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Local environmentalhealth planningGuidance for local andnational authorities

WHO Regional PublicationsEuropean Series, No. 95

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Local environmentalhealth planningGuidance for local and

national authorities

WHO Library Cataloguing in Publication Data

MacArthur, Ian D.Local environmental health planning : guidance for localand national authorities / Ian D. MacArthur

(WHO regional publications. European series ; No. 95)

1.Environmental health 2.Health planning3.Community health planning 4.Local government5.National health programs 6.Guidelines 7.EuropeI.Title II.Series

ISBN 92 890 1362 1 (NLM Classification: WA 30)ISSN 0378-2255

Text editing: Mary Stewart BurgherCover art: Polina Panainte (10 years old), Theoretical High School LapusnaVillage, Hîncesti, Republic of Moldova. The High School participates in theEuropean Network of Health Promoting Schools, a joint project of the Euro-pean Commission, the Council of Europe and the WHO Regional Office forEurope.

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Local environmentalhealth planning

Guidance for local andnational authorities

ByIan D. MacArthur

Chartered Institute of Environmental Health,London, United Kingdom

WHO Regional Publications, European Series, No. 95

ISBN 92 890 1362 1ISSN 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 tothe Publications unit, WHO Regional Off ice for Europe,Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark, which will beglad to provide the latest information on any changes made to thetext, plans for new editions, and reprints and translations alreadyavailable.

© World Health Organization 2002

Publications of the World Health Organization enjoy copyright protec-tion in accordance with the provisions of Protocol 2 of the UniversalCopyright Convention. All rights reserved.

The designations employed and the presentation of the material inthis publication do not imply the expression of any opinion whatsoeveron the part of the Secretariat of the World Health Organization concern-ing the legal status of any country, territory, city or area or of its authori-ties, or concerning the delimitation of its frontiers or boundaries. Thenames of countries or areas used in this publication are those that ob-tained at the time the original language edition of the book was pre-pared.

The mention of specific companies or of certain manufacturers’ prod-ucts does not imply that they are endorsed or recommended by the WorldHealth Organization in preference to others of a similar nature that arenot mentioned. Errors and omissions excepted, the names of proprietaryproducts are distinguished by initial capital letters.

The views expressed in this publication are those of the authorand do not necessarily represent the decisions or the stated policy ofthe World Health Organization.

PRINTED IN DENMARK

Contents

Page

Foreword ........................................................................................... vii

Acknowledgements .......................................................................... ix

Abbreviations ..................................................................................... x

Part 1. Background

Introduction ........................................................................................ 1

1. The environmental health approach ......................................... 112. International frameworks, national plans and

local action ................................................................................... 23

Part 2. Local environmental health planning

3. The LEHAP planning process ................................................... 41

Part 3. The national–local relationship

4. National perspectives .................................................................. 815. Institutional development ..........................................................876. Supportive action at the national level ..................................... 93

References ......................................................................................... 97

Annex 1. LEHAP coordinators/contact points .........................103Annex 2. Participants at the review meeting for the

WHO/Know How Fund project .................................105Annex 3. Report to the City Council coordinating the

development of the “Environment and Health”City Action Plan ..........................................................107

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Foreword

The concept of sustainable development was launched over 20 yearsago, as the international community realized the absolute need toreorient economic development if it wanted a safe and healthyearth. Linked with the globalization of trade, major environmentalthreats, such as climate change, remind societies that they still havea long way to go to achieve sustainable development.

In the WHO European Region, ministers of health and of theenvironment have taken the issue very seriously. In most countries,they are leading forces in developing national policy documentsthat act as safeguards for all economic sectors, providing thesesectors with signals and principles to use to develop their ownstrategies and policies for sustainable development. Notwith-standing this international commitment, national plans and pro-grammes will be ineffective if they are not implemented. In mostcases, implementation will have to take place at the local leveland in association with communities.

This book describes the principles that should guide localplanning for the environment and health through case studies thatshow how to integrate local policies in the national framework.It offers the basis for the development of consistent local policiesin the area of environment and health and for the involvementof the community, which provides the grounds for sustainabledevelopment.

This book is expected to provide local authorities and localprofessionals with help in their daily work. Climate change will be

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reduced if local energy policies are adapted. Sustainable develop-ment will be achieved if societies reduce the production of waste,stop leakages in water pipes and promote alternative modes oftransportation. Finally, social cohesion can be achieved if govern-ments listen to communities, particularly those facing the biggestproblems. Through the development of local environment andhealth programmes, local authorities and professionals can ensurethat their work contributes to these international goals. It is time forall to join forces to achieve this ambitious objective.

The WHO Regional Office for Europe is grateful to the Depart-ment for International Development in the United Kingdom for itstwo years’ financial support for the project that led to this book.Finally, a word of thanks to Mr Ian MacArthur, who coordinatedthe development of this project and wrote this book. I hope it willprovide readers with an inspiring experience.

Marc DanzonWHO Regional Director for Europe

The development of this guidance and the elaboration of a series oflocal environmental health action plan (LEHAP) processes acrossEurope has been carried out with the assistance of a vast array ofcolleagues and friends, far too numerous to list here. Specialmention and thanks are due to the people who have supported mein this project and who have performed most of the work indeveloping local planning processes and building local capacitiesfor environment and health:

� in Bulgaria: Dr Ivan Zlatarov, Mr Lyudmil Ikonomov, Dr IvanIvanov, Deputy Minister of the Environment Mariana Loukova,Ms Violeta Rioatchka, Ms Sylvia Stoynova and Dr MariaMinkova;

� in Kyrgyzstan: First Deputy Minister of Health Victor Glinenko,Dr Ainura Djumanalieva, Dr Kuba Monolbaev, Bishkek FirstVice-mayor Kulbaev and Bishkek Vice-mayor Melnichuk;

� in Latvia: Ms Spidola Lielmane, Ms Andris Urtans, Dr SigneVelina, Ms Gita Rutina and Mr Victor Gorsanovs; and

� in Slovakia: Dr Ivan Ronvy, Mrs Katarina Halzlova, Dr EleonoraFabianova, Dr Gejza Legen, Mr Kamil Vilinovic and Ms VieraGazikova.

I also thank colleagues at the WHO Regional Office for Europe,and the Department for International Development and the Char-tered Institute for Environmental Health in the United Kingdom.

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Acknowledgements

-

The entire project was made possible through funding by theDepartment’s Know How Fund. I gratefully acknowledge thecooperation and hospitality I encountered in the project countries,Bulgaria, Kyrgyzstan, Latvia and Slovakia.

Ian D. MacArthur

x

CCEE countries of central and eastern EuropeCIEH Chartered Institute of Environmental HealthCO

2carbon dioxide

EAP Environmental Action Programme for Central and East-ern Europe

EC European CommissionEMAS Eco-Audit Management SystemEU European UnionGIS geographical information systemLEAP local environmental action planLEHAP local environmental health action planNEAP national environmental action programmeNEHAP national environmental health action planNIS newly independent statesNGO nongovernmental organizationOECD Organisation for Economic Co-operation and Devel-

opmentUNCED United Nations Conference on Environment and De-

velopmentUN/ECE United Nations Economic Commission for Europe

Abbreviations

Part 1

Background

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Introduction

We all must move down from the Summit and into the trenches where thereal world actions and decisions are taken that will, in the final analysis,determine whether the vision of Rio will be fulfilled and the agreementsreached there implemented.

– Maurice Strong, Secretary General, UnitedNations Commission on Environment andDevelopment (1)

Action taken at the local level is now universally recognized as arequirement for the true achievement of global improvements inenvironmental health. Municipalities are the form of governmentnot only closest to the population but also often the most effectiveat working in partnership with community stakeholders: a pre-requisite for any initiative on environmental health action. In thissense, the process of local environmental health planning is in itselfextremely important in developing a framework for decision-making.

This publication is intended to address both local and nationalpolicy-makers and professionals. It provides an analysis of exist-ing local planning processes and initiatives in the WHO EuropeanRegion, identifies their common features and describes how theyinterrelate with and support national environmental health actionplans (NEHAPs). This book also provides guidance and options forthe development of local environmental health action plans(LEHAPs), which give the levels of flexibility necessary to ensurethat a bottom-up planning process can occur.

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A number of international initiatives have led to local action onthe environment and health. The most prominent of these is theframework that was provided following the United Nations Confer-ence on Environment and Development – held in Rio de Janeiro,Brazil in 1992 and thus often called the Rio Earth Summit – whenthe United Nations Commission on Environment and Developmentproposed Agenda 21 as the blueprint for development for the 21st

century. This gave birth to a large number of local Agenda 21initiatives. Since 1992, more than 1300 local authorities in 31 coun-tries around the world have responded to the local Agenda 21mandate by establishing their own action plans (2). The WHOHealthy Cities and the United Nations Sustainable Cities move-ments have also spawned numerous similar initiatives across theglobe. In the European Region, the development of NEHAPs hascreated a framework for the development of LEHAPs.

All of these local initiatives recognize the central role thatcommunities must play in bringing about change. This implies adegree of decentralization. Indeed, a global trend towards decen-tralized government services, and greater emphasis on health andenvironment actions taken by the community, can now be ob-served. All of these initiatives focus on the development of partici-patory planning models.

Although born from different sectoral interests, many of theseapproaches adopt very similar principles and key methodologies.In truth, there is very little to separate them. They are fundamen-tally about improving the health and quality of life of the localpopulation by involving the community in decision-making, andby integrating social, economic and environmental concerns intopolicy and action. The title attached to such initiatives – whetherlocal Agenda 21, Healthy Cities, environmental protection orLEHAP – therefore has little relevance to the final outcome. Thisguidance has been written from this perspective.

Requirements for successful action on theenvironment and health

Multisectoral approach, community participationEnvironmental health issues are by nature multisectoral. Theseissues are too complex to be left only to environment and health

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professionals, but too important to be managed and developedwithout them. Experience has shown that progress and success inaddressing environmental health issues come only when all agen-cies, at all levels, work together.

Another essential element of the environmental health ap-proach – community participation – can be extremely difficult toachieve, especially when, as in some countries in the EuropeanRegion, democratic principles are only beginning to be developed.A deeper discussion on how public participation can be effectivelyachieved follows later, but this section highlights why communityparticipation is valuable. It not only involves local people moredeeply but also develops mutual understanding and respect amongstakeholders, which can lead to greater local commitment andparticipation in solutions.

The development of participatory democracy is not advocatedjust because democracy is good. It is born out of a realization thatmany of the problems human beings face in environmental healthat the beginning of the 21st century will only be solved when wholecommunities can understand them and act together for their solu-tion. For example, an individual’s choice to use public transport,instead of a personal car, will make very little difference to airquality in a city; only when a large proportion of the wholecommunity changes its travelling habits will discernible changeoccur. This type of action can only be achieved through aninformed, engaged and empowered community.

Municipal action, national commitmentThe planning processes that are used to develop policies andstrategies on environment and health will inevitably vary, depend-ing on the constitution and governance of each country, region andlocal authority. Local authorities throughout the European Regionhave different powers and responsibilities; there is no universal orcorrect model. Municipalities’ local and democratic nature, how-ever, coupled with their ability to influence and work with andthrough other local and regional agencies, means that they are thenatural leaders for local environment and health planning.

Municipalities normally have wide roles that can encompassmore than just the provision of environmental and health services.Often they operate programmes that seek to develop the localeconomy, including transportation, tourism and industry. This

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provides local authorities with a sound basis upon which tointegrate environment and health issues into their polices on andactivities in other sectors.

Experience has shown that local environment and health plan-ning processes succeed only when they have clear and unambigu-ous commitment and leadership from the highest political level inthe country’s government; this in turn creates and supports similarcommitment at the highest levels in the local community. Ifnational policy and legislation create a helpful framework, localauthorities can have the tools, motivation and back-up for appro-priate action.

While the whole planning process is built from the bottom up,feeding on grassroots perspectives, this concept clearly needs tooperate within a system that is founded on serious high-levelpolitical commitment, and to have some practical results at the endof the day. No matter how hard they try, people on or near the frontline are in no position to launch or sustain the process of environ-mental health planning. They lack the breadth and perspectiveneeded to see the entire process through from start to finish, andthey have a limited ability to begin bringing different agencies andorganizations together. Additionally and inevitably, they can carrywith them their own agendas, which can sometimes act as barriersto the planning process and the development of joint work.

Steps in the planning processThe act of making a political commitment will mark the beginningof the planning process. This is merely a statement of commitmentto the process, however, and not the means of addressing the morespecific issues of particular environmental health problems.

This commitment can be demonstrated in a number of ways.Many municipalities have made and adopted their own charters forenvironmental health or mission statements for sustainable devel-opment. They have endorsed internationally agreed strategies orpolicies and then set out the mechanisms through which theyintend to fulfil their objectives.

Working in partnership is widely agreed to be essential toeffectively addressing environmental health issues. Environmen-tal health is such an all encompassing subject that no singleorganization could possibly deal with all of its aspects effectively.

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Environmental and health professionals, along with those workingin social welfare and education, need to work with the economicsectors and other major groups in society such as nongovernmentalorganizations (NGOs), religious groups and ethnic minorities. Allof these, and other appropriate stakeholders, need to be involvedin the environmental health planning process, and each recognizedas having an equal degree of commitment and responsibility to theprocess.

Falling into the hypocritical trap of not practising what onepreaches is all too easy when dealing with environmental healthissues. In this respect, municipal leaders must be seen to be puttingtheir own houses in order in terms of environmental health per-formance.

This section discusses eight steps in the planning process:

1. raising awareness;2. reviewing and managing municipal environmental health per-

formance;3. reviewing existing municipal policies affecting environmental

health;4. making and reporting a local situation analysis;5. building effective public participation;6. setting priorities for practicable action;7. drafting the LEHAP; and8. securing support from other levels.

AwarenessFirst, it may be necessary to raise awareness and perhaps providetraining for officers and employees of the municipality in the issuesthat are to be addressed under the environmental health planningprocess. As the process is adopted as a corporate policy, allemployees of the municipality, particularly those who have to dealwith members of the public, should be fully aware of, understand andbe committed to the process.

Municipal environmental health performanceSecond, the municipality and the other principal partners need toreview their own environmental health performance, and how theiractivities affect the environment and community. An internalmanagement system can be introduced that:

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� identifies the organization’s major impact on the environmentand community, actual and potential;

� can decide the organization’s overall aims and values withrespect to this impact;

� can commit the organization to action to implement the policy,with measurable targets for both activities and their results;

� specifies who will carry out the action, with what resources,over what time and how implementation and progress are to bemonitored; and

� allows the progress to be independently assessed and reportedto the public, and the policy and programme to be updated asneeded.

This internal management system is similar to the European Union(EU) Eco-Management and Audit Scheme (EMAS) (http://europa.eu.int/comm/environment/emas/, accessed 13 February 2002),which enterprises use to address their environmental performance.Local authorities can use EMAS as a management tool to help setand progress towards achieving their own targets for environmen-tal health performance; the process can be repeated at regularintervals.

Existing municipal policiesAnother element of the internal phase of local environmentalhealth planning is the review of the existing municipal policies thataffect the areas of environment and health. The planning processdoes not start from scratch. Many policies will already have beenformulated and strategies implemented that will cut across theenvironmental health agenda.

These existing efforts need to be recognized and integrated intothe new programme. Policies and strategies that need to be consid-ered under the umbrella of environmental health planning includethose on: land use planning, transport, economic development,housing services, tourism, welfare and health.

Situation analysisBefore a strategy can be devised to improve environmental healthfor a community, it is necessary to have some idea of the majorissues that need to be addressed. An analysis of the environmentalhealth status of the community provides some of this information.

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Many different agencies operating at the local level hold datarelated to environmental conditions and the health of the popula-tion that can be used in developing this situation analysis. Socio-economic factors are also relevant in this context. The process ofenvironmental health planning may well bring the relevant datatogether for the first time, and can thus draw out hitherto unseencorrelations and linkages. The report of the analysis can setenvironmental conditions against national and/or internationalnorms, and then make comparisons.

Such a report can also provide an analysis of the health statusof the population, containing all the usual and appropriate epi-demiological data. It may also provide data on the various elementsof the local environment, such as the quality of the air, water andsoil; the levels of noise and radiation; and the status of the physicalenvironment in terms of land use and green space.

The report of the situation analysis provides a major buildingblock for the planning process. Once completed, it should bewidely circulated among all the stakeholders and, through themajor groups, to the general public.

The report provides those who have to make decisions on thefinal plan and its priorities with an objective, academic and scien-tific perspective. This is an essential component if cost-effectiveaction is to be taken. This is only one perspective, however;decision-makers should also receive information on the localpopulation’s perceptions of environmental health problems in thelocality. These may not always match the scientific assessment,and may highlight human and social problems that statistics andhard measurements cannot demonstrate. The decision-makingprocess will contain a degree of value judgement that affect thelevel of priority a particular issue may attract.

Effective public participationSecuring the community’s views is the opening step in buildingeffective public consultation and participation in the planningprocess. It should therefore be carried out effectively and in a waythat builds trust and openness among the stakeholders and demon-strates the authorities’ strong commitment to recognizing thecommunity’s perceived needs.

The prospect of developing a strategy to engage and communi-cate with the whole community can be daunting. This is particularly

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true when the leaders of the process believe that contact has to bemade with everybody. Such a strategy can be superficial, particu-larly if it becomes a case of contacting only the group of NGOs thatis usually active in and in contact with the municipality. Thecommunity itself can be a major help in this process, as existinggroups, structures and lines of communication can often be used todisseminate and receive information.

There are a number of methods for developing effective publicengagement and participation, but no accepted model of goodpractice. Different approaches and methods will be needed. De-pending on the people involved and the issue to be considered, aseries of different techniques may need to be adopted. Some ofthese are described in Chapter 4.

Developing strategies for public consultation and participationis a major, complex and inevitably lengthy process. Methods andprocedures will need to be reviewed and changed as the planningand implementation process moves forward. In all of this, how-ever, the quick provision of meaningful feedback to those whohave participated is of paramount importance. The people engagedin the process must see that it is making a difference, or they willbegin to lose their enthusiasm for and commitment to it.

Priorities for practicable actionMaking decisions is the task of people who hold public office(politicians). It can often be difficult, and decision-makers canrarely keep all the people happy all the time. Nevertheless, makingbalanced and fair decisions is implicit in the responsibilities ofpublic office. In this respect, local decision-makers need to con-sider both the hard, objective information and the soft, subjectiveinformation when contemplating the priorities for the improve-ment of the environment and health and the action that needs to betaken.

As noted above, these two advisory opinions often differgreatly. Both are valid, however, and clear vision, coupled withsharp analytical skills, is required to choose a progressive wayforward. For instance, the technocratic community may believethat the pollution of water supplies with heavy metals is a majorpriority. As this issue is not easily apparent to members of thegeneral public, they are unlikely to share this view. Dealing withthe problems they perceive in their immediate surroundings, they

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may consider litter, dog fouling or noise to be the issue thatconcerns them most. These perceptions should not be discountedjust because they do not have a technical or scientific basis.

Of course, when balancing the weight of evidence presentedwith the options for action available, decision-makers need toconsider other elements. The most important of these are thephysical practicality of being able to do something about a problemand the financial and human resources that can be devoted to it.Action that is practical and measurable, and can make a differencesimply and quickly will show that the plan is more than just words.This helps to sustain interest in and support for the plan. As toresources, one of the benefits of securing broad-based partnershipis the possibility of developing jointly financed and staffed initia-tives. This can widen the opportunities for action. Techniques andprinciples for priority setting are discussed in detail in Chapter 3.

Draft of a LEHAPThe project team produces a first draft of the plan for a process ofwide-ranging consultation with the public and all the relevantpartners. Consulting the relevant national authorities – seekingtheir views on how the proposed plan fits with the nationalframework – may also be worth while.

Securing a high level of response to consultation exercises isdifficult, and makes the planning process harder and longer.Nevertheless, it also increases the effectiveness of the final plan.

