Economic and Social Council

 Distr. GENERAL
18 April 1994
ORIGINAL: ENGLISH

COMMISSION ON SUSTAINABLE DEVELOPMENT
Second session
16-27 May 1994
Item 6 (a) of the provisional agenda*

              REVIEW OF SECTORAL CLUSTERS, FIRST PHASE:  HEALTH,
                       HUMAN SETTLEMENTS AND FRESHWATER

               Progress in protecting and promoting human health

                        Report of the Secretary-General

                                    SUMMARY

     The present thematic report covers progress achieved in the
implementation of chapter 6 of Agenda 21 (Protecting and
promoting human health).  The report is based in large measure on
information supplied by the World Health Organization, acting as
Task Manager for the Inter-agency Committee on Sustainable
Development and other agencies of the United Nations system with
programmes and activities related to chapter 6 of Agenda 21.  The
full report of the Task Manager is available as a background
paper for the information of the Commission.  In addition, the
present report incorporates, to the extent possible, information
received from Governments and non-governmental organizations. The
recommendations contained in section III draw, in part, on the
results of an Inter-sessional Workshop on Health, the Environment
and Sustainable Development, held at Copenhagen in February 1994.

     *     E/CN.17/1994/1.

                                   CONTENTS

                                                      Paragraphs

INTRODUCTION ...............................................1 - 3

 I.  GENERAL OVERVIEW .....................................4 - 5

II.  REVIEW OF PROGRESS ACHIEVED IN PROGRAMME AREAS OF
     CHAPTER 6 OF AGENDA 21 ...............................6 - 74

     A.  International cooperation ........................6 - 33

     B.  National experience ..............................34 - 58

     C.  Role and contribution of major groups ............59 - 65

     D.  Capacity-building, technology and finance ........66 - 74

III.  CONCLUSIONS AND RECOMMENDATIONS FOR ACTION ...........75 - 82

Annex.  RECOMMENDATIONS OF THE INTER-SESSIONAL WORKSHOP ON
       HEALTH, THE ENVIRONMENT AND SUSTAINABLE DEVELOPMENT,
       ORGANIZED BY THE GOVERNMENT OF DENMARK

                                    INTRODUCTION

1.  The Commission on Sustainable Development adopted a
multi-year thematic programme of work at its first session, in
June 1993, as a framework for reviewing progress achieved in
implementing Agenda 21 (see E/1993/25/Add.1, chap. I, sect. A). 
Under the terms of this programme of work, the Commission
requested the Secretary-General to prepare thematic reports for
its sessions in 1994, 1995 and 1996.  The present report reviews
the trends and needs in implementing chapter 6 of Agenda 21 on
protecting and promoting human health. It is one of the five
thematic reports called for in the Commission's programme of work
for 1994.

2.  The report is based on the information available in a
background paper prepared by the World Health Organization (WHO),
1/ as well as on reports submitted by Governments and major
groups.  The background paper contains a detailed analysis of
international cooperation under chapter 6, identifies how health
is linked with other chapters of Agenda 21, and includes the most
important results of the Inter-sessional Workshop on Health, the
Environment and Sustainable Development, organized by the
Government of Denmark (Copenhagen, 23-25 February 1994).  The
recommendations of the Workshop are set out in the annex below.

3.  The report reviews the main trends in the activities of the
intergovernmental, governmental and non-governmental actors
following the programmatic outline of chapter 6, within the
limitations of the information made available by those actors.  A
set of recommendations is provided for the Commission's
consideration.

                             I.  GENERAL OVERVIEW

4.  Human and environmental health are mutually inclusive: 
healthy human beings can better combat poverty and care for their
environment, and a healthy environment is essential for a healthy
human being.  Promoting and protecting human health is a central
concern in sustainable development. This concern is reflected in
chapter 6 of, as well as throughout, Agenda 21 and in the Rio
Declaration on Environment and Development. 2/

5.  Chapter 6 has five programme areas containing over 100
activities.  The programme areas include:  (a) meeting primary
health care needs, particularly in rural areas; (b) control of
communicable diseases; (c) protecting vulnerable groups; (d)
meeting the urban health challenge; and (e) reducing health risks
from environmental pollution and hazards.

      II.   REVIEW OF PROGRESS ACHIEVED IN PROGRAMME AREAS OF
            CHAPTER 6 OF AGENDA 21

                         A.  International cooperation

6.  In general, United Nations agencies continue along
well-established programmatic lines regarding protection and
promotion of human health. Although many of these programmes do
not directly derive from chapter 6, or from Agenda 21, they
nevertheless cover areas that are integral to implementing the
health aspects of the global sustainable development agenda.

 Programme area A:  Meeting primary health care needs,
particularly in rural areas

7.  Four general trends are observed in this programme area:  (i)
increasing emphasis on investments in the social and
environmental sectors; (ii) increasing focus on
district/local-level health system efforts; (iii) greater support
for community participation; and (iv) reform efforts in the
health sector.

8.  The increasing emphasis on social and environmental
investments is creating opportunities for broader intersectoral
and inter-agency actions for health. These broader programmes
help improve the overall social infrastructure, which in turn
helps with particular health sector efforts.

