Updated regional strategy for the management of environmental determinants of human health in the African Region 2022–2032: report of the Secretariat

AFR/RC72/10 5 July 2022 REGIONAL COMMITTEE FOR AFRICA Seventy-second session Lomé, Republic of Togo, 22–26 August 2022 ORIGINAL: ENGLISH Provisional agenda item 13 UPDATED REGIONAL STRATEGY FOR THE MANAGEMENT OF ENVIRONMENTAL DETERMINANTS OF HUMAN HEALTH IN THE AFRICAN REGION 2022–2032 Report of the Secretariat EXECUTIVE SUMMARY 1. The planet and people’s health are central to the 2030 Agenda for Sustainable Development. Environmental risks account for a large fraction of the burden of disease. Nearly a quarter of all deaths in Africa are reportedly due to environmental causes, including the impacts of climate change. 2. The Libreville Declaration on health and environment was adopted in 2008 to jointly address health and environmental issues in Africa. In 2018, the Third Interministerial Conference on Health and Environment (IMCHE3) endorsed the Strategic Action Plan to scale up these interventions (2019–2029). 3. The Regional strategy for the management of environmental determinants of human health (2017–2021), adopted by the Sixty-seventh WHO Regional Committee for Africa, aimed to advance the agenda of the Libreville Declaration. Its principal focus areas were safe drinking water, sanitation and hygiene, air pollution and clean energy, chemicals and wastes, climate change, vector control and health in the workplace. 4. Limited investments and COVID-19 markedly slowed down the implementation of the previous strategy but provided lessons and opportunities for renewed action. The updated strategy that seeks to revitalize action on environmental determinants of human health and contribute to sustainable development, mainly updates key milestones and targets in light of recent developments, within the scope of the previous strategic document. It integrates recommendations from the WHO manifesto for a healthy recovery from the COVID-19 pandemic. 5. The Regional Committee is invited to review and adopt the proposed strategy. ii CONTENTS Paragraphs INTRODUCTION .................................................................................................................................... 1–4 SITUATION ANALYSIS AND JUSTIFICATION ............................................................................... 5–12 THE REGIONAL STRATEGY ........................................................................................................... 13–35 CONCLUSION ..................................................................................................................................... 36–38 AFR/RC72/10 Page 1 INTRODUCTION 1. “Health and environment” issues of concern include access to safe drinking water; sanitation and hygiene services; management of water, soil and air pollution; vector control and management of chemicals and waste; children’s environmental health; and health in the workplace.1 These issues are influenced by socioeconomic conditions and are adversely affected by climate change. There is a strong connection between human, environmental and animal health, which underpins the need to adopt the One Health approach to prevent emergent and recurrent diseases. 2. In sub-Saharan Africa, most environment-related deaths are primarily from infectious diseases. Most Member States are still grappling with traditional environmental health risks like poor access to safe drinking-water and sanitation, and cooking fuels. Meanwhile, air pollution, tobacco smoke and chemicals are driving the burden of noncommunicable diseases (NCDs). In Africa, an estimated 28% of all premature deaths are attributed to environmental factors.2 With weak health care systems and services, stronger intersectoral action to create healthier environments is paramount. 3. Recognizing the importance of environmental factors as determinants of human health, African ministers of health and environment adopted the Libreville Declaration on Health and Environment in Africa3 in 2008. The Declaration is an overarching policy framework within which Member States of the Region can coherently address environmental determinants of human health and ecosystem integrity. In Luanda (2010), ministers renewed their commitment to enhancing intersectoral actions and their co-benefits for human health and the environment.4 At their third conference in 2018, they adopted the strategic action plan to scale up health and environment interventions in Africa (2019–2029)5 to accelerate the implementation of the Libreville Declaration. 4. This updated regional strategy builds on the results of the previous strategy (2017–2021) adopted by the Sixty-seventh Regional Committee (AFR/RC67/6)6 and provides guidance and support to Member States on addressing health and environment linkages through the implementation of the Libreville Declaration. SITUATION ANALYSIS AND JUSTIFICATION 5. Progress to date has been slower than anticipated and reveals significant gaps. The main bottlenecks were the low operational uptake by Member States and limited access to financing. Interventions continue to be very limited in their scale and impact. The COVID-19 pandemic greatly impeded the implementation of the previous strategy, especially in term of workforce health and safety. 1 World Health Organization, République du Gabon and United Nations Environment Programme. New and Emerging Environmental Threats to Human Health. In First Interministerial Conference on Health and Environment in Africa: Health Security through Healthy Environments 6 (2008). 