As with all planning processes, monitoring and revision mecha-nisms will allow progress to be measured and a degree of flexibilityto be introduced. Planning processes are alive and organic. Theyare not one-off exercises; the successful ones are continuous,durable and sustainable.

Support from other levelsOf course, all of this local work will count for very little unlessnational governments and international organizations facilitateand support the processes and resultant action. In addition, na-tional frameworks provide inspiration and encouragement forlocal communities to begin their own planning processes. Forexample, most local Agenda 21 activity is taking place in countrieswith national campaigns or strategies. A recent survey (2) showedthat 88% of local initiatives were taking place in countries where

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national campaigns were either established or just starting. Sup-port – in the forms of national guidance, technical resource cen-tres, legislation and financial resources – can help communities toprogress in their own activities.

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1

The environmentalhealth approach

If the future of the human race is to be safeguarded, its manner of dealingwith the environment must change drastically … if the human racecontinues to ignore this fact, its improved health and well being will notbe an attainable goal.

– Our planet, our health (3)

International backgoundThe concept that environmental conditions can affect health isrelatively new. Nevertheless, it has become clear in recent yearsthat health is central to the pressing concerns of the environmentand development. Both the earliest and latest versions of theEuropean policy for health for all adopted by WHO Member States(4,5) address environmental health conditions and management. In1989, WHO held the First European Conference on Environmentand Health, at which European ministers of health and the environ-ment adopted the European Charter on Environment and Health(6). This was seen as the first major step towards the creation ofnational policies on environmental health.

Other international actions have also had a significant impacton this area of work. In 1992, the United Nations Conference onEnvironment and Development endorsed Agenda 21 (7): a visionfor ensuring that development is carried out in a sustainablemanner. The principles underlying the concepts of sustainabilityalso serve to mould the way in which environmental health issuesmust be addressed. The WHO global strategy for environment and

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health (8), produced in 1993, reflects the importance of the RioConference in dealing with environmental health.

Concerns about European environmental problems have re-ceived attention from others in the international community. TheUnited Nations Economic Commission for Europe (UN/ECE) andthe Organisation for Economic Co-operation and Development(OECD) have worked together to produce a broad strategy, anEnvironmental Action Programme for Central and Eastern Europe,which requires the production of individual national plans.

The most significant international event relating to environ-mental health planning took place in June 1994, when WHO heldthe Second European Conference on Environment and Health inHelsinki. This Conference sought to bring together some of theexisting initiatives and reflect on how best to advance the variousactions required. The Conference participants called for the crea-tion of NEHAPs by 1997, which would integrate the work that hadalready been done on environmental protection and sustainabledevelopment with components related to health. The Europeanenvironmental health action plan (9), which was adopted at theHelsinki Conference, recognized the need for improved environ-mental health services in countries as the foundation on which thedelivery of effective environmental health policies could be built.

Five years after the Helsinki Conference, government ministersmet again in London, at the Third Ministerial Conference onEnvironment and Health, to review progress and to set out anagenda for implementation, which included recognition of thelocal-level agenda. The London Conference was the biggest politi-cal event on environment and health ever held in Europe, attendedby over 70 ministers of health, environment and transport from54 countries. The next link in this chain of action and commitmentis a conference planned for Budapest in 2004.

The theme of the London Conference was action in partnership.The participants made decisions on 11 topics, resulting in (http://www.euro.who.int/aboutwho/Policy/20010825_2, accessed 13 Feb-ruary 2002):

1. a legally binding Protocol on Water and Health2. the Charter on Transport, Environment and Health (10)3. a declaration that includes the above and addresses children’s

health and the environment, national action plans, public

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participation, climate change, workplace health and safety,local projects, economics, a review of the last decade ofenvironment and health in Europe and research priorities.

Several of these elements – particularly the issues of workplacehealth and safety and environmental management, the links be-tween economy and environmental health, and transport prob-lems – are of vital importance to local environmental health planning.

During the development and transition period between theHelsinki and London conferences, much was learned through theexchange of information and experience among WHO EuropeanMember States and through the development of pilot NEHAPs. Thefollowing are the principal lessons to be taken from this period.

Lessons learnedThe implementation of any national plan depends implicitly on thecommitment of the responsible local authorities. This level ofcommitment can only be secured and sustained if local authoritieshave been involved in some way in the development of the nationalplans and strategies. Consulting, involving and working with otherpartners during national or local planning processes is time con-suming, but pays a useful dividend in the plan’s development andimplementation. Finally, if conflicts and disagreements have beentackled during the planning process, they can be avoided orovercome during the implementation phase.

International and national plans, commitments and legal regu-lations must be supportive of the required action at local level, andvice versa. In this way, the tangible result of action close to thepeople can be understood as positive results of a participatoryprocess of planning and implementation.

In political terms, the reforms that swept the countries of centraland eastern Europe (CCEE) and the newly independent states (NIS)of the former USSR in the late 1980s and early 1990s, the economicchanges now taking place and the prospect of EU membershiphave inevitably led to changes in governmental structures andinstitutions. In several countries, the so-called green movementand the environmental lobby were at the forefront of the pressureto change the former regimes. Only a few years, however, havebrought the realization that the new reforms will not heal the

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environmental damage that has been bequeathed to these coun-tries. Even the many internationally funded capital investmentprogrammes, aimed at producing specific solutions for particularproblems, have not made a significant impact on the environmentalhealth problems that the new governments in the eastern half of theEuropean Region have inherited.

It has become apparent that long-term investment in the capac-ities and structures within countries is required before lastingchanges can be made in the management of the environment. Manycountries are therefore reviewing and restructuring their entirelegal and institutional structures in relation to environmental healthservices. Many are developing new systems for environmentalprotection. Existing capacities and management traditions, how-ever, do not always allow for radical reforms in the strategy andpolicies of national, regional and local authorities, and inevitablysome environmental protection measures must wait.

The NEHAP concept has received a hearty welcome in theeastern half of the Region. The NEHAP process has given a strongimpetus for reform and for addressing issues in a more effectiveway. It has in essence demonstrated how intersectoral work can beachieved.

A NEHAP is a government statement of action taken andintended. It should:

1. provide an authoritative assessment of the position on the mostimportant environmental health issues in the country;

2. identify obstacles to improvement and options for action (in-cluding, where appropriate, research) to deal with the prob-lems;

3. set targets and timetables for improving the current situation;4. identify the most appropriate level for each action, and the key

actors and stakeholders;5. set out the resources needed for each option and indicate how

they might be obtained;6. consider the need for capacity building and training;7. include a strategy for implementation;8. include a communication strategy to inform and involve the

public and all the stakeholders; and9. include proposals for monitoring and evaluating and for report-

ing progress towards the targets set out in the NEHAP.

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Because of its intersectoral and holistic nature, a NEHAPprovides a mechanism for delivering the government’s principalpolicy objectives. Many of the actions to be undertaken in pursu-ance of a NEHAP are beneficial to several interested parties andshould be promoted in cooperation. A NEHAP is not separate fromother polices, but should be an integral part of them. Implementa-tion then becomes a win–win situation, reflecting the principle ofpartnership. When such mutually beneficial actions are imple-mented, what might have been a problem of competition forresources becomes a solution to meeting the aims of the interestedparties (11).

The NEHAP movement, facilitated through the WHO confer-ence process, has close links with and value in relation to EU policyon health and particularly the public health competence obtainedthrough Article 152 of the Amsterdam Treaty. Many countriesseeking membership of the EU are already using and developingNEHAPs and LEHAPs as a means to address the acquis communautaire.

The environmental health approach

Background forcesIn its report to the Rio+5 Forum, WHO (12) highlighted a series ofdriving forces that create the conditions in which threats to envi-ronmental health can develop or be averted, and pointed out thatthese forces are often associated simultaneously with a number ofhealth and environment issues. The report notes that governmentpolicies and programmes, which vary with the priorities and valuesof the government, change the direction or magnitude of the forcesand can therefore either alleviate or exacerbate environmentalhealth threats. It also notes the increasing recognition that elementsof global pressures are outside the control of nation states.

The first set of driving forces identified relates to population.Essentially, it multiplies the environmental impact of human activ-ities – particularly the consumption of natural resources and theproduction of wastes. In other words, the larger the number, thegreater the impact on the environment. This is particularly relevantin view of the swelling populations of cities. The level of consump-tion per person, however, is also of fundamental importance, sinceit determines the degree of such impacts.

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Closely linked to population growth is urbanization. The mi-gration from rural to urban settings increases stress on the urbanenvironment and the service infrastructures. Urban lifestyles bringmany pressures and stresses to bear, and can bring about anunhealthy tension between the environmental, social and eco-nomic aspirations of a society.

Poverty and inequity are also identified as major driving forces,in their influence on environmental and living conditions. Inequityin general and the marginalization of minority groups in particularcan lead to impoverished living environments for certain groups insociety.

Technological or scientific developments may give rise to newenvironmental health hazards or provide the means of addressingcurrent problems. Clearly these developments can influence con-sumption and production patterns, driving forces that can generatelarge-scale use of energy, water, land or other natural resources.

The final driving force – harmful environmental change – canoccur at any stage of economic development. Nevertheless, it alsocreates resources and opportunities for improving the quality ofliving conditions.

Basic assertionsA widely ranging yet deeply focused perspective sees action forenvironmental health as a mechanism to address various problemsin society. The environmental health approach rests on the follow-ing assertions.

The health of society is of crucial importance to everyone, nowand in the future. Good environmental conditions promote goodhealth and wellbeing. The problems that society faces at the start ofthe new millennium call for approaches that must recognize thecomplexity, the interrelated nature and the speed of life in the worldtoday.

The creation of conditions that promote health depends onstriking a balance between economic activity, the environment andthe community itself. All public and commercial decisions inevita-bly disturb that balance. To preserve it and thus prevent degradedenvironments and, ultimately, poor health, such decisions need tobe considered against a number of factors. The environmentalhealth approach can provide the checks and balances required toensure that the desired equilibrium is achieved and maintained.

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The factors of concern to environmental health change con-tinually. Nevertheless, they are contained within a matrix formedby the various types of exposure, the different environments inwhich human activity occurs and the categories of hazard to whicha population is exposed (Fig. 1).

Fig. 1. Factors of concern to environmental health services

Homeenvironment

Workenvironment

Recreationalenvironment

Livingenvironment

Biological

Chemical

Physical

Social

Psychosocial

stressors

stressors

stressors

stressors

stressors

Source: MacArthur & Bonnefoy (13).

The environmental health approach was not designed, butdeveloped organically. It has demonstrated that it can turn rhetoricinto action, and it adds considerable value to the process ofimproving human health and quality of life.

Seven founding principlesIn a world in such constant and turbulent metamorphosis, somecore values or principles should be retained as the touchstones forthe development of policy and the implementation of strategy. Allpolicy- and decision-makers – in all walks of life, in both theprivate and public sectors – can use the seven principles on whichthe environmental health approach is founded:

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1. focus on people2. redressing imbalances3. cooperation and partnership4. participatory democracy5. putting safety first6. international cooperation7. sustainable futures.

Following these principles can ensure that a proposed policy orstrategy will have a positive impact in creating supportive environ-ments for health.

Focus on peopleThe maintenance and improvement of the human condition is theprimary goal of all environmental health action. Considerationshould be given to the human and social aspects and impacts of anydecision, policy or strategy.

Redressing imbalancesThe disadvantaged groups in society often live in the worst hous-ing, with poor environmental conditions, work in the most danger-ous occupations and have limited access to a wholesome andvaried food supply. In short, they often live and work in the worstenvironments in a society.

Decisions, policies and strategies should allow everyone a fairopportunity to realize his or her full health potential. No one shouldbe hindered in this effort. Decision-making processes should givespecial consideration to disadvantaged sectors of society.

Cooperation and partnershipIn recognition of the complexity and interrelated nature of theproblems faced by society, cooperation and partnership among allrelevant stakeholders clearly need to be intensified. Because iso-lated decisions and acts cannot normally solve problems of envi-ronmental health, cooperative and partnership approaches need tobe applied across all sectors.

This approach has several implications. For example, a sectorincludes not only government agencies, but also all public andprivate organizations and interests that are active in the sector.Policy-makers, technical and service staff, and volunteers – at the

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national and local levels – have actual or potential functions toperform.

The problems tackled are common ones, in which all partici-pants have a role and interest. Different participants may playleading and supporting roles in action on different issues.

In addition, cooperation consists not only of ratifying propo-sals but also of participation in defining issues, prioritizing needs,collecting and interpreting information, shaping and evaluatingalternatives, and building needed capabilities for implementation.Stable cooperative mechanisms should be established, nurturedand revised according to experience.

Participatory democracySolving many current environmental health problems requiresaction from communities as a whole, rather than individuals. Thisis a major challenge to the traditional ways of addressing these issues.

Society has never been better informed or misinformed. Thewill and desire to participate in decision-making are growing;providing the public with information is no longer enough. Publicparticipation provides common ownership of problems, allowingbetter cooperation and speedier redress. Public participation is bestcarried out at the local level.

As technical solutions to environmental health problems be-come less successful, social and ethical changes will be needed.These will only be achieved through individuals’ and commu-nities’ direct participation in decision-making and action. This willinevitably lengthen decision-making and planning processes.

Putting safety firstEnvironmental health action works in three time phases: to repairpast damage, to control present risks and to prevent future prob-lems. The emphasis given to each phase is determined by acomplex formula of factors depending largely on an assessment ofrisks and the available resources. While the most pressing issuesshould be addressed first, within the environmental health ap-proach emphasis should be given to addressing and so avoidingfuture problems.

Prevention is better (if not cheaper, then more morally accept-able) than cure. Precautionary approaches are needed in the devel-opment of policy to avoid future problems.

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International cooperationDay by day, globalization is making the world smaller. Environ-mental health professionals have long recognized the fragility andproportions of the planet, and that contaminants in the environmentdo not respect national boundaries. Environmental health issueshave a truly international character.

The professional world of environmental health is also small.The people comprising the community of professionals around theworld, who dedicate their working lives to improving and protect-ing the places where people live for the common good, are muchfewer than the people who exploit and deplete the world’s re-sources in pursuit of wealth creation.

Nevertheless, the small size of the world’s environmentalhealth community brings great advantages. Professionals can andmust communicate with ease. Although languages, heritages andcultures, and thus systems for environmental protection differ, theproblems and approaches are shared. The commonwealth of inter-national knowledge and experience can provide an irresistible re-source for solving many of the perplexing problems in today’s society.

International cooperation is therefore a key principle for envi-ronmental health and, despite the distraction of immediate sur-roundings and problems, should not be overlooked. Globalizationand the information revolution have allowed broader communica-tion than ever before, which provides opportunities for widerdialogues and partnerships. Environmental health professionalsneed to rise above superficial and feigned differences and recog-nize their common resolve to improve the human living environment.

Sustainable futuresThe final principle cuts across the previous six; it is the notion ofsustainable development or sustainability. This concept, similarlyto that of environmental health, not only encompasses certainissues but also requires particular ways of managing them. Threeparticularly important threads in the policy-making process relat-ing to environmental health confirm the almost overlapping natureof environmental health and sustainable development:

1. policy integration: the bringing of environmental health con-siderations into all other areas of policy, tying together differentpolicy fields and different government levels;

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2. partnership: consultation with and the participation of all groupsin society in the planning and implementation of policies forsustainable development; and

3. appropriate scale: the handling of policy at the level of govern-ment (from local to international) at which each environmentalhealth issue occurs, with a bias towards or emphasis on theprinciple of subsidiarity.

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2

International frameworks,national plans and

local action

Agenda 21 and sustainable developmentBefore a description of the genesis and growth of the globalAgenda 21 movement can be given, a discussion of the conceptand meaning of the term sustainable development is probablynecessary. People who frequently read such texts as this will findthis process familiar, and for many it will cover knowledge that haslong been presumed. Nevertheless, revisiting such assumptionsand challenging personal perspectives are occasionally worth while.

For well over a decade now, the debate about economic progresslocally, nationally and internationally has focused on sustainabledevelopment. This key term has a myriad definitions (such as thatof Pearce et al. (14)). To many it has become an almost meaninglessmantra that can fulfil any intent an advocate wishes. It is a flagbehind which everyone can rally, a common aim that all sectors ofsociety can agree is a good thing and a goal towards which to strive.It is also a term loaded with value judgements; what constitutesdevelopment may differ between individuals, sectors or evencountries.

Defining sustainable development is in part a contradictoryprocess. Definitions by nature and purpose set limits and barriers.When the term being defined attempts to encompass everythingwithin the realm of human activity, both now and in the future, thesource of confusion and the profusion of definitions is easy to see.

The rarely discussed commentary that follows a classic defini-tion recognizes these phenomena. Our common future (15) – the

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report of the World Commission on Environment and Develop-ment – defines development as sustainable when it: “meets theneeds of the present generation without compromising the abilityof future generations to meet their own needs”. The paragraphs thatfollow this much repeated prose recognize that the concept ofsustainable development implies limits on environmental resources:not absolute limits, but those imposed by the present state oftechnology and social organization and by the ability of thebiosphere to absorb the effects of human activities.

In fact, the term sustainable development ought not to attracttoo much debate. Development is normally a set of desirable aimsand objectives for society. These undoubtedly include raisingstandards of living, but most people and most commentators on thesubject would also now agree that development means more thanrising real incomes or economic growth. Individuals and com-munities now understand the need also to emphasize quality-of-life issues: health, educational standards and general socialwellbeing.

Sustainable development involves devising a social and eco-nomic system that ensures that these goals are pursued to advancethe general quality of life. Achieving such a broad objective is bothcomplex and difficult, and requires that some key issues be takeninto account. Some of these points are summarized below.

Sustainable human developmentThe maintenance and improvement of the human condition are atthe centre of all action for sustainable development. The principleis the recognition that the main target of policies, strategies andactions is the wellbeing of the human race, and the factors in thesocial, economic and physical environment, however wide, thatmay affect it.

Valuing the environmentThe sustainable development approach relies on a significantlygreater emphasis on environmental issues in policy-making andstrategy implementation. Poor physical environments are increas-ingly linked with poor social and economic conditions. Environ-mental action can therefore have the added effect of addressingwider issues of quality of life, as well as the issues on the greenagenda.

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EquitySustainable development places strong emphasis on providing forthe needs of the least advantaged groups in society and the fairtreatment of future generations.

As recognized earlier, the disadvantaged are often the peoplewho live and work in the worst environments. They do notcomprise a single group: different people are at a disadvantage indifferent contexts. For example, low-income households in north-ern countries may be at risk of poor health owing to damp and coldhousing conditions, lack of fuel and/or inadequate nutrition.

WHO has recognized the importance of equity and the environ-ment to health. Access to appropriate medical technology cannotoffset the adverse effects of environmental degradation, and goodhealth will remain out of reach unless the environments in whichpeople live promote their health.

The reduction of inequalities requires equal access to publicservices and an uptake of services that relates to need. Theprovision of high-technology services to the population should notbe restricted by social or economic disadvantage, and servicesshould be sensitive to the needs of minority groups. To achievethis, disadvantaged groups will require special assistance andattention.

Extending the time frameThe core value – recognizing the needs of future generations –requires policy-makers and their advisers to look beyond the nextelection towards the longer term. Long-term planning is required toensure decision-makers keep the needs of future generations inmind while dealing with day-to-day problems.

Context and history of Agenda 21At the 1992 Rio Conference, more than 178 governments adoptedAgenda 21 (7) – a programme of action for sustainable develop-ment worldwide, and the Rio Declaration on Environment andDevelopment (h t tp : / /www.un .org /documents /ga /conf151/aconf15126-1annex1.htm, accessed 13 February 2002). Theseoutcomes fulfilled a mandate given by the United Nations GeneralAssembly when, in 1989, it called for a global meeting to deviseintegrated strategies that would halt and reverse the negative

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impact of human behaviour on the physical environment andpromote environmentally sustainable economic development in allcountries.

The agreements finalized in Rio were negotiated over theprevious two and a half years. While they lack the binding force ofinternational law, the adoption of the text carries a strong moralobligation to ensure their full implementation.