9.  The "district health system" concept aims at achieving an
equitable distribution of health resources by providing health
services, taking intersectoral action and encouraging community
participation.  WHO and the United Nations Development Programme
(UNDP), among other agencies, have been active in promoting this
concept.  WHO has also developed a set of guidelines to serve as
the basis for implementing district-level programmes.

10. Community action for health was one of the technical
discussion themes at the 1994 World Health Assembly of WHO and is
a core issue in providing primary health care.  A number of
agencies carry out programmes that contribute to increasing
community participation.  These include the Settlement
Infrastructure and Environment and Community Development
Programmes of the United Nations Centre for Human Settlements
(Habitat), the Education for All Programme of the United Nations
Educational, Scientific and Cultural Organization (UNESCO) and
the Community Nutrition Programme of the Food and Agriculture
Organization (FAO).  The concept of Primary Environmental Care
(PEC), 3/ is also emerging as an instrument of potential
importance that non-governmental organizations and various United
Nations agencies increasingly see as a means of improving the
quality of life of people through environmental regeneration.

11. There are national trends in favour of broad-based health
sector reform. The WHO second evaluation report on the
implementation of the Global Strategy for Health for All by the
Year 2000, for example, indicates a strong political commitment
to achieving health-for-all goals.

12. Two issues continue to be problematic in this programme area:
(i) primary health care continues to be a vertical process,
despite current intellectual awareness that health care needs to
be integrative; and (ii) there is little quantitative assessment
of the impact of health service privatization programmes on the
poor and the vulnerable, especially in the least developed
countries.

Programme area B:  Control of communicable diseases

13. Eradication and/or control of over a dozen communicable
diseases by target dates, and relevant infrastructural
improvements are the focus of this programme area.  The
activities and target dates are specific enough to warrant
quantitative indicators.  However, such information is not
available on a comprehensive basis.

14. The United Nations system, in particular WHO, has had
programmes on eradicating various communicable diseases for
several decades.  This long tradition has also lent itself to
well-established inter-agency cooperation. For example the WHO
Programme for the Control of Diarrhoeal Diseases (CDD) involves
UNDP, the United Nations Children's Fund (UNICEF) and the World
Bank. 4/  Similarly, the joint Panel of Experts on Environmental
Management of Vector Control (PEEM) involves WHO, FAO, the United
Nations Environment Programme (UNEP) and Habitat. 5/ 
International cooperation in this programme area also highlights
the intersectoral approaches to communicable diseases. For
example, FAO and WHO are working on the link between health and
disease transmission through food supplies.

15. More recent efforts have been more focused on new global
epidemics, such as acquired immunodeficiency syndrome (AIDS), and
on encouraging field research. Under AIDS-related programmes, WHO
and the World Bank have organized regional seminars on AIDS
prevention and care policies for high-level policy makers.  UNDP
efforts in this area involve strengthening community responses to
the AIDS epidemic in Asia and the Pacific.

16. A recent collaborative effort to encourage research is the
Task Force on Tropical Diseases and the Environment by the
Special Programme for Research and Training in Tropical Diseases
(TDR).  TDR is sponsored with WHO by UNDP and the World Bank, and
administered by WHO.  It was established to fund field research
on the correlation between agro-ecosystem changes and tropical
diseases.

17. Many of the disease control and eradication programmes of the
United Nations system have been successful.  Some problem areas
include insufficient human resource training and infrastructure
building; and continuing low levels of investment in public
health activities.

Programme area C:  Protecting vulnerable groups

18. This programme area focuses on children and youth, women, and
indigenous groups as particularly vulnerable groups for whom
Governments and agencies are asked to provide special services. 
The available information indicates that agencies, as well as
Governments and non-governmental organizations have established
programmes for some of the identified vulnerable groups.

19. There seem to be more instances of special agency programmes
for women and children than for indigenous groups or youth.  For
example, WHO and UNICEF have jointly formulated a set of
indicators and a global monitoring framework that focuses on
children.  WHO has established a Global Commission on Women's
Development and Health.  UNICEF, FAO and WHO are involved in
national follow-up to international and regional initiatives,
such as the World Summit for Children.  WHO and UNESCO have
jointly focused on improving the health of schoolchildren through
improved school environments.  The World Food Programme (WFP) is
providing food aid at health centres to encourage greater and
more regular attendance of mothers and young children.

20. Common strategies for two or more of the four groups are
rare.  A relevant initiative is the common goals set by FAO, WHO,
UNICEF and the United Nations Population Fund (UNFPA) to provide
a framework for in-country collaboration with respect to the
health of women and children.

21. A number of international frameworks relevant to vulnerable
groups are also being revived in the context of Agenda 21.  Among
them are the Convention on the Elimination of All Forms of
Discrimination Against Women (General Assembly resolution
34/180), the Convention on the Rights of the Child (General
Assembly resolution 44/25) and the International Labour
Organization (ILO) Conventions on Child Labour (Convention 138)
and Tribal and Indigenous Populations (Convention 107).

22. A problem area involves whether the vulnerable groups play a
passive-recipient or active-participant role in the design,
implementation and other decision-making relevant to national and
international health programmes. For example, it is not yet clear
whether vulnerable groups are integrated in the decision-making
of agencies or other actors particularly in local health issues,
as suggested in subsection (c) (i) of paragraph 6.27 of Agenda
21.  Similarly, it is not clear to what extent the traditional
knowledge held by indigenous groups and women is being integrated
into health systems and policies (para. 6.27, subsection (d)
(ii)).