2 WHO, Preventing disease through healthy environments: assessment of the burden of disease from environmental risks, Geneva, World Health Organization, 2018 3 WHO/UNEP, the Libreville Declaration on Health and Environment in Africa, Brazzaville, World Health Organization, 2008. 4 WHO/UNEP, Implementation of the Libreville Declaration on Health and Environment in Africa - Luanda Commitment - Luanda, 26 November 2010 – WHO – ISBN 978 929 023 1806 (NLM Classification: WA 670) 5 IMCHE3/CP4 - Outcome document of the third inter-ministerial conference on health and environment in Africa 6-9 November 2018, Libreville, Gabon - Strategic Action Plan to scale up Health and Environment Interventions in Africa 2019–2029. Adopted on 9 November 2018 by Decision IMCHE/3/1. 6 https://www.afro.who.int/sites/default/files/2017-12/AFR-RC67- 6%20Regional%20strategy%20for%20environ%20health%20determ%20Human%20Health.pdf AFR/RC72/10 Page 2 6. Climate change impacts health through increased vulnerability to airborne, waterborne and vector-borne diseases and malnutrition.7 Nineteen Member States8 completed climate change vulnerability and adaptation assessments and 22 developed health national adaptation plans (HNAPs).9 Furthermore, 11 Member States10 developed national health and climate country profiles.11 7. In 2017, at the 23rd Conference of the Parties (COP23) in Bonn, a Special Initiative on Climate Change and Health in Small Island Developing States (SIDS) was launched. The Initiative recognizes that SIDS are particularly vulnerable to a range of acute and long-term risks. Most of the African SIDS are characterized by limited freshwater lens (high water table), geographical remoteness, small economies and high unit costs hampering a rapid response to emergencies and adequate provision of primary health care and referrals. They have similar health challenges notably, a disproportionately high burden of obesity and noncommunicable and vector-borne diseases. 8. In 2021, WHO AFRO commissioned an assessment of the status of poison control centres or toxicology units across the Region with the aim of designing a strategy and an operational framework for strengthening the prevention and management of chemical risks and toxicological information in African countries. Factors limiting the performance of these centres include insufficient staff training (50%), limited availability of medical personnel (73%), and lack of sustainable funding (100%). In addition, following the onset of COVID-19, activity has reduced in 45% of the poison control centres. 9. Available data suggest that every child under five years of age in sub-Saharan Africa has been exposed to unsafe levels of air pollution, with lifelong consequences, including greater risk of chronic respiratory and cardiovascular diseases.12 To date, only 6% of under-five children live within range of an air pollution monitoring station,13 while 72 cities spread across 14 Member States actively monitor air quality.14 10. To reflect the changing global policy landscape, the Third Interministerial Conference on Health and Environment (IMCHE3-2018) endorsed a strategic action plan to scale up health and environment interventions in Africa (2019–2029). As recommended in the plan, 39 Member States15 completed situation analyses and needs assessments (SANAs) but only 22 prepared national plans of joint action (NPJAs).16 7 Resolution AFR/RC61/R2, Framework for Public Health Adaptation to Climate Change in the African Region. In: Sixty- first session of the WHO Regional Committee for Africa, Yamoussoukro, Côte d'Ivoire, 29 August–2 September 2011, Final Report. Brazzaville, World Health Organization, Regional Office for Africa, 2011 (AFR/RC61/14.), pp.8-10. 8 Benin, Burkina Faso, Cabo Verde, Côte d'Ivoire, Eritrea, Ethiopia, Ghana, Guinea, Kenya, Madagascar, Malawi, Mali, Mozambique, Nigeria, Sao Tome and Principe, Togo, Zambia, Rwanda, United Republic of Tanzania 9 Algeria, Benin, Botswana, Cabo Verde, Côte d'Ivoire, Eritrea, Ethiopia, Ghana, Guinea, Kenya, Madagascar, Malawi, Mozambique, Nigeria, Sao Tome and Principe, Seychelles, South Africa, Togo, Zambia, Rwanda, Uganda, United Republic of Tanzania 10 Algeria, Botswana, Ethiopia, Ghana, Kenya, Madagascar, Mauritius, Sao Tome and Principe, South Africa, Uganda and the United Republic of Tanzania 11 Health and Climate Change Country Profiles, Geneva, World Health Organization, 2021, https://www.who.int/activities/monitoring-health-impacts-of-climate-change-and-national-progress 12 https://www.earthobservations.org/documents/aws/rwanda_2019_air_quality_aws_proposal.pdf 13 https://www.unicef.org/media/55081/file/Silent%20suffocation%20in%20africa%20air%20pollution%202019%20.pdf 14 https://www.waqi.info/#/c/6.973/7.936/2.6z : World Air Quality Index project 15 Algeria, Angola, Burkina Faso, Botswana, Burundi, Cameroon, Cabo Verde, Central African Republic, Congo, Côte d’Ivoire, Democratic Republic of the of Congo, Eritrea, Eswatini, Ethiopia, Gabon, Gambia, Ghana, Guinea, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Niger, Rwanda, Sao Tome and Principe, Seychelles, Sierra Leone, South Africa, South Sudan, United Republic of Tanzania, Togo, Uganda, Zambia, Zimbabwe 16 2021 WHO Health and Climate Change Survey Report, Geneva, World Health Organization, 2021. AFR/RC72/10 Page 3 11. The WHO manifesto for a healthy