Agenda 21 has been promoted as a blueprint for action to betaken globally into the 21st century, by governments, UnitedNations organizations, development agencies, NGOs, municipal-ities, commerce and industry, and independent sector groups inevery area in which human activity affects the environment.

Global concern for these issues can be traced back to June 1972when roughly 1200 delegates from about 130 countries met inStockholm under the auspices of the United Nations Conference onthe Human Environment. Countries from the developed and devel-oping worlds met there to set out the rights of the global populationto a healthy and productive environment. A series of meetingsfollowed on people’s rights to adequate food, sound housing, safewater and population control measures. Not until 1983, however,did the United Nations General Assembly establish the WorldCommission on Environment and Development to produce aglobal agenda for change. This Commission, chaired by GroHaarlem Bruntland (now WHO Director-General), was asked topropose long-term environmental strategies for achieving sustain-able development for 2000 and beyond. The Commission’s report,Our common future (15), was submitted to the General Assemblyin 1987 and served as the bedrock for the 1992 Earth Summit.

One of the major outcomes of the Rio process was the establish-ment of the United Nations Commission on Sustainable Develop-ment. The Commission has met yearly since 1992 to reviewprogress and consider sectoral and emerging issues, and to pro-duce guidance. Five years after the Earth Summit, a United NationsGeneral Assembly Special Session was held to conduct a compre-hensive review of the process. While recognizing that progress hadbeen made in some areas, particularly forests, fresh water andtransport, the agreed text from the Special Session concluded thatthe global environment continued to deteriorate, and that signifi-cant environmental problems remained deeply embedded in thesocioeconomic fabric of countries in all regions. Nevertheless, an

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ambitious programme of activities for the Commission on Sustain-able Development was mapped out for the next five years, to 2002.

Principles of the Rio DeclarationTo obtain a clear picture of the issues that emerge from Agenda 21,one should read it in conjunction with the Rio Declaration onEnvironment and Development. The Rio Declaration sets out some27 principles that underpin and inform the Agenda 21 approach.Many of them are relevant and familiar to people working in thefields of environment and health, particularly at the local level. Forthe sake of brevity, this section discusses only the four principlesmost relevant to local environment and health planning processes.

Principle 1 of the Declaration is the cornerstone of the wholesubject: “Human beings are at the centre of concerns for sustain-able development. They are entitled to a healthy and productive lifein harmony with nature”. This principle reaffirms the human rootsof the sustainable development movement and places people’spractical needs at its heart. Nevertheless, this is probably theprinciple that has been most lost to sight since its inception. In therace to pursue environmental issues, many who have taken up thechallenge of Agenda 21 have failed to grasp the human nature ofthe objectives and the problems presented.

Principle 3 introduces the concept of equity: “The right todevelopment must be fulfilled so as to equitably meet developmen-tal and environmental needs of present and future generations”.This introduces the need to recognize the requirements of allsections of communities and adds the further dimension of lookingbeyond the traditional time horizon, at the needs of the next andfuture generations.

Principle 10 sets out some key statements on the governanceand decision-making mechanisms for sustainable development:

Environmental issues are best handled with the participation of allconcerned citizens, at the relevant level. At the national level, eachindividual shall have appropriate access to information concerning theenvironment that is held by public authorities, including informationon hazardous materials and activities in their communities, and theopportunity to participate in decision-making processes. States shallfacilitate and encourage public awareness and participation by makinginformation widely available. Effective access to judicial and adminis-trative proceedings, including redress and remedy, shall be provided.

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This language poses major challenges to many governmentsaround the world. In Europe, the UN/ECE Convention on Environ-mental Information and Decision-making (16) – often called theAarhus Convention – has incorporated a large part of this principle.Clearly it has repercussions for those engaged in local environmentand health planning processes, and how they communicate andengage with various community stakeholders.

Principle 22 of the Rio Declaration further emphasizes thispoint by addressing the needs of indigenous people and localcommunities:

Indigenous people and their communities and other local communitieshave a vital role in environmental management and development be-cause of their knowledge and traditional practices. States should recog-nize and duly support their identity, culture and interests and enabletheir effective participation in the achievement of sustainable develop-ment.

This principle provides one of the platforms outlined in the Decla-ration that further cement the intersectoral approach: the recogni-tion of global dimensions and the need to take precautions indrawing up plans and development programmes.

Agenda 21The text of Agenda 21 (7) runs to 40 chapters, set out in 4 mainsections: social and economic dimensions, conservation and man-agement of resources for development, strengthening the role ofmajor groups and the means of implementation.

The first section, on social and economic perspectives, dis-cusses several areas relevant to those working in the field ofenvironment and health, particularly: poverty, consumption pat-terns, demographics, human settlements and human health. Chap-ter 6 deals with a wide range of health issues, and provides a clearmandate for the health sector to play a curative and preventive rolein working towards sustainable development. Most of the informa-tion in this chapter was based on Our planet, our health (3), whichwas specifically produced to feed into the process of implementingthe agreements made at the Earth Summit.

Chapter 6 of Agenda 21 highlights needs for primary healthcare in rural areas, the control of communicable diseases, theprotection of vulnerable groups, the urban health challenge, and

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environmental hazards and pollution as the principal areas foraction. In each area, the text explores the basis for action, objec-tives, suggested activities and means of implementation.

In the third section of Agenda 21 (7), which deals with the rolesto be played by major groups, Chapter 28 highlights the keyposition of local authorities and municipalities in the movementtowards sustainable development:

Because so many of the problems and solutions being addressed byAgenda 21 have their roots in local activities, the participation andcooperation of local authorities will be a determining factor in fulfillingits objectives. Local authorities construct, operate and maintain eco-nomic, social, and environmental infrastructure, oversee planning proc-esses, establish local environmental policies and regulations, and assistin implementing national and subnational policies. As the level ofgovernance closest to the people, they play a vital role in educating,mobilizing and responding to the public to promote sustainable devel-opment.

The pre-eminent role given to local government in the promo-tion and delivery of grassroots action for sustainable developmentis key to the local environmental health agenda. The whole sustain-able development movement depends on the bottom-up approach,with local priorities building upwards to national strategies ratherthan national authorities dictating what needs to be done locally.This is the keynote for the future: the recognition of local andcultural diversity, facilitating national and international frame-works.

Local Agenda 21 in practiceLocal governments have demonstrated a deep commitment to theimplementation of Agenda 21. Since 1991, more than 1800 localgovernments in 64 countries have established processes to engagewith their communities to implement Agenda 21 at the local level(2). In addition, local authorities and their communities haveassumed new responsibilities for global environmental problems,such as climate change, forest destruction and water pollution.They have established their own international programmes, in thecontext of international conventions, to address these challenges.For example, 164 cities in 34 countries – accounting for 4% ofglobal carbon dioxide (CO

2) emissions – have joined a Cities for

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Climate Protection campaign to reduce their greenhouse gas emis-sions by as much as 20%.

National governments and the United Nations system haverecognized the growing role of local governments in the imple-mentation of Agenda 21. Nevertheless, this recognition has notalways been accompanied by discussion of the ability of localgovernments and communities to implement their local Agenda 21action plans or other responsibilities for sustainable development.

Over the past ten years, local governments in more than 60countries have received increased responsibilities for environmen-tal protection and social programmes as a result of national-levelderegulation, decentralization and so-called downloading of tradi-tional national- or state-level responsibilities (2). The institutionaland financial capacity of local governments to fulfil these man-dates, and the effects of rapid decentralization on the capacities ofthe public sector worldwide to implement sustainable developmenthave not been sufficiently reviewed.

The International Council for Local Environmental Initiativesanalysed local governments’ implementation of Agenda 21 duringthe period 1992–1996. It concluded that local government actionhas the greatest effects in the areas of institutional development,public participation and improved management systems. In thou-sands of cities and towns, individual projects to determine bestpractices have produced concrete, positive effects on specific areasof management. Few local governments, however, have yet de-monstrated their capacity to achieve dramatic improvements insocial and environmental trends, except in certain key areas oflocal responsibility, such as the management of solid waste orcontrol of water pollution. This conclusion highlights the impor-tance of the following critical issues to the successful, worldwideimplementation of Agenda 21.

During the past five years, local governments’ strategies andprojects for sustainable development have in general been isolatedfrom overall municipal budgeting, local development planning,land use control and economic development activities. As a result,strategies such as those for local action on Agenda 21 have resultedin significant changes in urban development trends in only alimited number of cases.

During the same period, many national governments havedownloaded their responsibilities for environmental protection

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and social development to local governments in order to addressnational fiscal problems. This has rarely been accompanied bypowers to generate new revenue or transfers of revenue that hadtraditionally been available for these tasks. The resulting increasein financial burdens on local governments is undermining theirability to implement local Agenda 21 strategies.

At the same time, reduced or poor national-level regulation ofeconomic activities is weakening the ability of local governmentsto hold local businesses and other institutions (including them-selves) accountable for the negative environmental and socialeffects of their activities.

National, subnational and local governments continue to main-tain policies, subsidies and fiscal frameworks that inhibit theefficient development, control and use of resources at the locallevel.

Transnational corporations and multilateral development insti-tutions have minimal incentives to accept accountability for andexpress commitment to local development strategies. Local gov-ernments have limited control over the properties, resourceefficiencies and packaging of the consumer products that are sold,used and disposed of within their jurisdictions.

Healthy Cities projectThe WHO Healthy Cities project is a long-term internationaldevelopment project that aims to place health high on the agendaof decision-makers in the cities of Europe and to promote compre-hensive local strategies for health and sustainable developmentbased on the principles and objectives of the strategy for health forall for the 21st century (5) and local Agenda 21. Ultimately, theHealthy Cities project seeks to enhance the physical, mental, socialand environmental wellbeing of the people who live and work incities (17).

Launched by the WHO Regional Office for Europe, the HealthyCities project has spawned numerous initiatives around the world,providing a catalyst for many positive changes in urban management.Major cities, urban neighbourhoods and even islands, villages andschools have taken up the theme. By focusing on health – a non-controversial objective – communities are able to build the foun-dations of cooperation between different interest groups. This

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can then lead to other improvements in aspects of urban life – suchas transport, housing and employment prospects – that affecthealth.

Literally thousands of cities worldwide have joined the HealthyCities movement under the auspices of WHO. In short, HealthyCities has caught the imagination of city managers across theworld. Although the movement began in industrialized Europe, ithas now spread to all parts of the world, appealing as much todeveloping and transition countries as much as it does to the richernations (18).

Healthy Cities projects promote innovation and change in localhealth policy, advocating new approaches to securing publichealth improvement. They are intended to provide leadershipthrough mechanisms that recognize and mediate between theinterests of different groups in the community. According to WHOguidance (19), Healthy Cities projects have six characteristics incommon.

1. They are based on a commitment to health. They affirm theholistic nature of health, recognizing the interaction between itsphysical, mental, social and spiritual dimensions. They alsorecognize that the cooperative efforts of individuals and groupsin cities can promote health.

2. They require political decision-making for public health. Citygovernments’ programmes on housing, environment, educa-tion and social and other services strongly influence the state ofhealth in cities. Healthy Cities projects strengthen the contribu-tion of such programmes to health by influencing the politicaldecisions of city councils.

3. They generate intersectoral action: the process through whichorganizations working outside the health sector change theiractivities so that they contribute more to health. Urban planningthat supports physical fitness by providing ample green spacefor recreation in the city is an example of intersectoral action.Healthy Cities projects create organizational mechanismsthrough which city departments and other bodies come togetherto negotiate their contribution to such action.

4. Healthy Cities projects emphasize community participation.People participate in health through their lifestyle choices, theiruse of health services, their views on health issues and their

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work in community groups. Healthy Cities projects promotemore active roles for people in all of these areas. They providemeans by which people can exert a direct influence on projectdecisions and, through the project, on the activities of citydepartments and other organizations.

5. They work through processes of innovation. Intersectoral ac-tion requires a constant search for new ideas and methods. Thesuccess of Healthy Cities projects depends on their ability tocreate opportunities for innovation within a climate that sup-ports change. Projects do this by spreading knowledge of newmethods, creating incentives and recognizing the achieve-ments of people who experiment with new policies and pro-grammes.

6. The outcome is healthy public policy. Healthy Cities projects’success is reflected in the degree to which policies that createsettings conducive to health are in effect throughout the cityadministration. Projects achieve their goals when homes,schools, workplaces and other parts of the urban environmentbecome healthier settings in which to live. Political decisions,intersectoral action, community participation and innovationpromoted through Healthy Cities projects work together toachieve healthy public policy.

The European Healthy Cities project is in its third phase (1998–2002). About 1100 cities and towns are linked with 26 national andseveral regional and thematic Healthy Cities networks in Europe.The strategic objectives of the third phase cover five main areas(17):

� accelerating the adoption and implementation of policies andintegrated strategic plans at the city level based on the strategyfor health for all for the 21st century (5) and local Agenda 21;

� promoting recognition of and political commitment to strength-ening the local action component in national and subnationalhealth policies;

� strengthening national and subnational, as well as subregionaland pan-European systems to support networking and capacitybuilding for healthy cities through out Europe;

� engaging all 51 Member States of the WHO European Regionin the Healthy Cities movement; and

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� expanding strategic links with the sectors and organizationsthat can influence urban development, and cooperating withother WHO regions.

Members of the Healthy Cities movement show a growingunderstanding and acceptance of the unbreakable link betweenhuman health and sustainable development (20). The HealthyCities project has developed strong links with the European Sus-tainable Cities and Towns Campaign, and it continues to work withthe Council of European Municipalities and Regions, the UnitedTowns Organisation and EUROCITIES (21). Further, with a rangeof partners, it has produced a series of publications drawing out thelinks, in theory and practice, between sustainable development andthe Healthy Cities approach (Table 1).

Principles and Health Localprocesses for all Agenda 21

PrinciplesEquity Yes YesSustainability Implicit YesHealth promotion Yes (Health)Intersectoral action Yes YesCommunity involvement Yes YesSupportive environment Yes YesInternational action Yes Yes

ProcessesConsideration of existing planningframeworks Yes YesAnalysis of health, environment andsocial conditions Yes YesPublic consultation on priorities Yes YesStructures for intersectoral involvement Yes ImplicitVision Yes YesLong-term action plan with targets Yes YesMonitoring and evaluation Yes Yes

Table 1. Comparison of principles and processes for planningfor health and sustainable urban development

from health for all and local Agenda 21

Source: Price & Tsouros (22).

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Establishing and running a Healthy Cities project requires astrong commitment, a high level of determination and a degree ofvision. In common with other local political planning processes, itdevelops through a series of stages, which continually seek to buildsupport and engage more and more sectors of society in thedevelopment of the project. This approach has been highly suc-cessful, and continues to attract more and more cities to theEuropean and national networks.

Environmental protection and local plansIn April 1993, the environment ministers from all across Europeagreed on a broad strategy for tackling environmental problemsthat was called the Environmental Action Programme for Centraland Eastern Europe (EAP) (23). It outlines a multistep process inwhich national governments can set environmental priorities andtake appropriate action to improve environmental conditions incentral and eastern Europe. EAP emphasizes the importance ofidentifying priority actions on the basis of environmental threats tothe health of human beings and of local ecosystems, and the needto identify a range of actions to reduce these threats. Further, EAPemphasizes strategies to prevent pollution and conserve resourcesthat require modest expenditure while achieving substantial envi-ronmental improvements.

National environmental action programmes (NEAPs) havelargely concentrated on green or ecological issues, and rarely makemore than a passing reference to public health issues. Normallythey are made without broad consultation or partnership withagencies or ministries outside the environmental sector. As a result,NEAPs tend to serve the interests and work programmes of envi-ronment ministries, rather than a broader agenda. (EAP and NEAPsare further discussed on pp. 82–85).

Nevertheless, a more expansive view could be taken, particu-larly at the local level where intersectoral work can be done moreeasily. The recent guidance on local environmental action plans(LEAPs) (24), demonstrates how similar the approaches can be.Very often, all that is needed in the development of a LEAP is theintroduction of some health aspects, data and information. Healthprofessionals’ participation in the formulation and implementationof LEAPs is essential.

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NEHAPs and the local agenda

We [the ministers of the environment and of health of the EuropeanMember States of WHO and the members of the European Commission(EC) responsible for environment and health] commit our respectivehealth and environment departments to developing jointly, not laterthan 1997, action plans on health and the environment, working withand through competent authorities or inviting them to draw up suchaction plans where appropriate and legally or constitutionally required.These plans should be integrated in or closely linked with both environ-mental action programmes and with health planning processes, and spe-cifically the action plans required by the UNCED follow-up and theEnvironment for Europe process. We will intensify cooperation withother governmental authorities, such as those responsible for agriculture,energy, industry, transport and tourism, in order to integrate environmentand health issues into their existing policies, as an important step to-wards sustainability.

We are convinced that there is a pressing need for a more comprehen-sive, integrated approach to creating healthy and ecologically soundlocal communities and for a much better understanding of the interplayof the many factors contributing to their wellbeing. We will act inresponse to UNCED’s call for countries “to develop plans for priorityactions based on cooperative planning by the various levels of govern-ment, nongovernmental organizations and local communities.

– Helsinki Declaration on Environment and Health (9)

A NEHAP defines the national framework but, in accordance withthe principle of subsidiarity, its successful implementation requiresmost action to be taken at the local level (11). This may be achievedin a variety of ways; the formal development of LEHAPs is one.Another is to use existing systems and plans, such as those for localdevelopment. Within existing systems, local authorities’ imple-mentation of the NEHAP may give additional impetus to their workon local Agenda 21 issues and in the Healthy Cities network(although NEHAPs address some problems that are rural, ratherthan urban). The integration of plans and initiatives at the locallevel will bring benefits similar to those from integration of plansat the national level, and many components of a NEHAP may becarried through under the auspices of another plan: these are otherexamples of a win–win situation.

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Whatever its nature, the local plan developed is likely to havesimilar principles, general approach and methodology to those ofa NEHAP, but to address fewer significant issues. Local authoritiescan ensure that the general public and all other interested parties areinvolved in the process of developing and implementing environ-mental health action in their areas. The central government and itsagencies need to support action being taken at the local level,particularly through setting up the planning process, preparingreports on environmental health status, selecting priorities andapplying to national and international donors for project funds.

Some local authorities and agencies face practical difficultiesarising from a lack of experience in using environmental healthmethodologies and public communication techniques. They mustbuild capacity in these areas if they are to take successful environ-mental health action.

Some measures or actions are specific to a particular area andperformed most appropriately by a local body. The funding of suchlocal work by central or local funds, or some combination of them,is crucial to successful implementation. Because limited financialresources are the principal impediment to implementation, clearcriteria are essential for setting funding priorities at the local leveland to ensure managers’ commitment to and continuing politicalsupport for implementation. The latter requires local politicians,interest groups and the public in the relevant area to be convincedof the merits of the NEHAP. Seed money from the central govern-ment can indicate the seriousness of its commitment. Alternatively,successful implementation of a pilot project may attract funds froma variety of sources for wider implementation. Projects work bestwhen they have an achievable scale and involve local people in allaspects, so that they can contribute to the resulting improvements.

In the light of the above-mentioned process and followingfurther endorsement by the European Environment and HealthCommittee, the WHO Regional Office for Europe began to addressthe implementation of NEHAPs at the local level. It was proposedthat a pilot project be developed to assist countries in developinglocal agendas for implementing their NEHAPs. This guidance isone of the principal products of that process.

The main objective of this project, undertaken by WHO andsupported by the Know How Fund of the Department for Inter-national Development in the United Kingdom, was to use the

38

experience and expertise of a small group of countries (Bulgaria,Kyrgyzstan, Latvia and Slovakia), which were already setting outto implement their NEHAPs, to develop assistance and options foraction that other countries could use to deal with problems inimplementing their own NEHAPs. Building on the experiences ofexisting local environmental health plans, Healthy Cities initiativesand local Agenda 21 programmes in a sample of European coun-tries, the project aimed:

� to make an analysis of existing local plans and initiatives in theWHO European Region, to identify what features they sharedand how they interrelated with and supported NEHAPs; and

� based on this analysis, to produce guidelines providing options forthe development of LEHAPs that give the necessary levels offlexibility to ensure that a bottom-up planning process can occur.