Programme area D:  Meeting the urban health challenge

23. This programme area focuses on meeting urban health
challenges.  Numerous United Nations agencies are helping to
improve the capacity of municipal governments to manage the urban
environment and improve living conditions in cities.  Efforts
have been increased in the recent years owing to rapid urban
growth and the growing need for health services in cities.

24. Among the current inter-agency initiatives are the Healthy
Cities Programme (WHO), the LIFE Programme (UNDP), the Labour
Intensive Public Works Programme (ILO), the Metropolitan
Environment Improvement and Metropolitan Development programmes
(World Bank/UNDP), the Sustainable Cities Programme (Habitat),
the CITYNET/Asia-Pacific 2000 Programme (ESCAP/UNDP) and the

Tropical Urban Climate Experiment (WMO).

25. There are also programmes that address the growing need to
network the available information.  A collaborative project
involving WHO, UNICEF, UNDP, the Rockefeller Foundation,
bilateral donors and research and development institutes 6/ aims
to develop a network of supporting institutions that will
mobilize needed technical and financial input in the
implementation of projects developed by the participating cities.

26. A positive trend among these and other ongoing efforts is the
focus on "supportive environments" or the "settings approach". 
This focuses attention on key urban settings and on relevant
ministries and local authorities.  It is emerging as an effective
and practical means of achieving intersectoral action. 7/

27. The role of health centres is receiving increased attention;
in part, as a result of the overall decentralization efforts. 
Currently, studies are being carried out in eight cities to
further develop the idea of designating one health centre in each
urban district as a "reference health centre".

28. Problem areas remain in reducing the extension of poor
quality health care, increasing the self-reliance of vulnerable
groups and local inhabitants, increasing community participation
in health-care programmes and reaching high-risk groups for
reproductive health care.

Programme area E:  Reducing health risks from environmental
pollution and hazards

29. There are two common elements among the activities of this
programme area: (i) the need to improve information capabilities,
and (ii) the linkages between programme area E and several other
chapters of Agenda 21. 8/

30. The health components of many ongoing United Nations agency
programmes, particularly those of WHO, UNEP and FAO, are building
blocks for the information content of this programme area.  These
activities include the health components of the Global
Environmental Monitoring System (GEMS), the Human Exposure
Assessment Locations (HEALS) and the Global Networks project for
education, training and research.  In addition, the UNEP APELL
and Cleaner Production projects provide industry with essential
information and advice to reduce pollution and related health
risks.

31. WHO has also been developing health criteria for quality of
air, drinking-water and coastal waters.  These increase organized
information capabilities and provide the base on which
Governments and local authorities build national standards or
establish local pollution control programmes. Environmental
health impact assessments, which are becoming prerequisites for
development projects, are also an important information
collection tool.

32. A new initiative involves the joint monitoring and assessment
initiative of UNEP/WHO, which aims to develop methodologies to
link data on environmental quality and the health status of
exposed populations.  It is planned to closely link this
initiative to the work of UNEP and the Statistical Division of
the United Nations Secretariat on harmonizing environmental
statistics and developing sustainable development indicators.

33. The content of programme area E is closely related to the
content of a number of sectoral Agenda 21 chapters, including
chapters 8, 9, 17-21 and 39. Integrated approaches to pollution
risk reduction, through a series of pilot projects, are expected
to lead to the development of comprehensive risk analysis,
pollution source identification and prioritization of remedial
action. These are likely to result in the formulation of
cost-effective health protection components and
prevention/control measures.  Focusing on specific target groups
is another approach that is likely to produce the desired
results. Such cross-linkages include the Healthy Cities project
and the supportive environment projects.

                          B.  National experience 9/

34. Agenda 21 is beginning to affect the health sector in some
countries. The slow rate of influence of sustainable development
approaches to health policies may be due to two factors inherent
in the health issue.  First, the challenge of allocating
responsibilities for activities that involve the competencies of
multiple ministries, agencies and other institutions. 10/
Secondly, Agenda 21's focus, in general, and the health focus, in
particular, strongly emphasize preventive measures, while most
current resources are allocated to curative processes. 11/

35. The information received from Governments regarding national
implementation activities under chapter 6 are summarized below by
groups of countries and programme areas of chapter 6.

                         1.  Developing countries 12/

Programme area A:  Meeting primary health needs, particularly in
rural areas

36. With the exception of one country, all indicated that they
had a national health plan.  In most cases the national strategy
is recently developed and is largely guided by the WHO Health for
All strategy.  One country indicated that its national health
strategy was integral to its overall environmental investment
programme.  A Latin American country indicated that it had
increased public health investments.  An Asian developing country
indicated that its national health strategy included standards
for management of health care, training of health personnel,
media education, immunization programmes and reduction of
malnutrition.

37. Overall there are indications in favour of decentralized
systems where districts and local authorities take greater roles
and responsibilities. Most are aware of or have been guided by
the Health for All strategy and Agenda 21.  However, the focus
does not yet appear to have shifted to preventive care.  Most
indications relate to provision of curative care. Several
strongly emphasize the need for training of personnel, education
programmes on environmental and health linkages and other
awareness campaigns.