and green recovery from COVID-19 and the African Green Stimulus Programme (AGSP) will support the continent's recovery from the pandemic's devastating socioeconomic and environmental impacts.17 The 26th Conference of the Parties (2021) reframed climate change as a health issue. Nineteen Member States18 committed to building resilient and low-carbon health systems.19 12. The initial strategy (2017–2021) encompassed the requisite features for addressing the environment and health nexus sustainably by its capacity and potential role in translating the continent’s aspirations into actions. The proposed update is principally aimed at renewing key milestones and targets in light of recent developments, within the scope of the previous strategic document. THE REGIONAL STRATEGY Aim, objectives, milestones, targets 13. Aim: To reduce the burden of diseases attributable to environmental determinants through safe, sustainable, and health-enhancing human environments across the Region. 14. Objectives: The general objective is to provide guidance to Member States on addressing health and environment linkages for achieving the SDGs. The specific objectives are to: (a) promote synergies and coordination between the health and environment sectors in support of implementing the Libreville Declaration. (b) develop and implement national joint action plans for the management of environmental risk factors of human health and ecosystem integrity. (c) strengthen national and regional capacity for integrated monitoring and surveillance of environmental determinants of health and ecosystem integrity through health and environment observatories. 15. Milestones and targets: Target by 2032: (a) Population using safely managed drinking-water sources increased by 30% (baseline 2016). (b) Population using safely managed sanitation services increased by 20% (baseline 2016). (c) Data on ambient air quality established in at least 40 Member States. (d) At least one functioning poison control centre or toxicology unit meeting WHO minimum requirements established in each country. https://www.who.int/publications-detail-redirect/9789240038509 17 UNEP, Proceedings of the 8th special session of African conference on Environment (AMCEN, 2020), the African Green Stimulus Programme AGSP 18 Cabo Verde, Central African Republic, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Guinea, Kenya, Madagascar, Mauritania, Malawi, Mozambique, Nigeria, Rwanda, Sao Tome and Principe, Sierra Leone, United Republic of Tanzania, Togo and Uganda 19 Health Programme of the 26th Conference of the Parties to the United Nations Framework Convention on Climate Change (UNFCCC), Geneva, World Health Organization, 2021, https://www.who.int/initiatives/cop26-health- programme AFR/RC72/10 Page 4 (e) National policy instruments for action on workers’ health developed by at least 25 Member States. Milestones by 2027: (a) Multisectoral country task team (CTT) established by all Member States with high-level anchorage for accountability at presidential or premier level where feasible. (b) National plans of joint action developed by all Member States. (c) Monitoring and evaluation frameworks established in all Member States. (d) National framework for water safety plans (WSP) developed in at least 30 Member States. (e) Health national adaptation plans to climate change developed in at least 30 Member States. (f) Health dimension included in Nationally Determined Contributions (NDCs) of All Member States. 16. Guiding principles: (a) Country ownership and leadership: National authorities spearhead the development of national plans of joint action in line with the SDGs (good governance). (b) Integration: Integrating proven interventions for tangible progress by optimizing synergies and minimizing duplication and transaction costs. (c) Win-win partnership and intersectoral collaboration: Coordinating and acting across sectors, as many different sectors play a crucial role in determining environmental risks and conditions. (d) Equity and human rights: Integrating the rights to life, health, food, water and sanitation with special attention to people disproportionately affected and disadvantaged. (e) Community engagement: Mainstreaming and embedding community systems within health service planning and addressing environmental health determinants. (f) Innovation and technology: Seek and make use of innovative mechanisms to secure the means and resources needed to get the work done. Priority actions 17. Strengthening the policy framework and institutional mechanisms for integrated environment and health interventions: In line with the Health and Environment Strategic Alliance in Africa (2010),20 a multisectoral and multidisciplinary country task team should be established associating all interested parties. Policies, laws and tools should also be developed to adequately address environmental protection. 18. Undertaking risk and capacity assessments: A situation analysis and needs assessment should be undertaken as a prerequisite for the development of national plans of joint action addressing the full array of environmental health determinants, the drivers that determine their associated risk levels and the management of these risks. 