, Sopwith W, Regan M, Hunter P et al. Cryptosporidiosis: a report on the surveillance and epidemiology of Cryptosporidium infection in England and Wales. London: Drinking-water Inspectorate; 2006. 12. Bhattacharya SC, Leon MA. Prospects for biomass gasifiers for cooking applications in Asia. In: World Renewable Energy Regional Conference, Jakarta, Indonesia, 18-21 April 2005. of outbreaks on water management is well-recognized – from the removal of the handle from the Broad Street pump when John Snow recognized it was a source of cholera infection in 1854 to contemporary outbreaks of waterborne Cryptosporidium ssp. that have trans- formed policy and practice of disinfec- tion and filtration in water supply.11 Health sector roles include maintaining a nucleus of expertise to advise on and conduct outbreak investigation; testing, implementing and revising procedures in cooperation with other actors; and updating regulation and policy based on insights gained. Threats and opportunities Maximizing public health requires identifying and tackling new, emerg- ing and re-emerging risks and pursuing innovation. Such “proactivity” implies outbreak investigation (e.g. the initial recognition of legionella), examination of the spatial distribution of disease (e.g. vector-borne diseases in relation to climate change), analysis of trends in diseases and their determinants over time (e.g. tuberculosis resurgence following the break-up of the Soviet Union) and recognition of the value of technological advancement. For exam- ple, the Indian development of a new generation of efficient gasifier stoves, which minimize pollutant emissions from biomass combustion at relatively low cost, is of direct relevance to health improvement and climate change miti- gation.12 Health sector roles include seeking evidence for causal associations between environmental factors and health, as well as assessing the potential values and harms of technology innova- tion and policy development. Conclusion Environmental health is a necessary element of the health system. We con- tend: that the six critical health sector functions identified here are essential in preventing a significant proportion of the burden of disease; that they ap- ply to both developing and developed countries; and that they provide an under-used opportunity to translate the concept of primary health care into practice. The health sector is well-placed to be leader and catalyst for complex multi-sectoral action. Mainstreaming health into other sectors’ policies and programmes may be effective in tack- ling residual disease burdens that can- not be reduced through health sector action alone. In many cases, interven- tion costs are largely borne directly by households and are outweighed by the value of the benefits; the accompanying programme costs tend to be borne by sectors other than health. The required interventions therefore do not compete with health-care interventions for funding and thus represent a significant opportunity to mobilize additional resources for health. We argue that the health sector needs to embrace each of these func- tions and roles; health professionals at all levels should engage more system- atically and consistently in them; and active review of their implementation and impact should be undertaken as a matter of routine. ■ Acknowledgements We thank Phil Callan, Majid Ezzati, Philipp Lambach and Martin Weber for their comments. At the time of writing, Eva A Rehfuess and Jamie K Bartram were affiliated with the Department of Public Health and Environment at the World Health Organization, Geneva, Switzerland. Competing interests: None declared.