Programme area B:  Control of communicable diseases

38. Many of the communicable diseases listed in chapter 6 are
health priorities and problems in most developing countries. 
Those that have provided information on this programme area
emphasize the need to eradicate poliomyelitis, malaria and
leprosy and reduce measles.  AIDS is a priority for developing
countries, as it is for developed countries.  Many developing
countries indicate they have collaborative projects with
international agencies and bilateral donors regarding the
reduction, eradication and control of the above diseases.  Many
also indicate they need more human and financial resources to
monitor illnesses and their sources, run education campaigns and
improve the overall health infrastructure.

Programme area C:  Protecting vulnerable groups

39. Most responding developing countries indicate that they have
health programmes for children.  Programmes for the other three
vulnerable groups appear to be fewer or lacking.  One country
also indicated the ageing as an additional vulnerable group.

Programme area D:  Meeting the urban health challenge

40. There is hardly any information on urban health challenges. 
The information received indicates there is some level of
decentralization and some surveying of needs in the urban
setting.  Overall, there appears to be extensive need among
developing countries for assistance in dealing with the rapid
trends of urbanization and related health and other social
services.

Programme area E:  Reducing health risks from environmental
pollution and hazards

41. Water pollution and the related health effects appear to be a
priority for developing countries.  In particular, the provision
of safe drinking water and solid waste management are high
priorities.  Most developing countries also indicate urgent needs
for monitoring and measuring pollutants in all media,
particularly air and water, and in relation to the health and
environmental effects of pesticides.  Environmental and health
impact assessments appear to be a priority area for future
development assistance needs, including technology, training and
information systems.

                          2.  Countries in transition

Programme area A:  Meeting primary health care needs,
particularly in rural areas

42. The responding countries in this category indicate that they
have adopted a national plan but that it is too early to assess
the impact on society. They also indicate having a rural focus
and expect to see more results in this area as
decentralization/privatization efforts continue.  Health
indicators appear to have deteriorated slightly during the
biennium 1989-1990.  The needs focus primarily on improving or
establishing information systems.

Programme area B:  Control of communicable diseases

43. The responding countries indicate that many of the
communicable diseases listed in chapter 6 are not applicable. 
Some of these diseases, such as measles, are prevented through
regular and/or comprehensive vaccination programmes.  They report
the occurrence of poliomyelitis and tuberculosis as well as of
AIDS.  One country indicates that a national committee to prevent
AIDS has been established.  Assistance needs fall under
improvement of health information and education services,
technologies, and codification and surveying of environmental
factors.

Programme area C:  Protecting vulnerable groups

44. Child care, prenatal care, immunization and vaccination
programmes, and family planning are listed as programmes directed
to vulnerable groups. Acute respiratory illnesses among children
have led to special programmes for schoolchildren.  One country
has a particular focus on the family as opposed to separate
vulnerable groups.  Assistance is needed primarily in modernizing
existing systems, particularly in schools.

Programme area D:  Meeting the urban health challenge

45. One responding country participates in the WHO Healthy Cities
programme. The same country also indicates that many local
authorities finance and run local programmes and that many
districts have their own regional programmes. Assistance is
needed in surveying the health and environmental needs of the
urban settings.

Programme area E:  Reducing health risks from environmental
pollution and hazards

46. Contamination of foodstuffs, nitrification of water and soil
from pesticide use, drinking water quality and noise are
mentioned as top health risks from urban pollution.  One country
has a government decree for monitoring health and environment
status, involving tens of districts. Another country indicates
that air pollution is monitored to some degree; it has no
information on indoor pollution, however.  The country is in the
process of reducing lead in fuel to improve air quality. 
Assistance needs relate to research and monitoring capabilities.

                            3.  Developed countries

Programme area A:  Meeting primary health care needs,
particularly in rural areas

47. In most responding developed countries, primary health care
is largely available; three quarters or more of the people have
access to health services and care.  In some countries the
coverage is entirely a public service and is almost universal. 
Most have national health plans and are part of the WHO Health
for All strategy.

48. In all responding developed countries, overall health
indicators are high:  life expectancies range from 70 to 80
years; there are adequate numbers of medical personnel,
health-care centres, research institutes; and low infant
mortality rates.  Most national efforts include intersectoral
coordination involving several ministries and local governments.

49. A problem area is the rapid decrease in the rural population
which (i) reduces incentives for medical personnel to work there
and (ii) no longer justifies rural medical centres as they become
less cost-effective.  One country has responded to the latter
problem by providing mobile health services in rural areas.

Programme area B:  Control of communicable diseases

50. Most communicable diseases listed in chapter 6 are no longer
a priority or no longer exist in developed countries.  Many
responding countries indicate no incidence of poliomyelitis,
malaria or leprosy.  Although some indicate a slight increase in
tuberculosis, numbers are too small to consider it an epidemic.

51. The current overall focus is more on the AIDS epidemic and on
cardiovascular diseases, cancer and occupational accidents.  AIDS
is reported as a priority by all responding developed countries
particularly in terms of controlling its spread, as is
health-related development assistance to developing countries.

Programme area C:  Protecting vulnerable groups

52. Of the four groups identified in this programme area,
children and women appear to receive more attention.  Most
responding developed countries have health care services for
infants, prenatal care, vaccination programmes, and other
services that are accessible.  One country indicated 99.9 per
cent coverage for prenatal and child care.  Some have particular
legislation that protects the rights of children and upholds the
relevant international instruments.