19. Building infrastructural, technical and institutional capacities: The capacity of national experts operating in relevant sectors should be jointly strengthened in the use of environmental data, including climate information in disease surveillance and early warning. Long-term human 20 WHO/UNEP. Arrangements of Health and Environment Strategic Alliance, Brazzaville, World Health Organization, 2010. AFR/RC72/10 Page 5 capacity building should integrate health education and environmental health promotion in the curricula of educational institutions. National environmental health services should use economic analysis and methodologies such as the cost of inaction to inform decision-making. 20. Establishing or enhancing integration and interoperability of health and environment surveillance systems: This integrated approach will help track trends in indicators that focus on environmental risk factors most relevant to health, health outcomes most influenced by the environment, and policy action deemed to reduce and prevent the risks. 21. Shaping the research agenda: Mechanisms should be established for consolidating scientific evidence and sharing experiences and lessons learnt to guide policies and practice on environmental health at regional and national levels. 22. Raising awareness and undertaking social mobilization: Community literacy on health and environment linkages, climate change, social and behavioural change should also be improved. Emphasis should be put on community empowerment for effective adoption and deployment of simple, cost-effective interventions. Scaling up cost-effective primary prevention interventions: 23. Improve access to safe drinking-water, sanitation and hygiene (WASH): In line with WHO guidelines for drinking-water quality,21 efforts should focus on scaling up existing initiatives such as water safety plans (WSP), sanitation safety planning (SSP), household water treatment and safe storage (HWTS), WASH in specific settings, including health facilities and schools, and mainstreaming WASH in health programmes (nutrition, neglected tropical diseases, maternal, child and newborn health, as well as infection prevention and control). 24. Manage air pollution and promote clean energy: National legislation and regulatory instruments on public health should be harmonized and enforced to promote the use of clean energy sources for cooking, heating and lighting (including in the health sector) and to enhance sustainable urban policies in energy, transport, waste management and industry to reduce the emission of short-lived climate pollutants. Air pollution monitoring should be promoted and evidence consolidated on its impact on human health. 25. Chemical and waste management should be conducted in line with the WHO road map to enhance health sector engagement in the strategic approach to international chemical management towards the 2020 goal and beyond,22 the Minamata Convention on mercury and other multilateral environment agreements23 ratified by Member States, as well as the International Health Regulations (2005). National frameworks should be developed for chemical and waste management, together with the establishment and strengthening of poisons control centres and multi-stakeholders’ surveillance alert and response mechanisms for chemical incidents. Analysis and guidance should be provided to limit the importation of second-hand 21 WHO, Guidelines for drinking-water quality: Fourth edition incorporating the first addendum. Geneva, World Health Organization, 2017. 22 WHO, The role of the health sector in the Strategic Approach to International Chemicals Management towards the 2020 Goal and beyond, May 2017, Geneva, World Health Organization, http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_36- en.pdf. 23 (a) Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal (1989); (b) Bamako Convention on the ban of the Import into Africa and the Control of Transboundary Movement and Management of Hazardous Wastes within Africa (1991); (c) Rotterdam Convention on the Prior Informed Consent Procedure for Certain Hazardous Chemicals and Pesticides in International Trade (1998); (d) Stockholm Convention on Persistent Organic Pollutants (2001). (d) Strategic Approach to International Chemicals Management (2006), and (e) Minamata Convention on Mercury (2013). AFR/RC72/10 Page 6 equipment (vehicles, machinery, and electronic devices) that contribute significantly to waste management challenges in the Region. 26. Integrated vector management (IVM): Integrated vector management strategies should be implemented in the context of the Global Vector Control Response24 to reduce disease transmission and reliance on chemicals and to effectively respond to emergencies due to vector- borne diseases. Marine and coastal pollution should be controlled through effective implementation of multilateral environmental agreements and enforcement of national policies and regulations. 27. Manage the impact of climate change on health: Vulnerability and adaptation to climate change assessments should be conducted where they are not available; otherwise, health national adaptation plans should be finalized and their implementation fast-tracked. Climate resilience should be mainstreamed in health plans and programmes to enhance early warning and surveillance of climate-sensitive diseases. Foster biodiversity conservation and natural resource management: “One health” platforms should be established to promote understanding and management of the interlinkages between human, animal, and environmental health, while integrated assessments should be periodically undertaken to address ecosystem degradation and biodiversity loss. 28. Promote occupational health and healthy setting initiatives: Based on the WHO Global plan of action on workers’ health,25 national plans on workers’ health should be developed and implemented (including for the health sector). Particular attention should be paid to scaling up cost-effective social protection schemes and initiatives on the promotion of healthy settings. 