Annexes 1 and 2 list the coordinators or contact points in theparticipating countries and the participants at a meeting held toreview the process, respectively.

The project also utilized the work that the Regional Office hadalready completed to develop the institutional tool-kit to assistenvironmental health services. The publications on policy options(13), training and professional development (25,26), and theevaluation of environmental health services were used to assistcountries directly with the implementation of their NEHAPs at thelocal level. The series of pamphlets for local authorities producedby the Regional Office was also of great value in this process.

Bringing it all togetherAs stated at the outset, the names or ideologies attached to a certainlocal planning process matter little when the intended outcomes arebroadly the same. As demonstrated by Price & Tsouros (22),broadly similar principles underpin the local Agenda 21 andHealthy Cities approaches. Both the LEHAP and the environmentalprotection approaches also urge participants to adopt such princi-ples. All four hope to improve health and the quality of life for allmembers of society in a way that does not harm the environmentand that looks beyond the needs and demands of the currentgeneration. They also use similar planning processes (Table 2).

39

Tab

le 2

. Com

paris

on o

f pla

nnin

g pr

oces

ses

for

loca

l Age

nda

21, H

ealth

y C

ities

, e

nviro

nmen

tal p

rote

ctio

n an

d LE

HA

Ps

Lo

cal A

gen

da

21:

Hea

lth

y C

itie

s:E

nvi

ron

men

tal

LE

HA

P:

6 ke

y el

emen

ts (

27)

20 s

tep

s (1

9)p

rote

ctio

n p

lan

s:10

sta

ges

(28

)5

ph

ases

(25

)

1.M

anag

ing

and

impr

ovin

g1.

Bui

ldin

g a

supp

ort

grou

p1.

Get

ting

star

ted

1.In

itial

pre

para

tory

wor

klo

cal

auth

oriti

es’

2.U

nder

stan

ding

ide

as2.

Ass

essi

ng e

nvir

onm

enta

l2.

Gai

ning

pol

itica

lsu

sta

ina

bili

ty3.

Kn

ow

ing

th

e c

ityis

sue

s a

nd

se

ttin

gco

mm

itme

nt

pe

rfo

rma

nce

4.F

indi

ng f

inan

cing

pri

ori

ties

3.G

athe

ring

par

tner

s2.

Inte

grat

ing

sust

aina

ble

5.D

eco

din

g

org

an

iza

tion

3.D

evel

opin

g an

4.P

ract

isin

g w

hat

one

deve

lopm

ent

issu

es i

nto

6.P

repa

ring

a p

ropo

sal

envi

ronm

enta

l ac

tion

pre

ach

es

loca

l a

uth

ori

ties’

7.G

ett

ing

ap

pro

val

pla

n5.

An

aly

sin

gp

ract

ice

s8.

App

oint

ing

a co

mm

ittee

4.Im

plem

entin

g ac

tions

en

viro

nm

en

tal

3.R

ais

ing

aw

are

ne

ss a

nd

9.A

na

lysi

ng

th

e e

nvi

ron

me

nt

5.M

on

itori

ng

an

dh

ea

lth s

tatu

se

du

cati

ng

10.

Def

inin

g pr

ojec

t w

ork

eval

uatin

g re

sults

6.G

augi

ng t

he p

ublic

’s4.

Co

nsu

ltin

g a

nd

in

volv

ing

11.

Se

ttin

g u

p a

n o

ffic

ep

erc

ep

tion

sth

e w

ide

r co

mm

un

ity a

nd

12.

Pla

nn

ing

a s

tra

teg

y7.

Se

ttin

g p

rio

ritie

s a

nd

the

gene

ral

publ

ic13

.B

uild

ing

capa

city

ma

kin

gd

eci

sio

ns

5.W

ork

ing

with

oth

ers

14.

Est

ab

lish

ing

a

cco

un

tab

ility

8.W

ide

spre

ad

6.M

easu

ring

, m

onito

ring

15.

Incr

easi

ng h

ealth

aw

aren

ess

con

sulta

tion

and

repo

rtin

g16

.A

dvoc

atin

g st

rate

gic

plan

ning

on t

he d

raft

pla

n17

.M

obili

zing

int

erse

ctor

al a

ctio

n9.

Re

vie

win

g,

am

en

din

g,

18.

Enc

oura

ging

com

mun

itypu

blis

hing

and

pa

rtic

ipa

tion

laun

chin

g th

e LE

HA

P19

.P

rom

otin

g in

nova

tion

10.M

onito

ring

, re

view

20.

Sec

urin

g he

alth

y pu

blic

pol

icy

and

revi

sion

thr

ough

out

imp

lem

en

tatio

n

40

Although each process is set out differently in Table 2, inpractice the various stages show a great deal of similarity. Whilesome initially concentrate more on process than action, they allresult in sustainable planning systems that can deliver consensus-building mechanisms for improving living environments and life-styles. All recognize the importance of gaining widespread supportfor the process, and seek both to engage directly with members ofthe community and to work with a range of stakeholders orpartners.

On a practical level, this demonstrates that local planning forenvironmental health can be multilayered and -faceted. Eachprocess provides a different dimension of a broadly similar theme.This implies that they overlap, so to run them concurrently wouldbe to reinvent the wheel. No one approach is pre-eminent; eachshould be considered for its suitability to address the needs of thecommunity, and elements from each can be mixed.

Historically, the local Agenda 21 approach has focused onenvironmental issues and as a result has often overlooked thehuman or health aspects. This tendency can also be found inenvironmental protection approaches. Similarly, the Healthy Citiesapproach can sometimes concentrate too much on health promo-tion, to the detriment of broader social, economic and environmen-tal aspects. The LEHAP process is not well enough established, ortried and tested, for any strong conclusions to be drawn about itsemphasis, although it faces the danger of being perceived as aservice plan rather than as a community process. Nevertheless, asthe LEHAP process attempts to span environmental and healthaspects, it may provide an impetus to put health into environmentalplans and the environment into health projects.

In determining the type of process that could be used forplanning, consideration may need to be given to the politicalacceptability of and cachet associated with the particular project.The existence of a national framework and/or funding mechanismsmay also determine the decision on which planning process is mostappealing and appropriate. In certain cases, if funding is availablefor both health and environment planning, it may be possible to runtwo projects that complement each other, rather than overlap.

Part 2

Local environmentalhealth planning

41

3

The LEHAPplanning process

Fig. 2 shows the relationships between the ten stages in developinga LEHAP. A summary of the participants in and content of eachstage is given in Table 4 (pp. 78–79).

Initial preparatory workInitially, a small group of committed professionals needs to cometogether to discuss and prepare the ground for the planning process.The group needs to have a basic level of information before makingany approach to the political level. To secure political support, itmust have some idea of the planning process, the time scalesinvolved and, most importantly, the costs in financial and humanresources. The group should also spell out the anticipated benefitsof and the added value associated with the planning process.

The group may be able to feed from examples in other parts ofthe country or in other countries. It may be able to secure supportthrough the regional and national governments, or seek interna-tional endorsement for the proposed municipal activities. All of thisundoubtedly helps the presentation of any proposed planningprocess to decision-making politicians.

Gaining political commitmentCommunities need a driving force if they are to develop. This forcemay take the forms of supportive facilitation or active leadership.

42

The leading organization in any community is normally the mu-nicipality or local authority: the politically constituted body that isseen to have both the mandate and the overview necessary todeliver community-wide projects and plans.

Local environmental health planning relies heavily on localauthorities and the roles that they can play and develop. Munici-palities often have the main responsibility for ensuring healthyliving environments, but they can only achieve this by working inpartnership with other tiers of government, NGOs, community-based organizations, the private sector and so on. Right across

Fig. 2. The ten stages of the LEHAP process

Practising what onepreaches

Reviewing, amending, publishingand launching the LEHAP Gauging the public's

perceptions

Setting priorities andmaking decisions

Consultation on thedraft plan

Gaining politicalcommitment

Gathering partners

Initial preparatory work

Analysing environmentalhealth status

Monitoring, review and revisionthroughout implementation

43

Europe, the traditional service roles of all such stakeholders haverapidly changed in recent years. The causes have been fiscalconstraints, constitutional and legal reforms, scarcity of resources,globalization of economies, liberalization of markets, ecologicalconcerns, changing social attitudes and demographic pressures(29). As a result, communities have seen the need to adopt apartnership approach to service provision and planning.

Local authorities are central to local environmental healthplanning because they often (30):

� operate the economic, social and environmental infrastructure;� oversee planning processes;� establish local policies and regulations;� determine parameters for economic development;� are important vehicles in the development and implementation

of local, regional and national policies; and� work in a democratic manner.

While local authorities provide the focus for leadership at the locallevel, they may require a degree of direction or inspiration. In thissense, leadership for – not of – the local environmental healthplanning process may come from the national level. This need notnecessarily mean the national government. For example, whilenational legislation in Hungary requires local authorities to preparelocal environmental programmes in line with the national environ-mental protection programme, it was through the national HealthyCities network that comprehensive guidance was produced toassist municipalities and others in developing LEHAPs (31).

This guidance comprises a comprehensive, step-by-step manualfor a LEHAP process that is appropriate to the legal, social andeconomic conditions in Hungary, and demonstrates a strong levelof leadership to local communities in their environmental healthplanning activities. In this way, a solid framework has been builtthat local authorities and communities can use to develop plans thataddress their needs and aspirations.

Statement of commitmentLocal political leadership and commitment are important for any-one who has to develop and manage a local planning process. Thisgives action legitimacy and can enable wider access for greater

44

levels of participation. At the beginning of the process, a decree orproclamation from the recognized leader of the local community –perhaps the mayor or governor – may be needed to set out terms ofreference of the planning process and his or her support for it. Themessage should be signed, dated and widely distributed throughvarious media to advise the community of the seriousness of andthe commitment to be given to the programme. Such a statementcould be included in the final planning documentation, as thepreface or foreword to the main report. Box. 1 gives a samplepolitical statement as foreword.

Message from the Mayor, Any Town Municipality

The care of the environment has always been one of the municipality’smajor priorities. The environmental strategy is an important part of theframework of our policy. Today, we are moving into new areas ofpartnership with the community and industry on environmental healthissues, towards a programme for the 21st century – an Agenda 21, asset out at the United Nations Conference on Environment and Devel-opment, held in Rio de Janeiro, Brazil in 1992.

The Any Town Environment Forum has already shown how commu-nication and information sharing can raise awareness about ourenvironment and the challenges facing all sections of our community.This report on the state of the environment is an important part of thatworking in partnership. It gives information but also raises questionsthat can be resolved by all interested groups working together. It is partof the wider Agenda 21 programme for local councils, about whichthere is more to come. Finally, it is about us, the citizens of Any Town,and where we live.

Mr/Ms Any Body, MayorDate

To show partnership and commitment through leadership, itmay also be possible to obtain several such statements from thevarious partners and stakeholders involved in the project. This canhelp to build a wide consensus and legitimacy for the project. It canreflect and express commitment to national or even internationalagreements, charters or protocols, and can set out a list of policyprinciples to follow.

Box 1. Sample foreword supporting the planning process

45

Choice of locationChoosing the location of the project within the organizationalhierarchy of the authority is an important task. It influences theorganizational structure and the administrative mechanisms of theproject. It determines relationships with politicians, organizationsworking as partners in the project and community groups. It alsoindicates who owns the project (19).

As leadership is so important, guidance materials (32,33) oftenrecommend that the secretariat or the executive for the planningprocess should be located close to the main political or executivepower of the municipality: that is, in the mayor or other chiefexecutive’s office. This places the subject at the heart of thedecision-making body, provides good access to politicians andother decision-makers, and can help facilitate intersectoral actionacross the local authority. It demonstrates to both internal andexternal partners the municipality’s seriousness about the pro-gramme and its desire to lead the process from the highest level. Italso shows that the issues that must be considered in developing aLEHAP will require a unified corporate response. The develop-ment and final elaboration of the plan are likely to involve allaspects of the local authority’s activities and jurisdiction, fromdirect services to financial and budget readjustments. Being at thecorporate centre makes it much easier to call on the time andresources of others. It also confirms that the issues are common andaction of mutual benefit, and part of the whole organization’scorporate objectives.

Many local environment and health planning processes never-theless occur lower in the hierarchy. Decision-makers often see theresponsibility for overseeing environmental health planning as atechnical task that is best undertaken within a health or environ-ment department. While technical departments’ expertise andparticipation are required to develop and implement any plan, thisapproach tends to perpetuate and reinforce professional and de-partmental jealousies and isolation.

Such an approach creates two major potential pitfalls. First, theplanning process and the resulting plan are likely to favour theoriginating department’s needs and desires, and can easily turn intoa wish list to bolster its work. This puts the plan in danger ofbecoming a departmental service plan rather than a cross-authorityproject that has all parties’ endorsement. Second, the other partners,

46

both within and outside the authority, are unlikely to invest heavilyin a plan that they view as not truly corporate and as benefitingothers at their expense. The key message here is that leadership isneeded that creates a cooperative environment and treats the majorpartners as equals.

A third and practical approach to siting the executive leader-ship role is to use an outside party to deliver the planning process.Two of the participants of the LEHAP project (undertaken by WHOand supported by the Know How Fund) used this approach to goodeffect. In both Varna, Bulgaria and Bishkek, Kyrgyzstan, inde-pendent contractors or third parties were employed to facilitate theLEHAP process.

Using this approach removes any possible claims of bias in thedevelopment of the plan, and can engender good intersectoralwork. It may even facilitate greater acceptance of the process byexternal partners and, if well managed, will lead to an open andpositive dialogue with NGOs and community groups. An externalproject office may also be useful when there is more than oneleading partner. For example, a municipality and a regional gov-ernment department may wish to collaborate in developing theplan for a particular project. In these circumstances it may be bestto form or contract a project office to work between the twoorganizations.

Beyond the planning stage, however, this type of arrangementneeds to be reviewed. The management and implementation of theproject may require a very different approach to that of the initialphase.

Again, strong corporate commitment to the LEHAP process byboth politicians and officers of the municipality is an essentialstarting point. A clear statement of the authority’s commitmentprovides the momentum needed to forward initiatives within theauthority and puts environmental health issues on the agenda ofother organizations in the locality.

Gathering partnersIn practical terms, once political commitment has been secured, thenext stage is to gather a range of partners, from both the municipal-ity and the wider community, to form a steering committee. Thisgroup can take many different forms, but it needs to be a manageable

47

size (with no more than, say, 15 people), to be chaired by a leadingcommunity representative (normally the mayor or vice-mayor) andto have sufficient delegated powers and resources to develop the plan.

The idea that partnerships are essential to addressing environ-mental health issues effectively is now well established and widelyaccepted. In many respects, health is not a natural product, but theresult of an interaction and balance between society, economy andenvironmental pressures and driving forces (Fig. 3).

Health

Economy

Environment

Society

Sustainable Liveable

Adequately prosperous

Fig. 3. A healthy and sustainable community

Source: Hancock (34).

To facilitate a planning process that recognizes this model, thecommittee must comprise a group of stakeholders that can repre-sent the entire spectrum of community aspirations and pressures. Ifthe final outcome of the planning process is to be a workable andachievable plan, it needs to reflect the views of that community andbe developed through consensus. Clearly, environment and healthprofessionals, along with those working in social welfare andeducation, must work hand in hand with the economic sectors andother major groups in society, such as NGOs, religious groups andethnic minorities. The major groups of any society as identified inAgenda 21 (7) are: women, children and young people, indigenous

48

people, NGOs, local authorities, trade unions, business and indus-try, academia and farmers. This is clearly an indicative and not aprescriptive list, but it shows the variety and range of views that theLEHAP planning process should consider.

The process of building an intersectoral approach, which rec-ognizes all facets of a community, helps in both making andimplementing a LEHAP. Many of the actions necessary to bring theplan to life will need whole communities to act or change the waysin which they live or consume. As experience in all large towns andcities teaches, changing human behaviour, without the resourcesof mass-marketing campaigns, can be extremely difficult andwould be almost impossible if members and leaders of the commu-nity were not involved in the decision-making and priority-settingprocesses. Their involvement provides a means of testing thefeasibility and practicality of a proposed solution, and they are aconduit for communicating and carrying the proposal into the heartof the community.

Partners is a loose term referring to those in society who havea major influence on environmental health issues. The followinglist of organizations, initially drawn up in the preparation of theLEHAP for the city of Bishkek, is an example:

1. state or public health organizations and agencies;2. state environmental protection organizations and agencies;3. organizations and agencies responsible for: housing provision,

transport, occupational health and safety, the supply and treat-ment of drinking-water, the treatment of wastewater, and thecollection and disposal of solid industrial and domestic wastes;

4. organizations and agencies representing particular sectors:commerce and business, industry, trade unions, agriculture andenergy;

5. NGOs addressing environmental health issues;6. community groups active in the locality;7. relevant departments or faculties in universities and schools;8. relevant international agencies active in the locality;9. neighbouring local authorities or municipalities; and10. the mass media.

While all these sectors cannot be represented on any committee orsteering group, all need to be seen as potential contributors to orpartners in the project.

49

Some of the less obvious partners in developing local plansdeserve special discussion. First, depending on the nature of thegovernance of the country, the involvement of state or regionalgovernment representatives may seem unusual for a plan dealingwith local issues. Any local plan, however, must fit within ahierarchy of other policies, plans and laws, and it is in everyone’sinterest to ensure that the local plan sits comfortably within nationaland regional frameworks, while recognizing local needs and de-sires. This is the key benefit of developing a LEHAP within theframework of a NEHAP. The latter not only provides a point ofreference for LEHAP development but also should provide astrong foundation and network on which the local plan candevelop.

Second, while the plan must have geographical limits, probablythe borders of the municipal jurisdiction, the process should beable to work outside them. Municipalities must frequently workwith their neighbours to address cross-border issues such as pollu-tion, transport and planning policies, and the planning processneeds to recognize these. In fact, the coordination required mayhave to take place at the international level. For example, the citiesof Ruse, Bulgaria and Giurgiu, Romania cooperate on local plansbecause they sit on opposite sides of the Danube. Involvingneighbouring local authorities in the planning process can alsoinspire them to develop their own LEHAPs. A municipality devel-oping a LEHAP can set an example for its neighbours, highlightingthe benefits of the planning process, and can enter into jointplanning activities on cross-border issues.

Finally, some may see the involvement of the mass media asunwarranted and taking openness too far. Experience from theWHO/Know How Fund project, however, has shown that involv-ing media representatives in the project from the outset and in theirown right – as contributors to and not reporters of the process – canbring great benefits. People working in the press and electronicmedia have valuable insights into public perception and opinion,and can use a number of techniques to assist in selling anymessages that need to be put across. Leading members of the massmedia are normally extremely well connected and have a strongunderstanding of the community and its problems. Further, if theyare strongly connected with the project, the media are more likelyto support it.

50

The partners that need to be brought together will vary from cityto city, town to town and village to village. Unfortunately, noprescriptive list can be provided.

A final issue to bear in mind is that assembling a group ofpartners can be difficult under certain conditions. Examples in-clude problems with bringing together a suitably diverse andrepresentative group in rural communities, and (as shown byexperience from the WHO/Know How Fund project) with findingrepresentatives of the general public and communities to partici-pate, particularly in countries where democracy is new. In suchcases, methods worth considering may include utilizing existingbodies that have established connections with members of thepublic, such as established community councils, or paying peopleto participate. This second option needs to be given careful consid-eration, as it can begin to undermine the process.