53. One country indicated that its development assistance
experience in developing countries is currently being used
internally in dealing with the needs of its indigenous people. 
Another country indicated that it carries out its programmes for
vulnerable groups through national non-governmental
organizations.

54. Almost all responding countries indicate at least two
additional groups as vulnerable groups.  These are the ageing and
the disabled.  One country also considers the unemployed a
vulnerable group with respect to health needs.  These groups also
receive health care and other social services through national 
strategies and policies.

Programme area D:  Meeting the urban health challenge

55. This programme area requires action regarding urban health
plans, surveying of health and environmental linkages in urban
settings, local health services and information networks in
cities.  Most developed countries indicate that local governments
and municipalities are involved in the overall provision of
health services.

56. Cities appear to have autonomous financial and
decision-making capabilities in many responding developed
countries.  This enables them to not only implement national
health plans and policies but also adopt local programmes to meet
local needs.  Most activities in this area, such as information
centres and surveys, are part of national health services and are
not separately reported.

Programme area E:  Reducing health risks from environmental
pollution and hazards

57. Developed countries have numerous success stories regarding
the measurement, monitoring and control of various environmental
pollution cases. Due to numerous and long-existing legal
frameworks, many health-related successes follow from the
information and monitoring infrastructure.  Some countries'
information systems also form the backbone of international
environmental monitoring systems.

58. Most responding developed countries list specialized
environmental legislation to deal with a range of problems, from
noise reduction to vehicle emission standards and energy
efficiency requirements.  Many also provide development
assistance in relevant monitoring technologies and training.  A
priority area in this context appears to be water pollution and
the reduction of relevant health effects.

                   C.  Role and contribution of major groups

59. Three major groups, as recognized in Agenda 21, are singled
out in chapter 6 as vulnerable groups:  children and youth,
women, and indigenous people.  However, given the central place
of human and environmental health in sustainable development, all
other major groups have a stake in helping to implement the
activities in chapter 6.

60. Non-governmental organizations have been particularly active
in the health area.  However, given that health is a fundamental
concern in environment and development, activities and efforts of
all other major groups are directly or indirectly linked to
promoting and protecting health. Scientific and technological
communities have a particular role in terms of generating the
methods that help assess various environmental risks, and provide
prevention and abatement processes for the use of public and
private institutions.

61. The growing importance of the role of major groups in the
health sector was highlighted at the Inter-sessional Workshop on
Health, the Environment and Sustainable Development, organized by
the Government of Denmark.  The conclusions of this meeting
include ensuring that, at the national and local levels, major
groups (especially community groups, women's groups, the private
sector and non-governmental organizations) are given better
opportunities to involve themselves in decisions and actions to
protect and promote health through protection of the local
environment, and to promote recognition of the expertise acquired
in doing so.

                      1.  Non-governmental organizations

62. Many national and international non-governmental
organizations are already important agents in the execution of
health programmes. Increasingly, bilateral and multilateral
donors either directly fund the efforts of those organizations or
require that they are involved in programme implementation.  They
are recognized as important partners in the delivery of services,
in the development of innovative action at the local level, in
the support of community-driven approaches to sustainability, in
assessing problems and evaluating policies and in collecting and
disseminating information.

63. One non-governmental organization officially submitted a
report to the Commission specifically on the health theme:  the
Women's Network on Pharmaceuticals (WEMOS), based in the
Netherlands. 13/  The WEMOS submission comprised three papers on
health and sustainable development in general; breast-feeding as
a sustainable method of infant feeding; and the rational use of
drugs in sustainable health policies.  Recommendations for health
and sustainable development focus on placing high priority on
reducing inappropriate medical intervention by the provision of
more independent consumer information and education on medical
intervention.  This non-governmental organization also suggests
that more traditional methods such as breast-feeding be promoted,
trade in dangerous drugs be reduced, dangerous pharmaceuticals be
included in an internationally agreed ban, health efforts focus
on prevention, and disclosure of information on toxicity and
exposure be increased.

                2.  The scientific and technological community

64. This major group has a particular role in promoting and
protecting health by generating the knowledge and technologies
necessary to carry out the objectives of chapter 6, as well as
other health-related matters in Agenda 21. One scientific
association submitted an official report on health:  the
Environmental Research Committee of the Japan Scientists
Association (JSA).

65. The JSA report proposes a model that illustrates the
importance of adopting a preventive approach.  The model focuses
on the cut-off point at which a healthy state is considered to
have become a state of "illness".  As these states are not
definite points but phases, they involve a transitional period
when neither of the states is clearly prevalent.  JSA is of the
opinion that greater focus on cut-off points that fall within the
transitional phase would lead to more preventive approaches.  The
model has significant policy implications.  For example, the
cut-off point determines when to provide health services and what
kind of health services to provide. Similarly, the cut-off point
affects legal requirements and regulations on the level of
acceptable "risk" related to various types of exposure to
environmental factors.

                 D.  Capacity-building, technology and finance

                     1.  Capacity-building and technology

66. Chapter 6 identifies scientific and technological means of
improving the understanding, forecasting and management of health
needs that can be grouped as follows:  (i) strategy design at the
national, district and local levels; (ii) improved information
management; (iii) health modelling; (iv) international generation
and sharing of health information.