29. Improve management of natural and human-induced disasters: Joint health and environment national and local disaster risk reduction strategies should be developed and implemented in line with the Sendai Framework for Disaster Risk Reduction; related concepts and practices should be integrated into educational curricula at all levels. 30. Establish a sustainable financing mechanism: The need for appropriate funding for the health and environment sectors (especially for work on health and environment linkages) was recognized in the Libreville Declaration, which called inter alia for "achieving a balance in the allocation of national budgetary resources for intersectoral health and environment programmes”. Roles and responsibilities 31. The Member States should: (a) Provide stewardship and leadership, forge partnerships with donors, multilateral agencies, the private sector and civil society. (b) Set standards to control environmental degradation for commercial actors and sectors (tourism, transport, urban development, mining, etc) whose business structures and operations entail environmental health risks. (c) Increase allocation of resources and scale up domestic investments on platforms, initiatives and programmes addressing the impact of environmental factors on health. (d) Champion intercountry stakeholder dialogue and promote public-private partnerships, 24 WHO Global vector control response, Geneva, World Health Organization, 2017: http://www.who.int/malaria/global- vector-control-response. 25 Resolution WHA60.26, Workers’ health: Global Plan of Action. In: Sixtieth World Health Assembly. World Health Organization, 23 May 2007. http://www.who.int/occupational_health/WHO_health_assembly_en_web.pdf. AFR/RC72/10 Page 7 including cross-border collaboration. (e) Set the research agenda, consolidate scientific evidence, and share experiences and lessons learnt on managing health and environment in the African Region. (f) Implement key priority actions and interventions including grassroot level. 32. Local communities should: (a) Adopt appropriate behaviour in environmental stewardship using biodegradable materials, reducing waste through recycling and considering the environmental impact of development initiatives. (b) Ensure that communities collaborate with their respective governments in environmental health promotion. 33. WHO and partners should: (a) Set and disseminate norms and standards, policy advice and implementation guidance, including methodologies and protocols to support country actions. (b) Facilitate capacity building and technical assistance for the development and implementation of national plans of joint action including cross-border dimensions. (c) Catalyse mobilization of domestic and external resources by supporting the development of national business cases for investment in priority health and environment interventions. (d) Advocate for heightened commitment, increased visibility, prioritization, and understanding of health and environment linkages within and beyond WHO. (e) Promote regional stakeholders’ dialogue and public-private partnerships. Resource implications 34. Sustained financial resources are needed to support intersectoral coordination mechanisms and to scale up investment in priority interventions. If half of the Member States receive technical support every year, the total financial implication for the Secretariat over the 10-year period is projected to be at least US$ 7.5 million. Member States should mobilize domestic and external resources to implement the strategy, tackling fragmentation and underfunding. Monitoring and evaluation 35. Member States should establish or consolidate an integrated national framework for joint monitoring and evaluation of priority intersectoral interventions on an annual basis; they should also participate in existing global monitoring initiatives. A progress report on the implementation of this strategy should be presented to the WHO Regional Committee every two years starting in 2024. CONCLUSION 36. Currently, environmental challenges are occurring at an unprecedented pace. With its highly vulnerable populations (especially in Small Island Developing States), the African Region is experiencing high burdens of both communicable and noncommunicable diseases. These include vector-borne, diarrhoeal and cardiovascular diseases, as well as lower respiratory infections that are significantly attributable to environmental determinants. Ambient and household air pollution and inadequate water, sanitation, and hygiene facilities are the environmental drivers of these diseases. Climate change, unplanned urbanization, rapid population growth, and urban migration exacerbate these factors. AFR/RC72/10 Page 8 37. Therefore, in line with the WHO manifesto for a healthy recovery from the COVID-19 pandemic, this 10-year strategy proposes the revitalization of action on environmental determinants of human health and ecosystem integrity. Its implementation by Member States is expected to significantly contribute to the attainment of the SDGs and beyond. 38. The Regional Committee is invited to review and adopt the strategy.