AGENDA 21 OBLIGATIONS

Chapter 6

PROTECTING AND PROMOTING HUMAN HEALTH

6.2. The following programme areas are contained in this chapter:

·        Meeting primary health care needs, particularly in rural areas;

·        Control of communicable diseases;

·        Protecting vulnerable groups;

·        Meeting the urban health challenge;

·        Reducing health risks from environmental pollution and hazards.

Objectives

6.4. Within the overall strategy to achieve health for all by the year 2000, the objectives are to meet the basic health needs of rural peri-urban and urban populations; to provide the necessary specialized environmental health services; and to coordinate the involvement of citizens, the health sector, the health-related sectors and relevant non-health sectors (business, social, educational and religious institutions) in solutions to health problems. As a matter of priority, health service coverage should be achieved for population groups in greatest need, particularly those living in rural areas.

Activities

6.5. National Governments and local authorities, with the support of relevant non-governmental organizations and international organizations, in the light of countries' specific conditions and needs, should strengthen their health sector programmes, with special attention to rural needs, to:

(a) Build basic health infrastructures, monitoring and planning systems:

·        Develop and strengthen primary health care systems that are practical, community-based, scientifically sound, socially acceptable and appropriate to their needs and that meet basic health needs for clean water, safe food and sanitation;

·        Support the use and strengthening of mechanisms that improve coordination between health and related sectors at all appropriate levels of government, and in communities and relevant organizations;

·        Develop and implement rational and affordable approaches to the establishment and maintenance of health facilities;

·        Ensure and, where appropriate, increase provision of social services support;

·        Develop strategies, including reliable health indicators, to monitor the progress and evaluate the effectiveness of health programmes;

·        Explore ways to finance the health system based on the assessment of the resources needed and identify the various financing alternatives;

·        Promote health education in schools, information exchange, technical support and training;

·        Support initiatives for self-management of services by vulnerable groups;

·        Integrate traditional knowledge and experience into national health systems, as appropriate;

·        Promote the provisions for necessary logistics for outreach activities, particularly in rural areas;

·        Promote and strengthen community-based rehabilitation activities for the rural handicapped.

(b) Support research and methodology development:

·        Establish mechanisms for sustained community involvement in environmental health activities, including optimization of the appropriate use of community financial and human resources;

·        Conduct environmental health research, including behaviour research and research on ways to increase coverage and ensure greater utilization of services by peripheral, underserved and vulnerable populations, as appropriate to good prevention services and health care;

·        Conduct research into traditional knowledge of prevention and curative health practices.

Means of implementation

(a) Financing and cost evaluation

6.6. The Conference secretariat has estimated the average total annual cost (1993-2000) of implementing the activities of this programme to be about $40 billion, including about $5 billion from the international community on grant or concessional terms. These are indicative and order-of-magnitude estimates only and have not been reviewed by Governments. Actual costs and financial terms, including any that are non-concessional, will depend upon, inter alia, the specific strategies and programmes Governments decide upon for implementation.

(b) Scientific and technological means

6.7. New approaches to planning and managing health care systems and facilities should be tested, and research on ways of integrating appropriate technologies into health infrastructures supported. The development of scientifically sound health technology should enhance adaptability to local needs and maintainability by community resources, including the maintenance and repair of equipment used in health care. Programmes to facilitate the transfer and sharing of information and expertise should be developed, including communication methods and educational materials.

(c) Human resource development

6.8. Intersectoral approaches to the reform of health personnel development should be strengthened to ensure its relevance to the "Health for All" strategies. Efforts to enhance managerial skills at the district level should be supported, with the aim of ensuring the systematic development and efficient operation of the basic health system. Intensive, short, practical training programmes with emphasis on skills in effective communication, community organization and facilitation of behaviour change should be developed in order to prepare the local personnel of all sectors involved in social development for carrying out their respective roles. In cooperation with the education sector, special health education programmes should be developed focusing on the role of women in the health-care system.