67. Strategy design.  Recent international developments signal an
opportunity for re-emphasizing health planning and related
activities with the expectation of near-term benefit.  These
include (i) use of cost-effectiveness in health strategy design;
(ii) new public health action, which is based on reviewing and
revising the extent of public responsibility in health; (iii)
decentralization of health planning; (iv) growing experience with
rapid assessment procedures; and (v) the WHO/UNICEF initiative
for building national capacity to monitor and manage water and
sanitation development.

68. Improved information management.  The rapidly advancing
micro-computer technology and data communications capability
offers considerable potential to improve the management of
extensive amounts of data generated by various agencies and some
countries.  Much of this data is underutilized. Technological
enhancement needs to focus on developing health indicators,
better use of modern communications and data analysis
technologies and training.

69. Health modelling.  Collaborative efforts of United Nations
agencies and other institutions should focus on providing
practical guidance for national health administrations,
particularly in computer modelling.  This focus could help with
analysis of health-related cause-effect relationships; assessing
the cost-effectiveness of potential interventions; and
forecasting and designing future scenarios. 14/

70. International cooperation in generating and sharing health
information. Globally available data should be shared and used
more effectively.  Among the sources of such data are (i) joint
exploration by WHO and the United States Centers for Disease
Control and Prevention (Atlanta) of the possibilities for global
monitoring of emerging infection and changing disease patterns;
and (ii) the Internet electronic network to gather and share
evidence of the effectiveness of new health strategies and
operational approaches. 15/

71. Capacity-building is an important part of the health and
technology issue, and needs inter-agency collaboration most.  A
number of agencies carry out programmes that focus on human
resource development in the health field. 16/  A relatively
simple but crucial aspect of the efforts in this area is
providing training materials in local languages.  It is also
essential to link the different training activities at the
national level into a common planning framework.  WHO has begun
work with the World Bank and UNDP to create a Network for
Capacity Building in Health Sector Reform.  The focus of the
proposed network is on information exchange, tools development
and advocacy.  The network can be an important means of pooling
expertise, linking people with similar vision and motivation,
thus breaking the isolation that many professionals charged with
designing and monitoring reform efforts are facing.

                                  2.  Finance

72. The estimated cost of implementing the activities of chapter
6 is US$ 51 billion a year, including US$ 6.4 billion from
multilateral sources in the form of grants and concessional
loans.

73. A number of costing methods have been applied by WHO to the
programme areas of chapter 6. 17/  This analysis argues that,
given the current total public health expenditures, it is both
feasible and economical to meet the estimated cost of chapter 6. 
The primary requirement in this context is to evaluate the
allocation of the expenditures to various health services and
assess their cost effectiveness in a "population-development
needs" matrix.

74. The recommendations of the WHO study on financing the
programme areas of chapter 6 focus on the reassessment of health
expenditures; implementation of cost-effective allocations with
long-term results; greater emphasis on financing preventive
programmes; establishing the "right" price signals and incentives
for health; emphasizing the long-term needs of the vulnerable and
high-risk groups; and evaluating health needs in the broader
context of other chapters of Agenda 21 and the overall goals of
sustainable development. These involve considerable reform within
the health sector and across all health-related sectors.  The WHO
study suggests that these reforms be undertaken in the context of
national sustainable development plans rather than as stand-alone
efforts for isolated health problems.

               III.  CONCLUSIONS AND RECOMMENDATIONS FOR ACTION

75. The main recommendation that stems from reviewing the
national and international activities under chapter 6 is that the
ongoing efforts for health sector reform should be supported by
international institutions in general and by the Commission in
particular.  In this context, the Commission may wish to take
into account the four broad "lines of reform" identified in the
background paper prepared by WHO:

   (i) Community (health) development:  achieving health
promotion and protection, especially among the vulnerable groups,
as part of more holistically conceived community development
programmes;

   (ii)     Health sector reform:  ministries of health
increasing the allocation of resources to the most cost-effective
programmes;

  (iii)     Environmental health:  increasing understanding of
sectoral linkages with health, and mobilizing action in other
sectors accordingly;

   (iv)     National decision-making and accounting: 
strengthening health representation in national decision-making,
and incorporating health and its financing in new accounting
systems for sustainable development.

76. Some specific recommendations are set out below.  In
addition, the full text of the recommendations of the
Inter-sessional Workshop on Health, the Environment and
Sustainable Development, organized by the Government of Denmark,
is contained in annex I.

77. Future reporting on progress in promoting and protecting
health:  The Commission may wish to consider requesting that
future national and international reporting on progress in
implementing the activities of chapter 6 should focus on the
steps taken to promote the four reform trends identified above.

78. Supporting the ongoing health reform process.  The Commission
may consider further stimulating the ongoing health sector reform
process by, inter alia, (a) calling upon Governments to host
meetings to elaborate the reform process in more detail; (b)
calling upon donor agencies to earmark funds for this process in
countries that are actively implementing sustainable development
policies; and (c) establishing special working groups to monitor
progress within the United Nations system to ensure that the
reform called for at the national level is leading to comparable
reform within and among the various agencies involved.  A
practical approach in this context could be to incorporate some
of these key elements into the Commission's multi-year thematic
programme of work.  For example, the issue of financing of health
in the context of sustainable development, strengthening health
representation in national decision-making, and the roles of
non-governmental organizations in health should be specifically
addressed under the appropriate agenda item at future sessions of
the Commission.