Practising what one preaches

Reviewing existing policiesEveryone involved in the process should realize from the outsetthat his or her commitment to developing a LEHAP will have widerand deeper repercussions than merely producing a printed docu-ment. It implies a serious commitment to reviewing and changingthe way in which the municipality operates and implements its ownpolicies. It calls for a strong and authority-wide determination topractise what it preaches about health, development and the envi-ronment. Indeed, it may identify a number of conflicts of interestthat will need to be resolved. Converting commitment into actionis probably the hardest single element of the LEHAP process; it canbe easily overlooked, but inaction ultimately undermines theprocess and the final plan.

Municipalities are under increasing pressure to act on issues ofenvironmental health and sustainable development. Nevertheless,there are tensions between the objectives of the different prioritiesand departments of a municipality. Economic development offic-ers, town planners and environment and health workers do notnormally share a common agenda and historically have not workedwell together. The LEHAP planning process needs to address and,whenever possible, resolve these tensions.

51

One of the starting points is to form a cross-departmental groupor committee to work through the various threads of existingpolicy, to determine their impact on environmental health andsustainable development. Committees could be set up to representboth officers and elected members with special responsibilities forthis area of work. These groups or committees should be estab-lished under the LEHAP steering committee, and should be suit-ably serviced and resourced. They will need to receive a clearmandate from the top of the organization. Group members need tofeel that their work is central to the running of the municipality andthe LEHAP, not a peripheral activity with little or no bearing on theoperation of the services or policy of the municipality. To facilitatethis, the chief executive’s or mayor’s office could lead or facilitatethe coordination of the groups (35).

Reviewing all municipal policies historically, in order to pro-duce a comprehensive action plan for environmental health acrossa whole community, certainly sounds daunting. Once an interdepart-mental working group has been established, however, a rollingprogramme can be set up to review all policies and strategies for theirimpact on environmental health and sustainable development issues.

Factors to consider and possible benefits to reapThe group reviewing policies and strategies can usefully considerfactors that affect the environmental, social and economic frame-work discussed earlier (see Fig. 3). As to the environment, wher-ever possible policies should seek (36):

� to use energy, water and other natural resources efficiently andwith care;

� to minimize waste; then to reuse or recover it through recycling,composting or energy recovery; and finally to disposesustainably of what is left;

� to limit pollution to levels that do not damage natural systems;and

� to value and protect the diversity of nature.

As to social factors, wherever possible policies should seek (36):

� to create or enhance places, spaces and buildings that work,wear and look well;

52

� to make settlements human in scale;� to value and protect diversity and local distinctiveness and

strengthen local community and cultural identity;� to protect human health and amenities through safe, clean

pleasant environments;� to emphasize prevention, as well as care, in health services;� to ensure access to good food, water, housing and fuel at

reasonable cost;� to meet local needs locally;� to maximize everyone’s access to the skills and knowledge

needed to play a full part in society; and� to empower all sections of the community to participate in

decision-making and to consider the social and communityaspects of decisions.

As to economic factors, wherever possible policies should seek (36):

� to create a vibrant local economy that gives satisfying andrewarding work without damaging the local, national or globalenvironment;

� to value unpaid work;� to encourage necessary access to facilities, services, goods and

other people in ways that make less use of cars and minimizeeffects on the environment; and

� to make opportunities for culture, leisure and recreation readilyavailable to all.

Each locality needs to review its own policies in its own way.The points listed above are not intended as a strait-jacket or rigidblueprint, since action must relate to local issues and resources.They can be used as a prompt or check-list for the review process,particularly to avoid the danger of a narrowly environmental focus(31).

A LEHAP is unlikely to be the first or only plan developed bya municipality, and compromises will be required to fit in with thesuite of existing strategies and plans. The municipality may alreadyhave plans, strategies and programmes on, for example, physicaldevelopment, economic development, health, the environment,energy, housing, transport, biodiversity and social issues. TheLEHAP framework provides a means to begin to integrate work on

53

some of these issues, and to investigate the links between differentsectoral plans. Thus, the process of developing the LEHAP canhave as significant an impact as the final document itself. It mayeven demonstrate hitherto unseen links, highlight duplicated workand activities and point towards cost savings. It may also showwhere gaps exist and new resources need to be directed.

Improving the municipality’s environmentalperformanceAnother part of municipalities’ practising what they preach isimplementing an environmental management system to ensure thattheir own activities are in line with their stated aims.

An environmental management system is a tool that helpsmunicipalities to make progress towards their own targets forenvironmental performance. The municipality chooses the targets,but they should reflect the standards that it demands from others.The municipality should: produce an action plan that addresses andsets targets for the significant environmental effects of the organi-zation, monitor its progress towards achieving the targets andperiodically publish a statement about its progress. It could seekexternal verification of its performance and seek accreditationto a national scheme if one exists, such as the EU’s EMAS (http://europa.eu.int/comm/environment/emas/, accessed 13 Febru-ary 2002).

Using such a management system allows the municipality toaffect the environment in two ways. It can have direct effects on,for example, paper use, council transport and the heating of counciloffices. It can also affect the environmental impact of people usinglocal authority services: service effects on, for example, the energyefficiency of municipal housing and the disposal of domesticrefuse.

The management process should be repeated at intervals of oneor more years, to ensure that municipal policies and practicesbecome progressively more sustainable. The main steps taken ineach round are:

� setting the corporate objectives for environment andsustainability issues;

� reviewing the council’s activities to identify and assess theirsignificant direct or service effects of the on the environment;

54

� setting objectives and targets for improvement;� designing programmes to achieve these targets;� identifying indicators to monitor both progress of the imple-

mentation of these programmes and progress towardssustainability; and

� monitoring the indicators and management of the programme.

One of the most significant characteristics of the environmentalmanagement system is its potential to mobilize all departments ofthe municipality to identify and begin to address their direct andservice effects on the environment and health, and to help differentprofessions and specialists take account of the environmentalhealth dimension of their work. It provides a mechanism for anintegrated approach to solving environmental problems, which canfacilitate the functional or problem-led approach required to tacklemany environmental health issues (37).

One of the key ways in which a municipality can simulta-neously practise what it preaches and begin to influence thesurrounding community is through its purchasing policies. Munici-palities and local authorities can have a major impact on environ-ment and health through the products and services they purchase.Often a municipality is the largest employer and consumer in anyone locality. One should not therefore underestimate its potentialimpact. Almost every service or type of goods that a municipalitypurchases has some kind of environmental health implication, andthese considerations need to be brought into the purchasing pro-cess. When making contracts for goods or services, municipalitiescan require suppliers to meet conditions on the environmentalhealth impact associated with the product or services. Thus, themunicipality no longer looks just for the lowest price or the bestvalue for money in making a decision but also at the environmentalhealth impact of the goods or services. This in turn forces manufac-turers and service providers to begin to think about their produc-tion processes and the sources of their raw materials (38).

The crux of the issues surrounding policy integration andaligning municipal policies and practices to respect environmentalhealth lies in the fact that municipalities are often responsible forboth economic development and environmental health protection.They fulfil both of these functions for the benefit of their commu-nities. Many believe that these duties conflict, because economic

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wellbeing depends on consumption, which requires resource use,which potentially causes environmental health damage. If this werealways true, sustainable development would be a contradiction interms. A rising material standard of living does not necessarilymean more consumption. In the context of local economic devel-opment, sustainable development means at least reducing currentlevels of energy and resource consumption and of waste productionin order not to damage the natural systems on which future genera-tions will rely to provide safe and healthy living conditions.Development can be made sustainable without sacrificing humanwelfare if care is taken to choose the correct types of development.

Greening the local economy is not justified only on environ-mental grounds. Environmental constraints are undoubtedly apotential threat to the commercial viability of businesses that do notunderstand and anticipate them. They also create opportunities forenormous expansion and prosperity in other industries. Environ-mental markets are now developing all across Europe.

Improving the quality of local environmental health and thesustainability of all local businesses and shifting the emphasistowards sustainability are increasingly important ways for a mu-nicipality to ensure the continuing economic health of its area. Fiveaims might act as the basis for an integrated approach to environ-mental and economic strategies (39):

1. to help local businesses reduce their effects on the environmentand health;

2. to encourage a move towards a more sustainable mix ofbusinesses in the area;

3. specifically to foster the development of an environmentalindustry in the area;

4. to protect environmental health in ways that do not threatenjobs; and

5. to seek business opportunities through environmental healthprotection and enhancement.

Analysing environmental health status(providing an objective assessment)Once the principles of the LEHAP approach have been agreed andthe constitutional and institutional arrangements have been

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completed, the first stage in the development of the plan can begin.The fundamental reason for developing a LEHAP is to provide areasoned basis for taking action with limited resources. It shouldprovide clues to the main priorities and actions that can make thegreatest impact on environmental health.

Before any decisions can be made on the action needed toimprove environmental health, however, planners need to under-stand the environmental conditions prevailing in the locality at theoutset of the planning process. An analysis of the environmentalhealth profile of the area has to be made to provide such anunderstanding.

The interrelationship between the environment and health isnot simple. There can be no simple formula or methodology todetermine the impact on community health of the inevitable mix ofenvironmental pressures and stresses present in every community.This means that setting environmental health priorities is a complexbalancing process. The precautionary and preventive nature ofenvironmental health approaches further complicates this task. Ifenvironmental health actions work, no adverse effects can bemeasured. Unfortunately, the effort needed to maintain the ab-sence of effect is almost impossible to quantify; this hindersprocesses of priority setting and resource allocation.

Nevertheless, to begin these processes, a report on the state ofenvironmental health should be produced. It should provide, asobjectively as possible, a review of the various environmentalstresses present in the community and their supposed impact onhuman health and wellbeing. Some indications of priority actionsmay emerge from this.

Reporting on the state of the environment has been popularamong national governments and some of the more progressivecities in Europe for some time, and at least since the RioConference and the publication of Agenda 21 (7), which callsfor such reporting in Chapter 40. The reports normally analysethe main environmental stressors or vectors and provide hardscientific monitoring data, which are normally compared tonational or international standards and norms. Environmentalperformance is gauged and priority areas are identified from theresults. Issues commonly included in reports on the state of theenvironment include the following, which fall into three groups(Table 3).

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Not all the information listed in Table 3 would be relevant at thelocal level, but it nevertheless shows what sort of areas could becovered. Some reports also consider the effects of different sectorsof the community, such as agriculture, energy and manufacturing.While some of the better reports may include health, it rarelyreceives sufficient attention or detailed coverage to give an effec-tive overview of environmental health. Normally, a health profilealso has to be produced to complete the picture.

In the Healthy Cities movement, making a city health profile isa key element in creating a city health plan (41). It is an invaluabletool for every participant in the project. It provides a lively,scientifically based account of health in the city; it can stimulatepublic interest and political commitment, and it can identify targetsfor the future and monitor progress towards them.

According to the WHO Healthy Cities project, a city’s healthprofile is a quantitative and qualitative description of the health ofthe citizens and the factors that influence it. The profile identifies

Category Issues

Media and resources Air qualityClimate changeFish resourcesForest resourcesNature and biodiversityOzone layerSoil and land resourcesWasteWater resources

Cross-cutting concerns AcidificationHazards and accidentsHealthNoiseRadiationToxic substances

Spatial systems Coastal and marine areasUrban settlements

Table 3. Issues includedin state-of-the-environment reports, by category

Source: Cookbook for SoE reporting (40).

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problems, proposes areas for improvement and stimulates action.As its main objectives, the city health profile should (41):

1. summarize health information relevant to the city;2. identify health problems in the city, factors that affect health

and suggested areas for action to improve it;3. stimulate health changes in the city and intersectoral action;4. set targets for achievement related to health;5. identify needs for new data on indicators of health;6. inform the public, politicians, professionals and policy-makers

about matters that affect health, in an easily understandableform;

7. make health and its determinants visible; and8. record the local community’s views on health issues in the city.

While this description of a healthy city profile provides for allthings, it probably goes beyond what is initially required for theLEHAP initial assessment of the relationship between environmentand health.

What is fundamentally required at this stage is strong epidemio-logical information that can be analysed with and against environ-mental data. This process may turn up more questions than answers,but, if the information is reliable, it may begin to highlight areas ofconcern. This is a task for professionals: the scientific and theacademic communities involved in developing the plan.

Correlation and associations between different factors may bedifficult to prove, but new understandings and links may emergefrom data comparison. Presenting environmental information along-side health data, even without proving or developing associations,can prove to be a powerful tool. To mark the Third MinisterialConference on Environment and Health in June 1999, a report (42)was published that placed environment and health data on Londonside by side, occasionally using a geographic information system(GIS) to illustrate trends and patterns. While no correlation wasdrawn out or proved in the report, it provided a stark illustration ofthe state of London’s environmental health.

The challenge of producing an environmental health profile fora locality may seem extremely onerous at the start. It may be lessdifficult, however, if tackled as a team effort. Beginning fromscratch – with a completely new survey and analysis of health and

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environmental conditions – is very rarely necessary. Environmen-tal and health profiles for the municipality may already exist, andcollating the information may be all that is needed. If such profilesare not to hand, health and environmental authorities almostcertainly hold sufficient data to begin compilation of an environ-mental health profile. This is certainly the case in the CCEE andNIS, where systems of environmental and epidemiological controlrelied principally on monitoring, measurement and data collection.While not all the figures will be completely up to date, they willnevertheless provide good baseline information, and may evenindicate trends if compared to previous information.

The first step should be to survey completely the existing data,which can be compiled into a report on the state of environmentalhealth. Very often, when first developing such plans, professionalsfeel an impulse to commission new research and to buy newmonitoring and laboratory equipment. This approach not onlyseverely delays the beginning of the planning process but also canbe extremely expensive, and diverts resources to measuring ratherthan addressing issues. Particular gaps may appear in the informa-tion that is collected, and new information may have to be sought.Professionals should decide to do more monitoring only after fullyand thoroughly auditing existing information sources. Severaldifferent sources of information can be available, from stateagencies to NGOs. Indeed, involving a wide group of agencies andindividuals to contribute to the baseline study helps to buildsupport and interest in the process.

When complete, the report on the state of environmental healthis a principal building-block for the LEHAP process, and should bewidely circulated to all stakeholders and made available to thegeneral public. Such reports are increasingly published electroni-cally on the Internet, allowing greater access to the reports and agreater degree of flexibility in the methodology of reporting.

Gauging the public’s perceptionsThe report should provide a strong analytical perspective on themajor issues in the environment that affect the health and wellbeingof the population. This is essential if cost-effective action is to betaken. As mentioned above, information must also be gathered onthe environmental health problems in the locality as perceived by

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the local population. The population’s view may not always matchprofessionals’ scientific assessment, and may highlight human andsocial problems that statistics and hard measurements cannotdemonstrate. The decision-making process needs to contain adegree of value judgement to use in determining the level ofpriority a particular issue may attract.

This is the opening step in building effective public consulta-tion and participation in the planning process, and should thereforebe taken effectively and in a way that builds trust and opennessamong the participants, and demonstrates a strong commitment tomeeting the community’s perceived needs.

Direct engagement with the general public to aid decision-making is a new approach to many municipalities and publicauthorities, especially in parts of the CCEE and NIS. It is a hugeleap to go from an undemocratic society to a system of representa-tive democracy and then to begin dialogue in a form of participa-tory democracy. Raising the prospect of this sort of approach needsto be handled carefully in this type of community, as both electedpoliticians and the public need to feel comfortable with it.

No one would suggest that creating the correct environment formeaningful community participation is easy. Experience has shownthat it is normally difficult and lengthy; although the body ofexperience is growing, it is still a largely uncharted area, wheredefinite answers are hard to find. Nevertheless, these reservationsshould not prevent the LEHAP steering committee from taking thefirst step. Community participation will offer real benefits to theprocess. Close working relationships between authorities and com-munities are always better than each side working alone or, worse,against each other. Further, a two-way process can utilize resourcesmore effectively and bring added value.

The initial stages and the planning of community involvementare extremely important. Failure to establish sound principles andrules for engagement at the outset inevitably creates tensions andsuspicions at a later stage. Good ground rules are essential in theimportant early stages of establishing procedures for engagement.A few that should be considered include:

1. partnership, as the LEHAP process thrives only on sharedobjectives, mutually agreed goals and mutual beneficial action:on stakeholders’ working together rather than separately;

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2. openness and accessibility, as information and ideas need to beopenly available to all, and the people and groups involvedshould be accessible by all;

3. honesty, as LEHAP participants must clearly communicatewhat can and what cannot be achieved, to avoid raising unreal-istic expectations;

4. relevance, as the process should start with the community’s owninterests and concerns, skills, knowledge and experience, mak-ing links between these and broader concerns;

5. achievement, as the process must contain action that is achiev-able in the short as well as the long term, to sustain interest andinvolvement;

6. learning from experience, as the way forward is unknown andparticipants can learn from their mistakes; and

7. commitment, as the process must include clear, sincere anddurable commitment to public participation (43).

As mentioned above, the prospect of developing a strategy toengage and communicate with the whole community can be daunting,particularly if one believes that contact has to be made with everybody.A strategy can also be superficial, if it involves merely contacting thenormal group of NGOs that is usually active in the areas and in contactwith the local authority. The community itself can be a major help inthis process, as existing groups, structures and lines of communicationcan often be used to disseminate and receive information.

As a starting point, the steering committee can use normal andestablished external contacts to broker introductions to other ele-ments of civil society, and so develop a wider constituency ofinterest. A number of mechanisms can be used to communicate theproject to the general public, including media contacts and/orparticipants, and the cascading of information through other com-munication networks. In addition, people need to be eased into theprocess. Many attempts at community participation have failedbecause members of the public are either uncomfortable with theconsultation process or are not confident about dealing with thesubject matter. Encouragement and a degree of training may helpto ensure a productive consultation process. The committee mayalso consider consulting and engaging with the local community onits own terms. From this starting point the onus and emphasis canbe reversed, leading to a strong and more equal relationship.

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Community participation and community involvement compriseumbrella terms for many different practices. In particular, one shouldrecognize the different levels of participation (44); these vary with thelevels of control exercised by the lead organization, as shown in Fig. 4.

Source: adapted from McCarthy & Ferguson (42) and Brager & Specht (45).

Fig. 4. Partnership and control in community participation

Level of Role of Examplecontrol community

High To control The organization asks the communityto identify the problem and to make allkey decisions on goals and means. It iswilling to help the community at eachstep to accomplish its goals.

To exercise The organization identifies and presentsdelegated a problem to the community, definingauthority limits and asking the community to

make a series of decisions that canbe embodied in a plan that it will accept.

To plan jointly The organization presents a tentativeplan, subject to change and open tochange from those affected. Theorganization expects to change the planat least slightly and perhaps moresubsequently.

To advise The organization presents a plan andinvites questions. It is prepared tochange the plan only if absolutelynecessary.

To be consulted The organization tries to promote aplan, seeking to develop support tofacilitate its acceptance or winsufficient sanction for plan so thatadministrative compliance can beexpected.

To receive The organization makes plan andinformation announces it. The community is

convened for informal purposes, and itscompliance is expected.

Low None The organization tells the communitynothing.

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Many local planning processes call for increased communityparticipation. The challenge for many will be to develop commu-nity acceptance and new forms of engagement to move further upthe ladder. New and innovative mechanisms are required to enableLEHAP participants to the move beyond more passive forms ofconsultation and providing information, and to engender involve-ment and empowerment.

Consulting the community on environmental health issuesshould be an essential and critical stage in developing the LEHAP.It can be undertaken at the same time and in parallel to the stage ofmaking the perhaps more objective report on the state of environ-mental health. The fundamental objective is to establish whatenvironmental health issues raise concern in community membersand what they think needs to be done, while ensuring that they areaware of the process that has been established to deal with theseissues.

MethodsWhile a number of methods can be used for developing effectivepublic engagement and participation, none is an accepted model ofgood practice. Different approaches and methods are needed,depending on the people involved and the issue to be considered,and it may be necessary to adopt a series of different techniques.These include the use of fora, focus groups, questionnaires andopinion polls and surveys.

If a forum is to be effective, it needs very clear terms ofreference and a small number of participants. Working proceduresneed to be creative and free, and the use of an experiencedfacilitator helps bring the best out of the group. Fora should begiven a set deadline for completing their work and reporting.