(d) Capacity-building

6.9. Governments should consider adopting enabling and facilitating strategies to promote the participation of communities in meeting their own needs, in addition to providing direct support to the provision of health-care services. A major focus should be the preparation of community-based health and health-related workers to assume an active role in community health education, with emphasis on team work, social mobilization and the support of other development workers. National programmes should cover district health systems in urban, peri-urban and rural areas, the delivery of health programmes at the district level, and the development and support of referral services.

B. Control of communicable diseases

Objectives

6.12. A number of goals have been formulated through extensive consultations in various international forums attended by virtually all Governments, relevant United Nations organizations (including WHO, UNICEF, UNFPA, UNESCO, UNDP and the World Bank) and a number of non-governmental organizations. Goals (including but not limited to those listed below) are recommended for implementation by all countries where they are applicable, with appropriate adaptation to the specific situation of each country in terms of phasing, standards, priorities and availability of resources, with respect for cultural, religious and social aspects, in keeping with freedom, dignity and personally held values and taking into account ethical considerations. Additional goals that are particularly relevant to a country's specific situation should be added in the country's national plan of action (Plan of Action for Implementing the World Declaration on the Survival, Protection and Development of Children in the 1990s). 1/ Such national level action plans should be coordinated and monitored from within the public health sector. Some major goals are:

·        By the year 2000, to eliminate guinea worm disease (dracunculiasis);

·        By the year 2000, eradicate polio;

·        By the year 2000, to effectively control onchocerciasis (river blindness) and leprosy;

·        By 1995, to reduce measles deaths by 95 per cent and reduce measles cases by 90 per cent compared with pre-immunization levels;

·        By continued efforts, to provide health and hygiene education and to ensure universal access to safe drinking water and universal access to sanitary measures of excreta disposal, thereby markedly reducing waterborne diseases such as cholera and schistosomiasis and reducing:

·        By the year 2000, the number of deaths from childhood diarrhoea in developing countries by 50 to 70 per cent;

·        By the year 2000, the incidence of childhood diarrhoea in developing countries by at least 25 to 50 per cent;

·        By the year 2000, to initiate comprehensive programmes to reduce mortality from acute respiratory infections in children under five years by at least one third, particularly in countries with high infant mortality;

·        By the year 2000, to provide 95 per cent of the world's child population with access to appropriate care for acute respiratory infections within the community and at first referral level;

·        By the year 2000, to institute anti-malaria programmes in all countries where malaria presents a significant health problem and maintain the transmission-free status of areas freed from endemic malaria;

·        By the year 2000, to implement control programmes in countries where major human parasitic infections are endemic and achieve an overall reduction in the prevalence of schistosomiasis and of other trematode infections by 40 per cent and 25 per cent, respectively, from a 1984 baseline, as well as a marked reduction in incidence, prevalence and intensity of filarial infections;

·        To mobilize and unify national and international efforts against AIDS to prevent infection and to reduce the personal and social impact of HIV infection;

·        To contain the resurgence of tuberculosis, with particular emphasis on multiple antibiotic resistant forms;

·        To accelerate research on improved vaccines and implement to the fullest extent possible the use of vaccines in the prevention of disease.

Activities

6.13. Each national Government, in accordance with national plans for public health, priorities and objectives, should consider developing a national health action plan with appropriate international assistance and support, including, at a minimum, the following components:

·        National public health systems:

·        Programmes to identify environmental hazards in the causation of communicable diseases;

·        Monitoring systems of epidemiological data to ensure adequate forecasting of the introduction, spread or aggravation of communicable diseases;

·        Intervention programmes, including measures consistent with the principles of the global AIDS strategy;

·        Vaccines for the prevention of communicable diseases;

·        Public information and health education: Provide education and disseminate information on the risks of endemic communicable diseases and build awareness on environmental methods for control of communicable diseases to enable communities to play a role in the control of communicable diseases;

·        Intersectoral cooperation and coordination:

·        Second experienced health professionals to relevant sectors, such as planning, housing and agriculture;

·        Develop guidelines for effective coordination in the areas of professional training, assessment of risks and development of control technology;