79. Broad approaches to health investments.  Narrow health
investments are curative and confined to the health sector, while
broad health investments are preventive, with important
contributions being made by all other sectors whose programmes
influence human health.  The Commission may wish to encourage
Governments and intergovernmental bodies to adopt a broad
approach at the regional, national and local levels.

80. Supportive environments for vulnerable groups.  Efforts for
better health care for vulnerable groups produce long-term
positive results when they take an integrated approach.  A
community focus could be more strategic than focusing on
programmes for individual groups.  The Commission may wish to
consider emphasizing a community focus in building community
care.

81. Partnership approach.  Inequitable distribution of resources,
irrational duplication and overlapping of functions, limited
authority at the local level, and uncoordinated efforts between
public, private, voluntary and non-governmental organizations
still dominate the urban scene.  Current experience indicates
that the partnership approach is common to successful programmes. 
The partnership approach should involve communities,
non-governmental organization, municipalities and local health
departments jointly addressing problems and mobilizing local
resources.

82. Environmental health impact assessments.  There is agreement
that new development projects should undergo an environmental
impact assessment.  This emerging agreement could benefit from
further political and institutional support.  The Commission may
consider requesting all United Nations agencies to run
environmental health impact assessments for new and existing
programmes.  In this context, the Commission may also wish to
suggest that major groups participate in such assessment
processes and/or undertake independent verification at the local
level.

                                     Annex

        RECOMMENDATIONS OF THE INTER-SESSIONAL WORKSHOP ON HEALTH, THE
           ENVIRONMENT AND SUSTAINABLE DEVELOPMENT, ORGANIZED BY THE
                             GOVERNMENT OF DENMARK

                       (Copenhagen, 23-25 February 1994)

   Building upon Agenda 21 of the United Nations Conference on
Environment and Development, participants in the Inter-sessional
Workshop on Health, the Environment and Sustainable Development,
held in Copenhagen, from 23 to 25 February 1994,

   Meeting as an integral part of the inter-sessional programme
of the Commission on Sustainable Development, and within the
framework of the forthcoming International Conference on
Population and Development and the Fourth World Conference on
Women, which all address important components of Agenda 21,

   With a view to further promoting the Chapters of Agenda 21
relevant to the Workshop,

   Guided by the objective of promoting the effective integration
of health and environmental considerations into the planning of
all development activities, and in the light of the many positive
experiences gained from primary health care and the drive towards
health for all,

   Convinced of the need for urgent action for a sustainable
future,

   Recognizing the important impact of population growth and
production and consumption patterns on health, the environment
and sustainable development,

   Invites the Commission on Sustainable Development to receive
for debate, and preferably for wide dissemination, the following
set of recommendations for urgent attention and follow up:

Priorities

   To promote awareness and commitment among concerned
authorities, the general public and specific target groups to the
close and fundamental relationship between health, the
environment and sustainable development;

   To convince Governments of the essential need for political
commitment to integrate the trinity of health, the environment
and sustainable development through innovative and holistic
approaches;

   To encourage a carefully planned redirection of national and
international resources, better understanding and coordination
among the authorities responsible, and increased funding for
health and the environment;

   To ensure, at the national level, that health, environment and
other relevant actors participate fully and democratically in a
sustainable planning process, particularly at the pre-investment
planning stage, and are given adequate resources, opportunities
and information as well as managerial and technical capacity;

   To ensure, at the national and local levels, that major groups
(especially community groups, women's groups, the private sector
and non-governmental organizations) are given better
opportunities to involve themselves in decisions and actions to
protect and promote health through protection of the local
environment, and to promote the recognition of their expertise
acquired in doing so;

   To ensure the development of participatory planning so that
decision- making and implementation take place at the
appropriate, decentralized level;

Means

   To build up greater institutional capacity for the conception,
planning and management of appropriate health and environment
policies and operational elements at the international, national,
local and community levels with the assistance of international
donors, if necessary;

   To support international and regional collaboration between
United Nations agencies and international bodies, including
non-governmental organizations, that aims at achieving human
health goals as explicitly and implicitly contained in Agenda 21;

   To request multilateral and bilateral cooperation agencies to
take into account these recommendations in the formulation of
policies and programmes aimed at supporting health, the
environment and sustainable development;

   To build on the achievements of existing approaches, such as
primary health care and healthy cities and municipalities, in
integrating health, the environment and sustainable development;

   To emphasize the usefulness in the national, local and
ecological context of enhancing all sustainable and participatory
planning methods with appropriate tools, including health impact
assessments, integrated within environment impact assessments,
and checklists based on the best available national and
international data;

   To develop and implement national accounting systems which
incorporate environmental and human health parameters;

   To promote multidisciplinary research on the links between
health, the environment and sustainable development, including
intersectoral data and indicators, operational and social
research, and case-studies;

   To increase the use of economic instruments (such as revenue
collection, taxes, levies or subsidies) to promote health through
the integration of health, the environment and sustainable
development;    To disseminate as widely as possible relevant and
available information and statistics on health and environment
parameters, translated into local languages, with a view to
alerting local authorities and local groups to possible risks or
benefits of alternative paths of action, as well as the
consequences of unsustainable lifestyles;

   To upgrade public health, the environment and sustainable
development, and their close interrelationship, as elements in
primary, secondary and adult education curricula, and to
encourage multisectoral seminars and training courses to improve
the understanding of primary health care and sustainable
development, and how these two conceptual frameworks complement
each other at all levels.