Focus groups can be a valuable complement to a forum. Theycan consider particular specific issues in a smaller, more dynamicgroup and report back to the forum.

If questionnaires are used, great care needs to be taken indrafting the questions to ensure that the replies received aremeaningful. The steering committee should bear in mind thatresources will be needed to carry out the collation and analysis ofthe responses. Experience shows that questionnaires are often mostuseful in smaller areas and communities and where the topics underdiscussion are well focused. The committee may consider providing

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some form of incentive for members of the public to return thequestionnaire.

Opinion polls and surveys can be very effective and provide ahigh response rate, especially if local people manage them. Again,relevant questions and effective interpretation are crucial if sur-veys are to be a valuable method of establishing the community’spriorities. They can be administered in a number of different waysand through various third parties. In one example, schoolchildrencarried a written questionnaire to their parents and grandparents.As saying no to a child often proves difficult, a response rate ofalmost 100% was achieved.

In a recent study, the Regional Environment Center for Centraland Eastern Europe noted that, although the texts of NEHAPs madelimited provision for public participation, the public is evidentlymore active in the process of local implementation and particularlyin LEHAP development (46). In addition, the success of publicparticipation in the LEHAP process can depend directly on thepractice of public participation in NEHAP preparation and theinfluence of public comments on the final version of the text,especially in the part that determines public participation andaccess to information.

Another specific feature of the LEHAP process is that it isassociated closely with the Healthy Cities project in most of theCCEE, and coordinating the two helps to facilitate both. From feed-back obtained on local environmental health planning processes,the Regional Environmental Centre report makes a number of generalobservations on public involvement in the LEHAP process (46).

1. High levels of public participation have been secured throughthe LEHAP model. National (NEHAP) and international (HealthyCities) frameworks assist in this process.

2. Some processes are more transparent than others, yet all seemto be making progress in the correct direction and utilizingvarious forms of the mass media.

3. The initiation of public participatory processes has led tofurther and sustained public participation in other areas.

4. Involvement within LEHAP processes has not been limited toNGOs but has included members of the general public. In somecircumstances, both have assisted in implementation as well asdevelopment.

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5. Where LEAPs have been developed, beginning a public dia-logue on environmental health issues has been easy.

6. In some towns and cities, innovative mechanisms for publicparticipation have been developed, including direct access anddiscussion between members of the public and elected officials.

7. Attitudes and responses to public comments on the draft planvary. This part of the process appears to be less open than theearlier stages. In most cases, the public takes little or no part inthe final decision to adopt the completed LEHAP. Thoroughinvolvement throughout the earlier stages of its development,however, should make this point less significant.

Developing strategies for public consultation and participationis a major, complex and inevitably lengthy process. Methods andprocedures need review and revision as the planning and imple-mentation process moves forward. In all of this, providing quickand meaningful feedback to those who have participated is ofparamount importance. The people engaged in the process must seeit making a difference, or they will begin to lose their enthusiasmand commitment.

Setting priorities and making decisionsOnce the technical and scientific information has been producedand digested and the public’s views have been recorded, decisionsare needed on the action part of the plan. The combination of issuespresented and their proposed solutions always exceeds the re-sources available to address them. Decisions must therefore setpriorities and allocate resources to make the best impact on healthand the quality of life.

The set of problems identified and their complexity and severitymay vary considerably, depending on the size of the community,the features of and the external pressures placed on the environ-ment, and the traditional values and the make-up of society. Asdiscussed above, not every objective can be attained immediately,usually owing to limitations on time and budgets. Accomplishingsome objectives entails a number of tasks of varying size, complex-ity, cost and duration, so these matters should be clarified beforethe problems are given their priorities. Determining these prioritiesis undoubtedly one of the most difficult parts of the LEHAP

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development process, in which considering the favourable orunfavourable effects of intervention is vital (29).

Problems in decision-making and measurementEnvironmental health problems rarely have simple solutions, andthe physical or financial resources that might be desirable forsolving them are rarely available. Indeed, all environmental healthproblems have been described as complex (47). Most peoplewould agree that the politician’s task – to strike a balance betweenthe scientific and public assessments of priority issues – is nearlyimpossible. Because one perspective is purely subjective and theother scientifically subjective, they are likely to indicate differentissues and priorities. The value systems, the reference time scales,the monitoring equipment – all mean that the two assessments willreach different conclusions, each highlighting issues to which theother is blind owing to prejudice or the lack of appropriate viewingaids or equipment.

To further compound the problem, the evaluation of environ-mental impact on health is now well recognized to be an inexactscience at best. So many compounding and synergistic factorscontribute to ill health and poor quality of life that identifyingenvironmental factors’ contribution becomes almost impossible.Indeed, even measuring health can be extremely difficult, and itnormally involves using illness or disease as a surrogate indicator.This practice fails to capture the more positive aspects of health,outside the range of absence of disease, and the beneficial effectsof good environments to human wellbeing.

Moreover, health outcomes depend not only on the environ-ments in which people live, work and play but also a whole rangeof individual characteristics: age, gender, social class, etc. Startingfrom this perspective, multilevel approaches can provide simulta-neous analyses of individuals and their ecologies. In using thismodel, the key consideration is whether analysis can distinguishbetween observed differences due to individual characteristics atone level and those resulting from the physical environment of anarea, the structures in the community that deliver health andpeople’s mobility (48).

A preoccupation with statistics has characterized the overallapproach to the principles and methods of epidemiological re-search. Users of this approach compare data over time, subject

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them to hypotheses and then interpret the findings. This scientificinference is therefore prone to using a degree of subjectivity.Presenting statistical information may have the administrativeobjective of guiding practical action, but it cannot be the onlyelement in the decision-making process. A decision of this sortshould not only consider the statistical information but also quan-tify the costs and benefits – including the social and political ones –associated with each possible action.

The linkage of environment and health data offers potentialbenefits for decision-makers, but it also poses risks if not carriedout carefully. Presumptions, misinterpretations, inconsistenciesand inaccuracies can all lead to faulty interpretations of relation-ships. In addition, most correlations between environment andhealth issues take comparatively long periods of time to determine.This means that new links are unlikely to be established during thedevelopment of a LEHAP.

Methods suitable for linking environmental and health datamust meet two criteria. First, they must be simple, inexpensive toimplement and operable with available data, thus allowing rapidassessment. Second, they must produce statistically valid andscientifically credible results if they are to be used as a basis foraction. This means they should be unbiased and sensitive to thevariations in the data at hand (46).

A GIS can be very effective in comparing data sets. Themanipulation of data into powerful graphic representation allowsfor a high level of interpretation and visual impact. A GIS is onlya tool, however, and a potentially expensive one at that. It shouldnot be viewed as a panacea for the interpretation and presentationof the data collected.

Considerations in setting prioritiesSeveral attempts have been made to produce criteria to guidedecision-making on priorities. Guidance from Hungary (29) sug-gests that priority should be given to action on an identifiedenvironmental problem if:

� the problem has very significant effects on the environment orenvironmental health; and

� immediate or urgent intervention is necessary to avoid irrepa-rable damage.

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The guidance goes on to suggest that either no clear-cut rankingcan be made or, while the importance of one or two problems maybe obvious, ranking the rest can be difficult.

In determining further priorities and ranking tasks, three factorsmay need consideration. The first is values exceeding environmen-tal quality cut-offs. How often and to what extent do pollutionlevels exceed specified permitted values? The second is the natureand extent of deviation from the norms and indices for the environ-mental condition. These indicators also show quality of life andenvironmental health conditions. The third factor is the number ofpeople or size of the area affected by the environmental problem orconflicts. Divergent evaluations should be made for problems thatcarry serious risk but affect only a few people or a small area andthose that are relatively less severe but affect a large segment of thepopulation or a sizeable area.

Relative risk analysis is a more comprehensive method thatcategorizes risks according to their impact on health, the ecosystemor the standard of living. The selection of appropriate criteria andthe determination of the magnitude of the risks enable a morecomprehensive ranking of problems. The formation of this prioritylist requires a larger amount of information and knowledge, however,and thus inevitably involves relying on experts and professionals.

The Environmental Health Action Plan for Europe (49) dividesdifferent types of action into three groups to help set priorities.Action in group one addresses the basic requirements for environ-mental health. It aims at preventing or mitigating conditions whoseenvironmental causes are well established and that can give rise towidespread and often acute health effects. Group-two action con-cerns the prevention and control of medium- and long-term envi-ronmental hazards. Causal relationships for these hazards may bemore difficult to establish at existing levels of environmentalexposure, but their potential for adverse effects on health isrecognized. Group-three action concerns the promotion of humanwellbeing and mental health, rather than the prevention of disease;the perception of the environment as unpleasant imposes stress onthe affected population.

The Plan proposes that group-one action is the most importantand should therefore be taken first; group-two action, less impor-tant and therefore not such a high priority; and group-three, almostan optional extra. Many find this approach too simple, but it serves

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a purpose by laying out priorities and the underlying reasoning ina straightforward and uncomplicated manner that all can under-stand.

The United Kingdom NEHAP (50) uses the three-group ap-proach, and considers that an essential prerequisite to determiningthe action to take and committing a country or locality to it is toidentify:

� the actual or potential hazards to health in the environment� the effects that they may have on health� the degree of priority with which each should be addressed� the relative costs and benefits of action� where resources are constrained, the most cost-effective action.

Expanding on this approach, the planning for action on environ-mental hazards needs to focus first on the identification andrecognition of the hazards and their associated risks to publichealth. As has been demonstrated, this is not always a straightfor-ward task, although a growing body of evidence is now availableon a number of links between health and the environment. In suchcircumstances, the process of prioritization takes the availableevidence and builds on it, reflecting local circumstances, the extentand severity of the health effect, and the resources available toreduce or remove the hazard.

Clearly, where environmental conditions present a serioushazard to public health, the ideal objective is the complete removalof the hazard. In some cases, this will not be possible, and thepriority then will be to reduce the risk and to plan eventually toremove it, if this is technically possible.

As LEHAPs are developed, implemented and moved forward,priority setting becomes an iterative process. Environmental healthconditions are monitored as changes occur, and scientific under-standing is gained and developed. Then priorities change and areupdated to reflect the impact of earlier action and the need toaddress other or new risks.

As part of the LEHAP process in Varna, Bulgaria (a partner inthe WHO/Know How Fund project), a unique methodology wasdeveloped to confront the decision-making problems presented inconsidering a report on the state of the environment and health andon the public’s perceptions. Annex 3 presents a full report of the

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Varna methodology, which attempts to track the main public healthconcerns and environmental stressors – with weighted ratios tosignify public concern, among other things – through to three mainpriorities.

This approach, designed by the people of Varna, created a verylarge agenda to be tackled and demonstrated wonderfully well thevast and interconnected nature of environmental health issues. Ittherefore fell into the trap of attempting to deal with too manyissues at once. While the result of this can be that no issue is dealtwith effectively, this danger was averted by a subsequent level ofpriority filtration. This filtration distinguished between priorityareas for action, such as noncommunicable diseases, and what wasessentially an overarching policy, such as the commitment to actand to address the needs of the most vulnerable.

Considerations in making decisionsAt the end of the day, no matter what methodologies are used tobring about significant correlation between environment and healthor what schemes are used to compare one risk to another, theultimate decision will be political. As there are very few black-or-white answers in environmental health, decision-making inevita-bly includes a degree of subjectivity and needs to strike a balance.Tough political choices must be made.

Of course, a number of other issues need to be considered indecisions on what actions should take priority. These include thelegality, economics, capacity-building factors, practicality, timescales, measurability and visibility of the various options.

Any proposed action should be within the legal competence ofthose who are identified to undertake it. In some countries, munici-palities and NGOs have few or minor legislative powers or legalrights to act. This can severely hinder the planning process andseverely diminishes the value of the LEHAP. Nevertheless, theLEHAP can be used to highlight gaps and legislative needs. In suchcases, a report to the Government needs to be made on the need forlegislative powers, and the LEHAP can then be used as a lobbyingtool. In any event, actions that are illegal should not be proposedor designed.

No organization, particularly one in the public sector, will everclaim to have enough money. Diminished budgets necessitatecareful planning to achieve the best value for money. In one

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respect, the LEHAP planning process is a mechanism to identifywhere resources can be put to best use. Again, projects and actionsstemming from the LEHAP process need adequate financing andsupport throughout the duration of the project. Failure to ensurethis will only lead to increased frustration and disillusionment withthe process. Avoiding the creation of unrealistic expectations isvital in all of this work.

If an element of the municipal budget can be set aside forLEHAP projects on a yearly basis, action will need to be plannedwithin those constraints. In addition, planners may form partner-ships with other bodies that hold budgets, to share resources andwork on implementation together. The LEHAP can also be used toraise funds from external, national or international organizations.The framework of the LEHAP provides a strong mechanism forsecuring support for community-wide priority projects. This typeof proposal will attract greater interest than a bid from an individualinstitution or organization because it has been through a rigorousprocess of testing and planning and has resulted in an agreed seriesof priorities.

Planners must also consider how the LEHAP can generatesustainable funding streams. The careful and considerate use oftaxation and the development of suitable fiscal instruments need tobe considered as part of the entire package to ensure continuedsupport and funding of the LEHAP process. The LEHAP must notbe seen as a first stage in developing a wish list for funding, but asa living process that can become self sufficient.

Finally, not all the actions contained in a LEHAP necessarilycost money to implement or achieve. Indeed, planners shouldconsciously build into it a significant number of elements andactions that cost nothing but good will and personal effort.

Not all localities and municipalities have access to the best ornecessary technical expertise. This is particularly true for isolatedand rural communities. Plans need to be able to reflect the technicalcapabilities of the personnel available in the community, andshould build into their proposals and budgets provisions for anyexternal assistance needed. Assistance from national centres ofexcellence, the academic community and international agenciesshould all be considered.

When deciding on the action that should be taken to addressenvironmental health issues, communities can very easily be too

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ambitious and plan the best bespoke solution possible. Many havecreated grandiose plans that were simply not achievable. TheLEHAP steering committee should guard against this type of dreamplanning. While it may win short-term political capital, in themedium to longer term plans viewed as unrealistic and impracticalwill be extremely detrimental to the whole process. The keymessage is: to keep it real.

Another common weakness of environmental health planningis to plan too far into the future. Clearly, the concept of sustainabledevelopment requires planners to consider distant times and tothink beyond the needs of the current generation. When the LEHAPrelies on the participation of various partners and the public,however, sustaining interest can be difficult if the results will notappear for years. Planning for the short as well as the medium andlong term is therefore necessary. A LEHAP should include anumber of actions that can be achieved in, say, 12 to 18 months. Inthis way, participants can begin to see progress and be encouragedto participate further.

Linked to short time scales is the need for the action to betangible and measurable. Many of the outcomes of environmentalhealth action can be hard to measure, especially if the action resultsin the reduction or the elimination of certain phenomena. Takingaction to create a non-event is difficult to become excited about.Certain actions should therefore be created that provide discerniblechange that can be measured over time. The section on themonitoring of the LEHAP discusses this issue further.

Finally, the action needs to be visible to the public. To becomea living and vibrant document that will be sustained over time, theLEHAP needs to garner and maintain public support. One way ofachieving this is to include a series of actions that members of thepublic can see and appreciate for themselves. The LEHAP shouldnot become a redundant service plan or a series of aspirationalstatements that remain within the municipality; to succeed, it mustbecome a living process that is visible to and resonates within thecommunity it serves.

Consultation on the draft planOnce the actions have been chosen, the steering committee shoulddistribute the draft to as many community stakeholders as possible.

73

The committee should also send it to national and neighbouringauthorities to ensure that the proposals fit within any nationalframework and do not create too many pressures on neighbouringmunicipalities and communities.

The draft plan should be written in a way that encouragescontributions and comments. It should avoid a prescriptive style,which conveys the feeling that the plan is already carved in stoneand that the consultation process will bring only minor changes.Typically, the first public draft will contain:

1. information on the process of developing the plan2. the purpose of the consultation period3. a description of the main issues to be considered4. a list of the various partners involved5. some options for addressing the issues raised6. the indicators proposed to measure progress7. the proposed targets and time scales.

Allowing enough time for the formulation of responses is vital.Organizations, as well as individuals, may wish to make commentson the draft. As such responses are normally collated from a numberof different perspectives, a reasonable length of time may beneeded for the draft to circulate, for people to comment and then forthe responses to be collated. A consultation period of at least threemonths is therefore advisable. The length will obviously vary withthe nature and length of the draft plan, and the time of year in whichthe consultation period falls, as more time is needed during holidayperiods.

Wide consultation undoubtedly brings benefits: it improves thedocument, prepares people for action and makes the actions andprocesses more workable. Nevertheless, the consultation processalso makes the planning process more difficult and certainly longer.

Increasing the effectiveness of consultationA number of steps can be taken to increase the effectiveness ofconsultation. These can include:

� at the outset, securing the support of the mass media (the localpress, television and radio) to inform the general public aboutthe proposed plan and the consultation process;

74

� providing in the budget for the printing of sufficient copies ofthe draft (although publishing the draft in a high-quality formatis not necessary);

� using new technology, such as publishing the draft on theInternet and arranging to accept comments through e-mail;

� running a number of community-based consultation work-shops to supplement the consultation process (which can bebest managed by community groups or by NGOs with the inputof the municipality); and

� to assist people in formulating their responses, highlighting somekey comments in the draft or including a form in the consultationdocument that respondents can fill in as appropriate and return.

Pre-paid postage may also be considered as an option to secure ahigh level of response.

The steering committee should consider all comments receivedduring the consultation period. Depending on the level of re-sponse, some form of analysis of the types of comments receivedmay help to indicate where the main areas for action lie. Thecommittee should consider amending the plan in areas wherestrong and widely supported comments have been made.

Where long and detailed comments have been submitted,replying to the points raised – setting out the rationale for takingaction or not – may be worth while. This will ensure that the mostinterested parties continue to feel part of the process.

Once the LEHAP is complete, it should be published, launchedand made available to the public. A press conference may be asuitable event for the launch.

Monitoring, review and revision throughoutimplementationEvaluating the implementation of the LEHAP is a crucial elementin the management cycle of policy, planning, implementation andevaluation. The evaluation element closes the loop and can drivethe process forward (see Fig. 2, p. 42). Despite the imperfectionsin its methodology, evaluation is the only way to learn whatbenefits the planned actions may be providing and at what cost tosociety. The project steering committee should be responsible foroverseeing and monitoring the implementation of the LEHAP.

75

The primary reasons for evaluating environmental health ac-tions are (51):

1. to draw on experience to improve overall service delivery andimpact;

2. to improve the efficiency of services and projects;3. to determine the relevance, adequacy, effectiveness and impact

of goals, objectives and services;4. to describe expenditure on environmental health action to

political leaders and communities;5. to recognize and respond to public needs and wants;6. to prioritize research, planning, decisions and action for the

future; and7. to find allies in other agencies, services or sectors.

Environmental health actions are particularly hard to evaluatethrough traditional methods. Several years ago a WHO workinggroup identified many of these difficulties (52). The main barriersto effective evaluation are the following (52).

� Environmental health action tries to produce a non-event; howcan a non-event be proved to be the result of an action?

� Several different sectors, such as agencies and industries con-cerned with health, the environment and agriculture, takeaction.

� Environmental health action must work to address issues fromthe past, the present and the future.

� Environmental and health effects have many weak and indirectlinks; long latency periods are usually associated with diseasesknown to have environmental causes.

� Identifying the community to receive environmental healthaction is not always easy, so determining the relevance andadequacy of the action is difficult.

� Unreliable information limits long-term comparisons.

Despite these problems, some attempts at monitoring andevaluating the LEHAP are required, particularly to ensure that theproject remains dynamic. First, a protocol must be established,setting out the timing and frequency of any monitoring andevaluation procedures. After the project has run for, say, 12 months,

76

it may be worth while to review it and to revise timings and progressaccordingly. Much will depend upon the types of action that havebeen planned and the rate at which progress can be achieved.