·        Control of environmental factors that influence the spread of communicable diseases: Apply methods for the prevention and control of communicable diseases, including water supply and sanitation control, water pollution control, food quality control, integrated vector control, garbage collection and disposal and environmentally sound irrigation practices;

·        Primary health care system:

·        Strengthen prevention programmes, with particular emphasis on adequate and balanced nutrition;

·        Strengthen early diagnostic programmes and improve capacities for early preventative/treatment action;

·        Reduce the vulnerability to HIV infection of women and their offspring;

·        Support for research and methodology development:

·        Intensify and expand multidisciplinary research, including focused efforts on the mitigation and environmental control of tropical diseases;

·        Carry out intervention studies to provide a solid epidemiological basis for control policies and to evaluate the efficiency of alternative approaches;

·        Undertake studies in the population and among health workers to determine the influence of cultural, behavioural and social factors on control policies;

·        Development and dissemination of technology:

·        Develop new technologies for the effective control of communicable diseases;

·        Promote studies to determine how to optimally disseminate results from research;

·        Ensure technical assistance, including the sharing of knowledge and know-how.

Means of implementation

(a) Financing and cost evaluation

6.14. The Conference secretariat has estimated the average total annual cost (1993-2000) of implementing the activities of this programme to be about $4 billion, including about $900 million from the international community on grant or concessional terms. These are indicative and order-of-magnitude estimates only and have not been reviewed by Governments. Actual costs and financial terms, including any that are non-concessional, will depend upon, inter alia, the specific strategies and programmes Governments decide upon for implementation.

(b) Scientific and technological means

6.15. Efforts to prevent and control diseases should include investigations of the epidemiological, social and economic bases for the development of more effective national strategies for the integrated control of communicable diseases. Cost-effective methods of environmental control should be adapted to local developmental conditions.

(c) Human resource development

6.16. National and regional training institutions should promote broad intersectoral approaches to prevention and control of communicable diseases, including training in epidemiology and community prevention and control, immunology, molecular biology and the application of new vaccines. Health education materials should be developed for use by community workers and for the education of mothers for the prevention and treatment of diarrhoeal diseases in the home.

(d) Capacity-building

6.17. The health sector should develop adequate data on the distribution of communicable diseases, as well as the institutional capacity to respond and collaborate with other sectors for prevention, mitigation and correction of communicable disease hazards through environmental protection. The advocacy at policy- and decision-making levels should be gained, professional and societal support mobilized, and communities organized in developing self-reliance.

C. Protecting vulnerable groups

Objectives

6.23. The general objectives of protecting vulnerable groups are to ensure that all such individuals should be allowed to develop to their full potential (including healthy physical, mental and spiritual development); to ensure that young people can develop, establish and maintain healthy lives; to allow women to perform their key role in society; and to support indigenous people through educational, economic and technical opportunities.

6.24. Specific major goals for child survival, development and protection were agreed upon at the World Summit for Children and remain valid also for Agenda 21. Supporting and sectoral goals cover women's health and education, nutrition, child health, water and sanitation, basic education and children in difficult circumstances.

6.25. Governments should take active steps to implement, as a matter of urgency, in accordance with country specific conditions and legal systems, measures to ensure that women and men have the same right to decide freely and responsibly on the number and spacing of their children, to have access to the information, education and means, as appropriate, to enable them to exercise this right in keeping with their freedom, dignity and personally held values, taking into account ethical and cultural considerations.

6.26. Governments should take active steps to implement programmes to establish and strengthen preventive and curative health facilities which include women-centred, women-managed, safe and effective reproductive health care and affordable, accessible services, as appropriate, for the responsible planning of family size, in keeping with freedom, dignity and personally held values and taking into account ethical and cultural considerations. Programmes should focus on providing comprehensive health care, including pre-natal care, education and information on health and responsible parenthood and should provide the opportunity for all women to breast-feed fully, at least during the first four months post-partum. Programmes should fully support women's productive and reproductive roles and well being, with special attention to the need for providing equal and improved health care for all children and the need to reduce the risk of maternal and child mortality and sickness.