                                     Notes

   1/  WHO is the Task Manager for chapter 6, in accordance with
the decision of the Inter-Agency Committee on Sustainable
Development at its 2nd meeting, in 1993.  The Task Manager's
report was prepared in collaboration with the following
organizations and programmes:  United Nations Children's Fund,
United Nations Development Programme, United Nations Environment
Programme, United Nations Population Fund, United Nations Relief
and Works Agency for Palestine Refugees in the Near East, World
Food Programme, United Nations Centre for Human Settlements
(Habitat), International Labour Organization, Food and
Agriculture Organization of the United Nations, United Nations
Educational, Scientific and Cultural Organization, World Bank,
International Telecommunication Union, World Meteorological
Organization, United Nations Industrial Development Organization
and International Atomic Energy Agency.

   2/  Report of the United Nations Conference on Environment and
Development, Rio de Janeiro, 3-14 June 1992, vol. I, Resolutions
Adopted by the Conference (United Nations publication, Sales No.
E.93.I.8 and corrigendum), resolution 1, annex I (Rio Declaration
on Environment and Development), principle 1:  "Human beings are
at the centre of concerns for sustainable development.  They are
entitled to a healthy and productive life in harmony with
nature."

   3/  Primary Environmental Care (PEC) is a process by which
communities, with multilateral and bilateral support, organize
themselves and strengthen, enrich and apply their own means and
capacities (know-how, technologies and practices) for the care of
their environment, while simultaneously satisfying their needs. 
The concept's origin is not clear, but is attributed to
non-governmental sources.

   4/  Plans are under way to extend inter-agency involvement in
this programme to other United Nations agencies.

   5/  PEEM is a collaborative arrangement focusing on prevention
of vector-borne diseases.  PEEM's more recent focus has been on
policy formulation, research and development, and
capacity-building in the field.

   6/  London School of Hygiene and Tropical Medicine; Aga Khan
University, Karachi; Harvard School of Public Health, Boston;
Department of Public Health, University of Liverpool; Liverpool
School of Tropical Medicine; Catholic University, Nijmegen;
School of Public Health, Berkeley University; Tata Institute of
Social Sciences, Bombay; Centre for Urban Policy Studies, Manila;
Faculty of Public Health, Jakarta University; ASEAN Institute for
Health Development, Bangkok.

   7/  An example of this approach is the national school health
programme in Ghana.

   8/  Particularly the chapters on decision-making, (chap. 8),
protection of the atmosphere (chap. 9), protection of the oceans,
(chap. 17), protection of freshwater resources, (chap. 18),
management of toxic chemicals (chap. 19), hazardous wastes (chap.
20), solid wastes (chap. 21) and international legal instruments
and mechanisms (chap. 39).

   9/  The information provided in this section is based on the
responses of Governments to the questionnaire prepared by the
Secretariat.  The questionnaire covered all the cross-sectoral
and sectoral themes that are before the Commission at its present
session.  To date, the Secretariat has received six responses
related to health from developed countries, five from developing
countries and two from countries with economies in transition.

   10/ Health is not a stand-alone issue; it cuts across the
areas of competence not only of the health sector but also of the
industrial, social welfare, agricultural, environmental sciences
and education sectors, among others.  This makes both the
allocation of responsibilities and the coordination of activities
a challenge.  Success of relevant efforts depends on the level of
coordination between the various ministries, as well as between
national and local/regional administrative structures.  Similar
coordination and delineation of responsibilities challenges exist
at the international level.

   11/ Health-related efforts currently concentrate more on
curative processes than on the preventive efforts required by
sustainable development. Curative services account for the most
of the human, material and financial, resources available to the
health sector in most countries.  World-wide economic
difficulties raise additional barriers to increasing preventive
services and therefore to fulfilling the goals of Agenda 21.

   12/ The developing country respondents were few.  Hence the
present analysis has limited reliability in terms of generalizing
the behaviour of over three quarters of the people of the world
and their Governments.

   13/ The work of most non-governmental organizations in
sustainable development is closely linked to health concerns and
a lack of official submissions to the Commission does not
indicate the absence of non-governmental organizations in this
field.

   14/ A current WHO/WMO/UNEP project to produce a book on
potential health impacts of climate change is relevant in this
context.  This activity takes place in close coordination with
the impact assessment work of the Intergovernmental Panel on
Climate Change (IPCC), whose climatological modelling scenarios
for 2020 and 2050 serve as baseline material.

   15/ An inter-agency project on Databases and Methodologies for
Comparative Assessment of Different Energy Systems for
Electricity Generation (DECADES), while not specific to health,
is of relevance in illustrating the extent to which inter-agency
cooperation is possible in this area.

   16/ WHO, together with FAO, UNEP, UNESCO, UNICEF and the
United Nations Institute for Training and Research (with funding
from UNDP, the World Bank, regional banks and other sources).

   17/ See the background paper prepared by WHO for the second
session of the Commission for details of these costing
projections.

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Date last posted: 1 December 1999 12:18:30
Comments and suggestions: DESA/DSD