As mentioned above, before evaluation starts – in fact, duringthe determination of priority actions – data and indicators that candemonstrate progress should be selected.

Indicators for evaluationIndicators are often used as surrogates for measuring a parameterof interest because practical difficulties prevent its exact measure-ment. For example, no one has yet found a suitable measure for thequality of life, so people use a range of indicators that give cluesand suggestions as to how it is developing. This being understood,many still assume that indicators are an accurate reflection ofevents, even though they cannot provide the whole picture. Indi-cators are useful if they can be used to show changes over time, andchanges in different situations in different populations at the sametime.

Indicators can be a principal evaluation tool to help decision-makers establish whether their programmes are working. Threemajor applications for indicators have been identified: decision-making, communication and follow-up to policy.

Indicators support decision-making and comparisons by giv-ing information about problems or the efficiency and effectivenessof attempted solutions. Decisions about the priority of services,sequence of activities and allocation of resources are often basedon the changes in a series of indicators.

Municipalities engaged in the LEHAP process need to commu-nicate effectively with all their partners and stakeholders. Indica-tors are critical for productive communication because their use ina consistent framework for measurement promotes a commonunderstanding.

Indicators are also used to determine how well goals are beingmet and policies are being followed. Performance indicators areincreasingly being used to monitor implementation.

Evaluators should seek a set of qualities in indicators. No singleindicator can possess them all. Evaluators commonly use suites ofindicators to counteract the limitations of any one single indicator.Indicators should be valid, internally and externally reliable, spe-cific, sensitive and relevant.

77

A valid indicator accurately measures what it is supposed tomeasure. This may sound self-evident, but is worth stating, particu-larly in view of the doubts about the accuracy of results obtainedfrom old and un-calibrated measuring equipment.

An indicator is internally reliable when its use allows differentpeople in similar circumstances to make the same inferences.External reliability demands that evaluators draw the same conclu-sions from an indicator, irrespective of the size or location of thepopulation examined. In other words, the indicators need to beamenable to general use.

An indicator is specific if its value remains stable when theother data in the same context change: in other words, if it reflectsonly the parameter in question. The indicator must change whenthe parameter changes, and must remain constant as the parameterdoes. This is one of the most difficult properties to ensure, mostlybecause so many factors (such as socioeconomic conditions)interact and are thus difficult to separate.

An indicator is sensitive if small fluctuations in the indicatorreflect small fluctuations in the parameter.

Indicators are said to be relevant if they relate to the appropriatedata or the phenomenon studied. Relevance is a property not asmuch of one indicator as of a group of indicators within a givenframework.

Evaluators should consider all these factors when selectingindicators for assessing the LEHAP.

Evaluations of progress can be conducted internally or exter-nally. If internally, an external audit of the final report may be ofvalue to provide a clear and unbiased view of how things havedeveloped. The results of evaluations should be published andpublicized, and a subsequent action programme should be pro-duced to address the issues that have been raised.

If operated effectively and without prejudice, the evaluationprocess should allow the participants to celebrate the LEHAP’ssuccesses and maintain its momentum for future and more directaction.

SummaryTable 4 summarizes the ten stages in developing a LEHAP.

78

Sta

ge

Par

tici

pan

tsW

hat

they

do

1.In

itial

pre

para

tory

A s

mal

l tea

m o

f com

mitt

edT

he t

eam

bui

lds

up a

ran

ge o

f in

form

atio

n an

d ev

iden

ce o

n th

e ne

edw

ork

prof

essi

onal

s fr

om a

ran

gefo

r a

LEH

AP

app

roac

h, t

he r

esou

rces

tha

t w

ill b

e ne

eded

and

the

of b

ackg

roun

ds w

ithin

the

pote

ntia

l be

nefit

s.m

unic

ipal

ity

2.G

aini

ng p

oliti

cal

The

tea

m,

the

high

est

The

tea

m s

ecur

es a

pol

itica

l sta

tem

ent

setti

ng o

ut t

he c

ore

valu

es o

fco

mm

itmen

tde

moc

ratic

ally

ele

cted

and

polit

ical

com

mitm

ent

to e

nviro

nmen

tal h

ealth

pro

tect

ion

and

the

offic

ial f

or t

he a

rea

and

LEH

AP

pro

cess

. R

egio

nal a

nd n

atio

nal s

uppo

rt c

an a

lso

be u

sefu

l.pe

rhap

s al

so r

egio

nal

offic

ials

and

natio

nal

min

istr

ies

3.G

athe

ring

part

ners

The

pol

itica

l lea

der

of t

heT

o bu

ild a

com

mitt

ed p

artn

ersh

ip w

ith a

wid

e ra

nge

of a

genc

ies

LEH

AP

pro

cess

and

a w

ide

and

inte

rest

gro

ups,

the

pol

itica

l lea

der

of t

he L

EH

AP

pro

cess

rang

e of

par

tner

sin

vite

s a

wid

e ra

nge

of p

artn

ers

– bo

th in

divi

dual

ly a

nd a

sre

pres

enta

tives

of

orga

niza

tions

– t

o pa

rtic

ipat

e. T

his

grou

p is

form

ally

co

nstit

uted

as

the

stee

ring

com

mitt

ee fo

r th

e LE

HA

P p

roje

ct.

4.P

ract

isin

g w

hat

one

Lead

ers,

all

staf

f of t

heT

he p

artic

ipan

ts t

horo

ughl

y re

view

, fr

om a

n en

viro

nmen

tal

prea

ches

mun

icip

ality

and

all

part

ners

heal

th p

ersp

ectiv

e, a

ll th

e m

unic

ipal

ity’s

pol

icie

s an

d pr

actic

esco

mm

itted

to th

e LE

HA

Pan

d de

velo

p a

prog

ram

me

of a

ctio

n to

ens

ure

that

the

se h

ave

apr

oces

slim

ited

nega

tive

impa

ct o

n en

viro

nmen

tal

heal

th i

ssue

s.

5.A

naly

sing

Bro

ad g

roup

of

prof

essi

onal

sT

his

grou

p br

ings

tog

ethe

r ex

istin

g in

form

atio

n an

d da

ta o

n th

een

viro

nmen

tal

in t

he s

cien

tific

and

aca

dem

icen

viro

nmen

t of

and

hea

lth in

the

reg

ion,

mak

ing

conn

ectio

ns a

ndhe

alth

sta

tus

com

mun

ityco

rrel

atio

ns b

etw

een

envi

ronm

ent

and

heal

th,

and

iden

tifyi

ng g

aps

in d

ata,

inf

orm

atio

n an

d kn

owle

dge.

Tab

le 4

. Sum

mar

y of

the

LEH

AP

pla

nnin

g pr

oces

s

79

6.G

augi

ng t

he p

ublic

’sLE

HA

P s

teer

ing

com

mitt

ee,

The

com

mitt

ee c

olle

cts

info

rmat

ion

on t

he g

ener

al p

ublic

’spe

rcep

tions

with

par

ticul

ar a

ssis

tanc

epe

rcep

tions

of

the

maj

or e

nviro

nmen

tal h

ealth

issu

es a

nd h

azar

dsfr

om N

GO

s, th

e m

ass

med

ia,

and

of h

ow t

hese

cou

ld b

e re

solv

ed.

The

com

mitt

eeca

n us

e a

scho

ols

and

the

gene

ral

num

ber o

f mea

ns, i

nclu

ding

the

dire

ct c

onsu

ltatio

n of

the

publ

ic th

roug

hp

ub

licqu

estio

nnai

res,

wor

ksho

ps,

mee

tings

,foc

us g

roup

s, e

tc.

7.S

ettin

g pr

iorit

ies

and

LEH

AP

ste

erin

g co

mm

ittee

,T

he c

omm

ittee

has

to

mak

e de

cisi

ons

– co

nsid

erin

g th

e su

bjec

tive

mak

ing

deci

sion

sw

ith a

hea

vy f

ocus

on

the

and

the

obje

ctiv

e vi

ews

of th

e co

mm

unity

– th

at s

et p

riorit

ies

for

actio

n.po

litic

al r

epre

sent

ativ

esT

he r

esul

ting

prop

osed

act

ion

need

s to

be

lega

l, af

ford

able

,te

chni

cally

pos

sibl

e, p

ract

ical

, ai

med

at

both

the

sho

rt a

nd lo

ng t

erm

,m

easu

rabl

e an

d vi

sibl

e.

8.C

onsu

ltatio

n on

the

LEH

AP

ste

erin

g co

mm

ittee

The

com

mitt

ee o

vers

ees

the

deve

lopm

ent o

f the

con

sulta

tion

proc

ess.

draf

t pl

anIt

unde

rtak

es w

ides

prea

d co

nsul

tatio

n w

ith t

he g

ener

al p

opul

atio

nan

d th

e ag

enci

es t

hat

will

be

affe

cted

by

the

LEH

AP

. S

ome

key

ques

tions

may

be

draw

n ou

t an

d hi

ghlig

hted

dur

ing

the

cons

ulta

tion

peri

od.

9.R

evi

ew

ing

,LE

HA

P s

teer

ing

com

mitt

eeT

he c

omm

ittee

con

side

rs t

he s

igni

fican

t re

spon

ses

to t

he d

raft,

and

amen

ding

, pu

blis

hing

and

lead

ing

polit

icia

nsam

ends

it

acco

rdin

gly

whe

re r

easo

nabl

e an

d pr

actic

al.

The

and

laun

chin

g th

eco

mm

ittee

laun

ches

the

LE

HA

P p

ublic

ly,

to g

ive

it vi

sibi

lity

and

toLE

HA

Pin

crea

se in

tere

st in

and

pre

ssur

e fo

r its

impl

emen

tatio

n.

10.

Mon

itorin

g, r

evie

wLE

HA

P s

teer

ing

com

mitt

eeA

s al

l the

iden

tifie

d pa

rtne

rs a

nd a

ctor

s im

plem

ent

the

LEH

AP

, th

ean

d re

visi

onan

d al

l id

entif

ied

part

ners

stee

ring

com

mitt

ee b

oth

cont

inuo

usly

and

per

iodi

cally

mon

itors

the

thro

ugho

utan

d ac

tors

prog

ress

mad

e, r

evie

ws

the

mec

hani

sms

bein

g us

ed a

nd r

evis

es t

heim

plem

enta

tion

LEH

AP

in t

he li

ght

of t

he c

hang

ing

envi

ronm

enta

l hea

lth c

ondi

tions

or p

ublic

per

cept

ions

. P

erio

dic

revi

ews

will

inv

olve

gre

ater

ana

lysi

san

d re

view

s of

act

ion

agai

nst

targ

ets.

Part 3

The national–localrelationship

81

4

National perspectives

The ultimate responsibility for protecting the environment andimproving the population’s health lies mainly at the national level.This responsibility cannot be completely abdicated, even thoughaction may be taken at various other levels. This implies thatnational governments must establish suitable frameworks andmechanisms to support regional and local organizations and agen-cies. If action is to be effective, national authorities cannot placethe responsibility for environmental health issues at the local levelwithout providing the means for action, in terms of legislation,fiscal and collaborative powers. A complex balance of capacitiesand responsibilities is required. As noted earlier, 88% of localAgenda 21 initiatives take place within the framework of a nationalplan or programme (2). There is no reason to suppose that thedevelopment dynamics of LEHAPs should be any different. In-deed, responsibility for giving impetus to LEHAPs rests even moreheavily on the national level, as the NEHAP movement is notnearly as well known or publicized as Agenda 21.

Environmental health is traditionally a municipal responsibilityin Europe (53). It finds its roots as a service in the municipalprovision of water, waste management and housing during theIndustrial Revolution. Several models for environmental healthsubsidiarity exist in the European Region, and many are in differentstages of transition. Particularly in the CCEE and NIS, there arepressures to decentralize or, perhaps more accurately, to democra-tize local services. Sanitary–epidemiological (sanepid) systems, in

82

which single stations carry out both public health and environmen-tal health functions, still exist in these countries. Traditionally,these stations have been centrally directed and funded. Since thedevelopment of market economies, sanepid services have under-gone some surprisingly tentative and minor reforms, although thedesire is growing to make local units more autonomous and locallyresponsive and accountable.

National environmental action programmes(NEAPs)The goal of common principles for environmental protection inEurope has led to the development of the Environmental ActionProgramme for Central and Eastern Europe (EAP) (23) (http://www1.oecd.org/env/eap/eaptf/eap.htm, accessed 13 February2002). Adopted by the participants of the second ministerialconference of the “Environment for Europe” process, which washeld in Lucerne in 1993, EAP articulates the methodology forcreating strategic environmental priorities at the national level.

The main goal of EAP is to help the CCEE find realistic, efficientand cost-effective methods of improving the environment. Settingenvironmental priorities, assessing risks and involving the public inenvironmental decision-making are the foundation of a properstrategy for environmental protection. Such a strategy can deter-mine investments and propose measures for accomplishing socialand environmental objectives in the most efficient manner.

EAP proposes a methodology that may help to accomplish thisgoal. The main obstacles facing the CCEE are the lack of financialresources and institutional background. EAP therefore proposes toconcentrate on the following activities:

� environmental policy, which includes setting priorities, identi-fying tools and measures of effective environmental manage-ment and involving the public in environmental decision-making;

� strengthening institutions, to increase efficiency in environ-mental administrations, and to improve environmental monitor-ing and control and the enforcement of environmentalregulations; and

� environmental investments that address immediate local andregional problems and identify long-term sustainable solutions.

83

EAP provides recommendations and guidelines on the rationalallocation of limited financial resources. It stresses the importanceof building consensus while planning environmental and eco-nomic development. These plans, coupled with policy, investmentand institutional reform, can maximize the efficiency of environ-ment-related spending. Only such an integrated approach to envi-ronmental protection can maximize the use of natural resources.

In addition to increasing efficiency, EAP stresses the public’sparticipation in environmental policy development and implemen-tation. It pays attention to the role of different units of the stateadministration (especially on the national level) and to that ofbusiness. Active public participation is required in both the devel-opment and implementation of national environmental policies.

From EAP to NEAPEAP is not a final document with specified objectives that countriesmust precisely follow and implement. It is an instrument or meth-odology that countries can use to draft viable plans for environmen-tal protection. The role of the EAP methodology is also to show thatenvironmental planning can be a creative and mobilizing tool ofenvironmental policy; countries should use it when writing NEAPs.If successfully implemented, the NEAP can then provide a compre-hensive framework for environmental policy, institutional strength-ening and investments. The process of creating an NEAP in linewith the EAP methodology has several significant features.

1. Each country should prepare its own environmental protectionprogramme, based on the state of its environment and itspriorities (which reflect its levels of economic, social andpolitical development).

2. Countries are expected to design their own systems of environ-mental monitoring, information dissemination, comprehensiveenvironmental legislation and public administration, includinginspection to supervise the implementation of the programmeand adequate technology to carry it out.

3. Countries should draft their NEAPs to ensure the use of acombination of regulatory (command-and-control) instrumentsand economic tools (market incentives), which have not beenproperly balanced in the Region before.

84

4. The drafting the NEAP should be coordinated from above,usually by the environment ministry and (if established) itsspecialized environmental policy department. Combining in-ternational, national and regional aspects of environmentalprotection is usually helpful.

5. The ministry should draft the NEAP in close cooperation withgovernment authorities responsible for other sectors of thecountry’s development (economy, industry, finance, transport,agriculture, etc.). This makes the NEAP, not the environmentministry’s document, but a programme of the whole govern-ment (cabinet). This approach provides an opportunity tointegrate environmental requirements with other aspects of thecountry’s development, particularly social and economic ones,which may lead to initiating work towards sustainable develop-ment.

6. Public participation in drafting and implementing the NEAPshould include representatives of not only businesses but alsoacademia and NGOs. They should play a responsible role in allstages of the NEAP’s development and implementation.

7. Information on the environment and the development of theNEAP document should be widely available. Free access is aprecondition for the successful implementation of environmen-tal policy.

Real meaning of the NEAP processThe NEAP should not be either another concept document thatdemonstrates the country’s ability to write policy papers or in-tended to mobilize donors’ financial support for the country. Thegoal of the planning process is to develop a comprehensiveprogramme to reduce pollution and improve the environment at thelowest cost. The process should lead the country from draftingvague strategic concepts to implementing the problem-orientedprogrammes designed to achieve particular goals within a certaintime and with a certain budget. An NEAP should also encouragethe efficient use of available financial and human resources, andstrengthen the capacities of public administrations, polluters andNGOs to deal with the environment. Although an NEAP should bevery specific, it should also contribute to the implementation ofsustainable environmental policies.

85

According to the principles of EAP, a country must use its ownfinancial and human resources in the process of drafting an NEAP.The environmental goals identified in the NEAP should be tied tothe sustainable development of the economy, thereby introducingmarket mechanisms and integrated economic planning to environ-mental protection. Developing the NEAP is a significant steptowards an efficient environmental protection programme.

The NEAP process does more than integrate economic infor-mation with environmental activities. It encourages an open anddemocratic procedure in selecting targets and choosing objectivesin environmental protection. The process can encourage the coun-try consciously to adopt principles of sustainable developmentwhile implementing a viable plan to solve the most urgent environ-mental problems.

87

5

Institutional development

Effective decentralizationThe decentralization of administrative and political responsibilityis taking place at differing rates throughout Europe, either as partof planned reforms or as a result of increasing regionalization incountries. This process has emphasized assigning responsibilityfor environmental health management to local government.

Decentralization takes two principal forms. First, in partial(vertical) decentralization, central authorities strengthen their re-gional or local implementation offices. While the primary respon-sibility does not change significantly, the degree of activity at thelocal and regional levels increases. The second form is full decen-tralization, in which both activity and responsibility are transferredto the regional or local level. Unfortunately, this transference of fullor major responsibility does not always include the supportingmechanisms and infrastructures necessary to ensure effective op-eration at the local level.

To ensure the provision of effective environmental healthservices, both forms of decentralization require institutional sup-port to be available at the national level (13). For example, partialdecentralization needs to be balanced and effectively controlled.Options for ensuring this include establishing:

� an institutional framework at the national level that sets guid-ance and controls that permit decentralized services to makeinformed decisions; or

88

� comprehensive prescriptive guidance and supporting infra-structures that enable the local level to provide services adapt-able to the needs of the population.

Full decentralization, however, requires the establishment ofnational-level supporting infrastructures; the options for these arearrangements:

� for the provision of technical support by a centre of excellence;� for the provision of a legal foundation and support for the

establishment of decentralized institutions;� to ensure financial support for decentralized responsibilities;� for institutions to provide training and education for service

providers; and� for the provision of support for decentralized work by research

institutions.

Basic structures for regional servicesThe regional administration of environmental health services var-ies widely across Europe, as does the definition of what constitutesa regional authority. For the purposes of this book, a regionalauthority is a controlling body that is responsible for a geographi-cal area smaller than the country as a whole yet larger than the areascovered by municipalities or communes. This regional area con-tains several municipalities or communes. Although each countrydiffers in its approach to organizing regional services, basic struc-tures can be identified. They vary according to the type of controlover the activities of the regional administration that the centralgovernment retains: direct, partial or indirect control.

As discussed above, municipalities form the base unit of localgovernment throughout the European Region. Municipalities orcommunes are formed upon a different basis than the majority ofregional government agencies and services. They are normallyremoved from direct control by the central government and, aslocal democratic bodies, can claim to represent the desires of theircommunities. The status, functions and capabilities of municipal-ities vary tremendously within the Region, largely depending ontheir legal status and responsibilities, and their financial and otherresources.

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Normally, the centralized approach to local and regional ser-vices has no formal mechanism for intersectoral work prior to thedelivery of the services. Individual ministries have their networksof regional and subregional offices, which are not necessarilylinked to any other ministry’s regional office. In addition, there areno established links between regional and municipal services. Interms of environmental health, only through ad hoc arrangementsat the regional level do services for health and the environmentmeet to discuss matters of mutual interest.