Activities

6.27. National Governments, in cooperation with local and non-governmental organizations, should initiate or enhance programmes in the following areas:

·        Infants and children:

·        Strengthen basic health-care services for children in the context of primary health-care delivery, including prenatal care, breast-feeding, immunization and nutrition programmes;

·        Undertake widespread adult education on the use of oral rehydration therapy for diarrhoea, treatment of respiratory infections and prevention of communicable diseases;

·        Promote the creation, amendment and enforcement of a legal framework protecting children from sexual and workplace exploitation;

·        Protect children from the effects of environmental and occupational toxic compounds;

·        Youth: Strengthen services for youth in health, education and social sectors in order to provide better information, education, counselling and treatment for specific health problems, including drug abuse;

·        Women:

·        Involve women's groups in decision-making at the national and community levels to identify health risks and incorporate health issues in national action programmes on women and development;

·        Provide concrete incentives to encourage and maintain attendance of women of all ages at school and adult education courses, including health education and training in primary, home and maternal health care;

·        Carry out baseline surveys and knowledge, attitude and practice studies on the health and nutrition of women throughout their life cycle, especially as related to the impact of environmental degradation and adequate resources;

·        Indigenous people and their communities:

·        Strengthen, through resources and self-management, preventative and curative health services;

·        Integrate traditional knowledge and experience into health systems.

Means of implementation

(a) Financing and cost evaluation

6.28. The Conference secretariat has estimated the average total annual cost (1993-2000) of implementing the activities of this programme to be about $3.7 billion, including about $400 billion from the international community on grant or concessional terms. These are indicative and order-of-magnitude estimates only and have not been reviewed by Governments. Actual costs and financial terms, including any that are non-concessional, will depend upon, inter alia, the specific strategies and programmes Governments decide upon for implementation.

(b) Scientific and technological means

6.29. Educational, health and research institutions should be strengthened to provide support to improve the health of vulnerable groups. Social research on the specific problems of these groups should be expanded and methods for implementing flexible pragmatic solutions explored, with emphasis on preventive measures. Technical support should be provided to Governments, institutions and non-governmental organizations for youth, women and indigenous people in the health sector.

(c) Human resources development

6.30. The development of human resources for the health of children, youth and women should include reinforcement of educational institutions, promotion of interactive methods of education for health and increased use of mass media in disseminating information to the target groups. This requires the training of more community health workers, nurses, midwives, physicians, social scientists and educators, the education of mothers, families and communities and the strengthening of ministries of education, health, population etc.

(d) Capacity-building

6.31. Governments should promote, where necessary: (i) the organization of national, intercountry and interregional symposia and other meetings for the exchange of information among agencies and groups concerned with the health of children, youth, women and indigenous people, and (ii) women's organizations, youth groups and indigenous people's organizations to facilitate health and consult them on the creation, amendment and enforcement of legal frameworks to ensure a healthy environment for children, youth, women and indigenous peoples.

D. Meeting the urban health challenge

Objectives

6.33. The health and well-being of all urban dwellers must be improved so that they can contribute to economic and social development. The global objective is to achieve a 10 to 40 per cent improvement in health indicators by the year 2000. The same rate of improvement should be achieved for environmental, housing and health service indicators. These include the development of quantitative objectives for infant mortality, maternal mortality, percentage of low birth weight newborns and specific indicators (e.g. tuberculosis as an indicator of crowded housing, diarrhoeal diseases as indicators of inadequate water and sanitation, rates of industrial and transportation accidents that indicate possible opportunities for prevention of injury, and social problems such as drug abuse, violence and crime that indicate underlying social disorders).