Decentralized systems of control over local government aremainly found in parts of western Europe. In such systems, aframework of legislation and statutory guidance controls relation-ships between levels; this framework is flexible enough to betailored to the individual needs of a region or locality.

Partially decentralized systems rely on both local democracyand state control, and can be found in several countries of westernand southern Europe. They rely on the use of a prefect appointedby the central government, who guides and influences the work ofthe local tiers of government to ensure that local decisions andpolicies follow its thinking.

Both the fully and partially decentralized systems have advan-tages and disadvantages. They have been developed over centuriesof experience with local government and have evolved throughvarious social changes and needs. Obviously, a system that issatisfactory for one country does not necessarily suit the needs ofanother. Nevertheless, the basic frameworks described here maygive the people charged with reforming services some guidingprinciples for adaptation and adoption.

Several factors at the regional and local levels should beconsidered in reforming the environmental health service. Theprocesses of decentralization under way in many parts of Europeneed to be managed and tailored to the needs of the communitiesthat local authorities are to serve. Whether to decentralize istherefore the first question to consider. Many countries, particu-larly the CCEE, are now formally committed to this course throughtheir change from centralized to market economies. Nevertheless,highlighting the advantages and disadvantages of the varioussystems that can be used is worth while. Second, considerationneeds to be given to choosing what services are to be provided atwhat level: local or regional. Such decisions should not be taken

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lightly; their full consequences should be realized. Third, provid-ing supporting mechanisms and financial systems for regional andlocal authorities is vital to the authorities’ effective operation.

The processes of decentralization offer many options for thedelivery of environmental health services. To be effective, envi-ronmental health services must clearly be adaptable to the needsand desires of populations, as these may vary considerably withina country: not only between city and rural communities but alsobetween differing cultural and social groups within those commu-nities. In this respect, the localization of services can have distinctadvantages for the public they serve. Improving services, how-ever, has not always been the motive for desiring to decentralize.Too often, responsibility has been delegated to lower governmentlevels to reduce national burdens, but without the necessary sup-porting mechanisms in place. This causes a net reduction in thecapacity of the services. In some countries, the desire for rapidchange has caused decentralization to be carried out too quickly.This results in ineffective institutional arrangements.

Again, decentralization must be balanced and controlled toensure the provision of effective environmental health services.Table 5 lists four options for suggested action to create effectiveand responsive environmental health services at the local level,with their advantages and disadvantages (13). To implement na-tional policies on environmental health, governments may (13):

1. provide individual regional and local offices of the environ-ment ministry, dealing only with issues relating to the environ-ment;

2. provide regional government offices that contain personnel ofall relevant ministries, with coordination by a regional gover-nor or prefect and dealing with relevant issues in all sectors;

3. use municipalities and communes, acting within the frameworkof national guidelines and legislation; or

4. use a mixture of municipalities and regional offices, with theformer responsible for local concerns and the latter, for strate-gic national issues.

This list is by no means prescriptive or comprehensive, but indi-cates the types of issue that need to be considered.

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Options Advantages Disadvantages

Regional and Strong central control No intersectoral worklocal offices of of policy No local decision-makingenvironment Unresponsive to local needsministry and concerns

No local publicaccountability

Regional offices Intersectoral work No local publicof all relevant Elements of local accountabilityministries decision-making Inability to change policy to

Responsiveness to local reflect local conditionsneeds and concerns

Municipalities Local decision-making Policy fragmentationand communes and priority setting Lack of standardization/

Community consistencyaccountability and Variation in profiles andinvolvement capacitiesIntersectoral work Lack of independenceAdaptability

Mixture of Balance between local Possible confusion in themunicipalities independence and public about the division ofand regional central control responsibilitiesoffices Dealing with issues at

appropriate levelsResponsiveness to localneeds and concerns

Table 5. Options for decentralizationof environmental health services

Source: MacArthur & Bonnefoy (13).

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6

Supportive action at thenational level

The central government can take a number of actions to helpsupport municipalities and other local agencies in developing localenvironmental health action.

The first step is to produce a NEHAP that recognizes the roleand capacity of local authorities and others to assist in its imple-mentation. Very often, it is drafted using a bottom-up approach, inwhich the following could be the principal stages of preparation:the government (54):

� invites regional and local authorities and other interested par-ties to make their proposals for a plan;

� integrates the various proposals into a coherent draft nationalplan (or designates an agency to do so);

� publishes or releases the draft for comment by all interestedparties; and

� takes account of comments in a definitive NEHAP and takesany constitutional steps necessary for its approval.

If developed with the full involvement of local partners, theNEHAP process encourages and inspires local action and the localplanning process. The bottom-up approach provides an environ-ment in which localities can dictate their own priorities and influ-ence national policy to reflect local needs. This is more likely toobtain widespread support than imposing a centrally concocteddocument. While the NEHAP can provide a national framework for

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local action, on its own it cannot guarantee the development of aLEHAP movement. This requires additional supportive action. Theparticipants at a recent workshop concluded that central govern-ments can (55):

1. provide the legal framework for local action;2. provide national guidelines on the development of LEHAPs

and recommendations on key areas, but not explicit orders;3. help set priorities;4. help develop national indicators for local use and information

systems that are user-friendly at the local level;5. promote integration across sectors;6. encourage the involvement of the academic sector in environ-

mental health risk assessment and cost–benefit analysis;7. release or provide access to funds, provide seed money for the

development of LEHAPs and LEHAP projects, and fund dem-onstration projects;

8. provide increased local discretionary powers;9. accept ultimate responsibility for the environmental health

system; and10. assist with transboundary issues.

The participants also noted that central governments should makemaximum use of existing local networks, as trust is greater in peernetworks than in initiatives presented by central governments.

Legal frameworkIn many countries, local government can only act on the issuesover which it has distinct and specific legal powers. In suchconstitutional circumstances, the national government should pro-vide the necessary legal basis to develop a LEHAP. This mayrequire subsequent and related powers, for example, to raise fundsthrough taxation or other external mechanisms, to engage inpartnership and joint funding arrangements, and either to takeaction or require action to be taken on certain issues.

FundingWith the exception of a few simple actions, LEHAP developmentand implementation cost resources in terms of either money or

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personnel. Undoubtedly, the LEHAP process can redirect existingfunding to more strategic uses, can open up the opportunity forsharing budgets across organizations and sectors, and may alsoeliminate the duplication of work. Nevertheless, help from thenational level may be needed to kick-start the process and todemonstrate how the LEHAP can bring added value. The centralgovernment can provide such assistance, and may even be able tofacilitate effective intersectoral work. Examples from aroundEurope show how funding is made available only when partnersbegin to work together to identify and address mutual interests andproblems. In addition, national-level funding of demonstrationprojects can provide an impetus for local action.

Further, national authorities should remember that LEHAPsneed to establish sustainable funding flows if they are to maintaintheir impact and continue to benefit and grow with the communitiesthey serve. Authorities should therefore consider establishinginnovative fund-raising mechanisms to enable local governmentsto continue their own programmes. This may require the centralauthorities to provide technical administrative advice and to reviewlocal governments’ financing procedures and mechanisms.

Technical assistance and intersectoralityNational governments may need to provide local authorities withtechnical assistance to fulfil their programmes of action. Author-ities, particularly in small and rural local areas, often lack thenecessary technical capacity. Recognizing this, central authoritiescan assist by providing access to a pool of expertise and technicalinformation from which local authorities can draw assistance.

In addition, the professions in a community can raise barriersto intersectoral work. Professions tend to be conservative, and toresist change. As a result, partnership and the sharing of agendascan prove difficult. National governments need to recognize thisphenomenon and work with national professional bodies to bringabout a progressive change in attitudes to help create more openworking relationships at the local level.

Other issuesAll these practical steps can assist municipalities to rise to thechallenge of local environmental health planning. Central

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governments, however, need to address a number of other issuesif they are sincere in their efforts to create sustainable localcommunities.

Owing to the increasing internationalization of production andthe globalization of economies and advertising, local authoritiescan do little to affect the driving forces that operate at the nationaland international levels and, some would argue, hinder any progresstowards effective environmental health management or sustain-able development. For example, there is little point to a municipal-ity’s attempting to develop a strategic approach to wastemanagement when, nationally and internationally, individuals andcommunities are being encouraged to consume more and more.

In their own aims, objectives and plans, national authoritiesshould therefore maintain and support the ethos and principles thatunderpin the sustainable development and environmental healthapproaches (56). National authorities that are seen to be workingfor similar objectives and in the same direction as communities,towns and cities will provide the greatest support and encourage-ment to the LEHAP process.

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Annex 1

LEHAP coordinators/contact points

WHO has not published the LEHAPs produced as a result of theWHO/Know How Fund project, but copies may be obtained bycontacting the people listed below.

BulgariaMr Lyudmil Ikonomov

Environmental Adviser, Union of Black Sea Local Authorities,Varna

KyrgyzstanDr Ainura Djumanalieva

LEHAP Coordinator, Department of Transport, CommunalServices, Municipality of Bishkek, Bishkek

LatviaMs Spidola Lielmane

Limbazi District Council, Limbazi

SlovakiaMrs Katarina Halzlova

Head of Section, Protection of Population Health, Ministry ofHealth, Bratislava

^ ^

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Annex 2

Participants at the reviewmeeting for the WHO/

Know How Fund project

The following were the participants at a meeting – held in Londonon 10–11 July 2000 by the WHO Regional Office for Europe andthe Department for International Development in the United King-dom – to review the LEHAP project.

BulgariaMr Lyudmil Ikonomov

Environmental Adviser, Union of Black Sea Local Authorities,Varna

KyrgyzstanDr Ainura Djumanalieva

LEHAP Coordinator, Department of Transport, Communal Serv-ices, Municipality of Bishkek, Bishkek

LatviaMs Spidola Lielmane

Limbazi District Council, Limbazi

Ms Gita RutinaDirector, Department of Public Health, Ministry of Welfare, Riga

SlovakiaDr Eleonora Fabianova

Director, State Public Health Institute, Banská Bystrica

^ ^

-

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Mrs Katarina HalzlovaHead of Section, Protection of Population Health, Ministry ofHealth, Bratislava

WHO Regional Office for EuropeMr Xavier Bonnefoy

Regional Adviser, Environmental Health Planning

Other organizations

Chartered Institute of Environmental HealthMr Graham Jukes

Director of Professional Services, London, United Kingdom

Mr Ian MacArthurInternational Project Manager, London, United Kingdom

Sheffield City CouncilMr Gary McGrogan

Director, Public and Environmental Health Department, Shef-field, United Kingdom

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Annex 3

Report to the City Councilcoordinating the development

of the “Environment andHealth” City Action Plan

This is a full report on the methodology used to devise the LEHAPfor Varna, Bulgaria, written by the coordinator/contact point,Mr Lyudmil Ikonomov.

Health ecology, working and socialenvironmental priorities in the City of VarnaThis report covers health, ecological, work and social environmentpriorities for the population of Varna, which have been reachedfollowing surveys conducted and an analysis of their results. Thesepriorities are presented for the attention of the City Council coordi-nating the development of the “Environment and Health” CityAction Plan; [the Council] must study and accept them or add to andamend them as [it] considers appropriate.

The analysis was conducted by the following team of experts:Senior Assistant Professor Dimcho Tomov, Associate ProfessorNevyana Feschieva and Associate Professor Stoyanka Popova. Theteam completed the task of identifying the above[-mentioned]priorities in accordance with the assignment by the “Environmentand Heath” City Action Plan project leader and on the basis of thefindings of the following two studies:

1. assessment of the state of the environment in the Municipalityof Varna (including assessment of public health in the city) forthe period 1987–1998 (The results of this assessment were

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presented to the City Council at [its] first and second sessions inOctober and December 1998 respectively.);

2. public opinion survey among the people of Varna on the state ofthe environment and public health, and their views on the meas-ures needed to improve these, 1999 (The results from the surveywere presented to the City Council at [its] third session in March1999.).

In addition to the above two studies, the authors have also used allother materials available to them relating to the Municipality of Varna,as well as their own longstanding experience and expertise in this field.The assessment was conducted on the basis of the above informationand it outlined the following:

1. health problems recorded in the Municipality of Varna;2. the three main public health priorities identified from the health

problems observed;3. ecological, working and social environment components and

parameters, and conduct affecting public health;4. functional link between environmental behavioural parameters on

the one hand, and identified health problems on the other.

Weighting ratios and how they are determinedIn accordance with the methodology set out by the assigning body,each priority, health problem, environmental component and param-eter is given a weighting ratio. The assessment uses an expert-definedten-point rating system, reflecting the significance of each elementwith regard to the particular health problem. The final result – theenvironmental weighting ratios (WRs) – are calculated using thecompounding method; the WR of a priority is multiplied by the WR ofthe health problem relating to that priority; the result is then multipliedby the WR of the relevant environmental component affecting theproblem and that total is then multiplied by the by the WR of theenvironmental component parameter. A parameter may be linked toseveral health problems and thus have a WR for each one of them. Theactual WR of a parameter is the sum of the WRs calculated for allpossible problems. The WR of each environmental and health main-tenance behaviour parameter presents a qualitative computation of theeffect these parameters have on the health problems in the City of Varna.

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The result of the above calculation of WRs established the follow-ing components as leading (i.e. having a most negative impact onpublic health): air quality, vegetation and radiation. The leadingworking environment components include air quality, radiation andnoise levels. The major components of the social environment includehealth services, social realization of individuals, transport systems andthe road network. The most significant components of health mainte-nance behaviour and activities appear to be smoking, eating habits andrecreation.

Table 1 [not shown here] presents the WRs of the ecologicalenvironment parameters. The leading parameters (those with thehighest WRs and therefore with the most negative effect) are as follows:

� radiometric indicators� provision of green areas� sulfur dioxide in the air.

Table 2 [not shown here] presents the WRs of the working environ-ment parameters. The leading parameters (those with the highest WRsand therefore with the most negative effect) are as follows:

� dose inhaled (a radiometric indicator)� toxic substances in the working environment air� dust (general and fine) in the working environment air.

Table 3 [not shown here] presents the WRs of the social environmentparameters. The leading parameters (those with the highest WRs andtherefore with the most negative effect) are as follows:

� the extent of preventive screening and intervention� access to primary health and medical care� income� unemployment levels.

Table 4 [not shown here] presents the WRs of the health maintenancebehaviour and activities. The highest WRs, those considerably aheadof the rest, are as follows:

� structure and characteristics of nutrition� number of smokers� intensity of smoking.

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Interpretation of resultsThe following points must be taken into account when interpretingthe above findings.

There is a comparatively small number of expert studies on theeffect [that] the environmental components and parameters haveon public health at a local level. Such studies do not cover allpossible aspects of the effects that have been identified and arediscussed in this report. In cases where there is insufficient datafrom specialist data from specialist studies, the assessment hasbeen made by the experts.

Despite the fact that the intensity of some of the environmentalparameters is within the existing norms or does not deviate signifyfrom these norms, in practice, they do not have an effect on publichealth because of their prolonged duration or their uninterruptednature and effect on the population. On the other hand, in additionto the effect of each individual parameter, in most cases we aredealing with their combined, compound effect on the specificclimatic and geographical characteristics of the City of Varna. Thecompounding of a number of parameters of even low intensity canlead to an accumulative effect on public health. This, together withthe fact that public health is affected by numerous factors, requiresthat one adopt an integrated approach when interpreting the WRsof each parameter.

With the approach chosen to determine the final WRs, thevalues of these ratios reflect the functional link(s) of each compo-nent and parameter with a particular number of formulated healthproblems. Therefore some parameters have a low final WR despitethe fact that their individual WR is high (e.g. the parameters of seaand lake waters, landslide occurrence, destruction of the shoreline,access to health and environmental information, number of straydogs, etc.). This does not mean that these parameters should beignored in the “Environment and Health” Action Plan just becausetheir effect on public health is indirect and difficult to establishclearly by applying the WR calculators.

Special consideration must be given to the radiometric indica-tors for air purity [and] deposits in the atmosphere, drinking-waterand food, which take a leading position in the ecological environ-ment parameters. Their high WR may mislead a non-expert intobelieving that this high ratio is a result of significant deviation fromthe existing norms. There are currently no objective data on

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systematic deviation in this respect. The high WR of the ecologicalradiometric indicators is due to the fact that this is a parameter witha constant effect on people (throughout their whole [lives]) havingpotentially high health risks with effects that are considerablydistant in time. We must also remember that people are verysensitive to the radiation factor, which was also confirmed by thesociological survey carried out by Geopont-Intercom OOD inwhich the people of Varna expressed their views on the state of theenvironment, public health and the measures needed for theirimprovement. In addition, there may exist permanent sources ofion radiation, which are still unknown. All this involves thenecessity for unceasing checking of the radiation factor and sys-tematic provision of widely available information on the state ofthis factor within the various environmental components on theMunicipality of Varna.

Recommendations to the City CouncilOn the basis of the above presented information, we recommendthat the City Council adopt the priorities presented in the Appendix[not shown here] and approve for inclusion in the “Environmentand Health” City Action Plan the measures aimed at improving thefollowing environmental and behavioural parameters that have thegreatest effect on the identified health problems:

1. ecology: (1) provision of green areas, including recreationarea, (2) sulfur dioxide content [and] dust content in the air(these parameters relate to traffic pollution and local sources ofair pollution), (3) contamination of vegetable and meat food-stuffs, (4) contamination of sea and lake foodstuffs, (5) numberof stray dogs;

2. working environment: (1) dust content in the air, (2) toxicsubstance content in the air, (3) noise level, (4) provision ofergonomically designed workplaces;

3. social environment: (1) percentage of the population involvedin preventive intervention programmes, (2) unemploymentlevel, (3) access to primary health care, (4) effectiveness of themaintenance of recreational resources (including maintenanceof the beach and control of landslides), (5) effectiveness ofsolid domestic waste management;

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4. health maintenance behaviour and activities: (1) percentageof smokers, (2) intensity of smoking, (3) frequency of freshfruit and vegetable consumption, (4) ratio of vegetable:meat fatconsumption in food, (5) level of physical activity.

In addition to the measures designed to alter the above-men-tioned environmental and behavioural parameters it is also recom-mended that the “Environment and Health” City Action Planinclude the following measures for monitoring and provision ofinformation:

1. monitoring of the link between environment and public health:(1) establishment of a system for monitoring the radiometriccharacteristics of the air, water and food products in order toidentify previously unknown sources of ionizing radiation; (2)establishment of a system of a system for monitoring a range ofindicators designed with the specific aim to study the functionallink between environment and public health;

2. establishment of a system for the provision of information tothe public and specialists on the state of the components of theecological environment and public health in the city, as well asto regulate the access to such information.

Achieving global improvements in environmental healthrequires action at the local level – this is now universallyrecognized. Municipalities are the form of government notonly closest to the population but also often the most effectiveat working in partnership with community stakeholders: aprerequisite for any environmental health initiative.Nevertheless, local action cannot succeed in isolation; it musttake its place in a supportive framework of national plansand international commitment. The trends towards thedecentralization of services and globalization of economiesreinforce the need for different levels to play their parts.

International initiatives, such as Agenda 21, have led to localaction on the environment and health. These local initiativesseek to improve the health and quality of life of localpopulations by involving the community in decision-makingand by integrating social, economic and environmental con-cerns into policy and action. In the WHO European Region,agreements reached at Region-wide ministerial conferencesled to the development of national environmental health actionplans (NEHAPs), which in turn has created a framework forthe development of local environmental health action plans(LEHAPs).

This book discusses the international background, analysesexisting local planning processes and initiatives in the WHOEuropean Region, identifies their common features anddescribes how they interrelate with and support NEHAPs.Based on a two-year project carried out in the eastern half ofthe Region, this book also provides guidance and optionsfor the development of LEHAPs that give the levels offlexibility necessary to ensure that a bottom-up planningprocess can occur. This publication addresses both local andnational policy-makers and professionals in the environ-mental, health and other sectors. It provides valuable readingfor anyone interested in integrated action to improve andprotect the environment and health.

ISBN 92 890 1362 1 Sw.fr. 30.–

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