Activities

6.34. Local authorities, with the appropriate support of national Governments and international organizations should be encouraged to take effective measures to initiate or strengthen the following activities:

·        Develop and implement municipal and local health plans:

·        Establish or strengthen intersectoral committees at both the political and technical level, including active collaboration on linkages with scientific, cultural, religious, medical, business, social and other city institutions, using networking arrangements;

·        Adopt or strengthen municipal or local "enabling strategies" that emphasize "doing with" rather than "doing for" and create supportive environments for health;

·        Ensure that public health education in schools, workplace, mass media etc. is provided or strengthened;

·        Encourage communities to develop personal skills and awareness of primary health care;

·        Promote and strengthen community-based rehabilitation activities for the urban and peri-urban disabled and the elderly;

·        Survey, where necessary, the existing health, social and environmental conditions in cities, including documentation of intra-urban differences;

·        Strengthen environmental health services:

·        Adopt health impact and environmental impact assessment procedures;

·        Provide basic and in-service training for new and existing personnel;

·        Establish and maintain city networks for collaboration and exchange of models of good practice.

Means of implementation

(a) Financing and cost evaluation

6.35. The Conference secretariat has estimated the average total annual cost (1993-2000) of implementing the activities of this programme to be about $222 million, including about $22 million from the international community on grant or concessional terms. These are indicative and order-of-magnitude estimates only and have not been reviewed by Governments. Actual costs and financial terms, including any that are non-concessional, will depend upon, inter alia, the specific strategies and programmes Governments decide upon for implementation.

(b) Scientific and technological means

6.36. Decision-making models should be further developed and more widely used to assess the costs and the health and environment impacts of alternative technologies and strategies. Improvement in urban development and management requires better national and municipal statistics based on practical, standardized indicators. Development of methods is a priority for the measurement of intra-urban and intra-district variations in health status and environmental conditions, and for the application of this information in planning and management.

(c) Human resources development

6.37. Programmes must supply the orientation and basic training of municipal staff required for the healthy city processes. Basic and in-service training of environmental health personnel will also be needed.

(d) Capacity-building

6.38. The programme is aimed towards improved planning and management capabilities in the municipal and local government and its partners in central Government, the private sector and universities. Capacity development should be focused on obtaining sufficient information, improving coordination mechanisms linking all the key actors, and making better use of available instruments and resources for implementation.

E. Reducing health risks from environmental pollution and hazards

Objectives

6.40. The overall objective is to minimize hazards and maintain the environment to a degree that human health and safety is not impaired or endangered and yet encourage development to proceed. Specific programme objectives are:

·        By the year 2000, to incorporate appropriate environmental and health safeguards as part of national development programmes in all countries;

·        By the year 2000, to establish, as appropriate, adequate national infrastructure and programmes for providing environmental injury, hazard surveillance and the basis for abatement in all countries;

·        By the year 2000, to establish, as appropriate, integrated programmes for tackling pollution at the source and at the disposal site, with a focus on abatement actions in all countries;

·        To identify and compile, as appropriate, the necessary statistical information on health effects to support cost/benefit analysis, including environmental health impact assessment for pollution control, prevention and abatement measures.

Activities

6.41. Nationally determined action programmes, with international assistance, support and coordination, where necessary, in this area should include:

·        Urban air pollution:

·        Develop appropriate pollution control technology on the basis of risk assessment and epidemiological research for the introduction of environmentally sound production processes and suitable safe mass transport;

·        Develop air pollution control capacities in large cities, emphasizing enforcement programmes and using monitoring networks, as appropriate;

·        Indoor air pollution:

·        Support research and develop programmes for applying prevention and control methods to reducing indoor air pollution, including the provision of economic incentives for the installation of appropriate technology;

·        Develop and implement health education campaigns, particularly in developing countries, to reduce the health impact of domestic use of biomass and coal;

·        Water pollution:

·        Develop appropriate water pollution control technologies on the basis of health risk assessment;

·        Develop water pollution control capacities in large cities;

·        Pesticides: Develop mechanisms to control the distribution and use of pesticides in order to minimize the risks to human health by transportation, storage, application and residual effects of pesticides used in agriculture and preservation of wood;

·        Solid waste:

·        Develop appropriate solid waste disposal technologies on the basis of health risk assessment;

·        Develop appropriate solid waste disposal capacities in large cities;

·        Human settlements: Develop programmes for improving health conditions in human settlements, in particular within slums and non-tenured settlements, on the basis of health risk assessment;

·        Noise: Develop criteria for maximum permitted safe noise exposure levels and promote noise assessment and control as part of environmental health programmes;

·        Ionizing and non-ionizing radiation: Develop and implement appropriate national legislation, standards and enforcement procedures on the basis of existing international guidelines;

·        Effects of ultraviolet radiation: Undertake, as a matter of urgency, research on the effects on human health of the increasing ultraviolet radiation reaching the earth's surface as a consequence of depletion of the stratospheric ozone layer;

·        On the basis of the outcome of this research, consider taking appropriate remedial measures to mitigate the above-mentioned effects on human beings;

·        Industry and energy production:

·        Establish environmental health impact assessment procedures for the planning and development of new industries and energy facilities;

·        Incorporate appropriate health risk analysis in all national programmes for pollution control and management, with particular emphasis on toxic compounds such as lead;

·        Establish industrial hygiene programmes in all major industries for the surveillance of workers' exposure to health hazards;

·        Promote the introduction of environmentally sound technologies within the industry and energy sectors;

·        Monitoring and assessment: Establish, as appropriate, adequate environmental monitoring capacities for the surveillance of environmental quality and the health status of populations;

·        Injury monitoring and reduction:

·        Support, as appropriate, the development of systems to monitor the incidence and cause of injury to allow well-targeted intervention/prevention strategies;

·        Develop, in accordance with national plans, strategies in all sectors (industry, traffic and others) consistent with the WHO safe cities and safe communities programmes, to reduce the frequency and severity of injury;

·        Emphasize preventive strategies to reduce occupationally derived diseases and diseases caused by environmental and occupational toxins to enhance worker safety;

·        Research promotion and methodology development:

·        Support the development of new methods for the quantitative assessment of health benefits and cost associated with different pollution control strategies;

·        Develop and carry out interdisciplinary research on the combined health effects of exposure to multiple environmental hazards, including epidemiological investigations of long-term exposures to low levels of pollutants and the use of biological markers capable of estimating human exposures, adverse effects and susceptibility to environmental agents.

Means of implementation

(a) Financing and cost evaluation

6.42. The Conference secretariat has estimated the average total annual cost (1993-2000) of implementing the activities of this programme to be about $3 billion, including about $115 million from the international community on grant or concessional terms. These are indicative and order-of-magnitude estimates only and have not been reviewed by Governments. Actual costs and financial terms, including any that are non-concessional, will depend upon, inter alia, the specific strategies and programmes Governments decide upon for implementation.

(b) Scientific and technological means

6.43. Although technology to prevent or abate pollution is readily available for a large number of problems, for programme and policy development countries should undertake research within an intersectoral framework. Such efforts should include collaboration with the business sector. Cost/effect analysis and environmental impact assessment methods should be developed through cooperative international programmes and applied to the setting of priorities and strategies in relation to health and development.

6.44. In the activities listed in paragraph 6.41 (a) to (m) above, developing country efforts should be facilitated by access to and transfer of technology, know-how and information, from the repositories of such knowledge and technologies, in conformity with chapter 34.

(c) Human resource development

6.45. Comprehensive national strategies should be designed to overcome the lack of qualified human resources, which is a major impediment to progress in dealing with environmental health hazards. Training should include environmental and health officials at all levels from managers to inspectors. More emphasis needs to be placed on including the subject of environmental health in the curricula of secondary schools and universities and on educating the public.

(d) Capacity-building

6.46. Each country should develop the knowledge and practical skills to foresee and identify environmental health hazards, and the capacity to reduce the risks. Basic capacity requirements must include knowledge about environmental health problems and awareness on the part of leaders, citizens and specialists; operational mechanisms for intersectoral and intergovernmental cooperation in development planning and management and in combating pollution; arrangements for involving private and community interests in dealing with social issues; delegation of authority and distribution of resources to intermediate and local levels of government to provide front-line capabilities to meet environmental health needs.