Poverty, Health and the Environment Integrating environmental health into poverty reduction strategies 11th PEP Meeting, 18-20 June 2007 Copenhagen, Denmark

EH is important in poverty reduction. Burden of disease falls disproportionately on poor The poor live where environmental conditions are worst Disease contributes to poverty (loss of income). The poor pay more for environmental health services (e.g. water) Other benefits to better EH: lower cost of living, gender equality, etc. Improved EH contributes to several MDGs Polluted environment  Ill health  Productivity  Lost earnings

Water, sanitation & hygiene and air pollution are important EH issues. Attributable mortality & DALY for selected environmental risk factors Source: Adapted from WHO 2002 World Health Report, in Leitner 2005

EH affects the poor of Africa and South Asia the most. Environmental disease burden in DALY per 1000 people (Source: WHO 2006)

Costs associated with poor EH Economic burden associated with poor EH can account for between 2 and 5% of GDP Costs borne disproportionately by the poor Source: World Bank CEAs

EH in poverty reduction goals, targets and strategies (I) Review of MDG Goal 7: Environmental sustainability (UNDP 2006) and Millennium Project Task Force Reports on MDG Targets Overall weak reporting on MDG7; with only 8 out of 158 countries reporting on all global environmental indicators Actual reporting of progress is even weaker: 116 countries have access to sanitation indicator but only 70 countries reported on it. Causal link between environment and poverty not well articulated Slow progress on MDG7

EH in poverty reduction goals, targets and strategies (II) Review of health (WHO 2004) and EH (WB 2006) in PRSPS EH is not systematically addressed Water & sanitation feature more often in PRSPs than any other EH issue; often independent of the health component; with sanitation remains secondary Opportunities for multi-agency collaboration; however need to clarify EH related mandates of different agencies Need for better data and monitoring

Incorporating EH in PRSP PRSP Process EH Input Key actors: Central govt & inter-ministerial Groups Parliaments, etc Private sector NGOs, CSOs The public (national, sub- Regional, household) External partners Understanding nature Of poverty Cross-cutting Themes: 6. Participation & Stakeholder involvement 7. Awareness Raising and Strategic Communication Understanding linkage between EH & poverty Choosing poverty reduction objectives 2. Prioritizing EH objectives Defining strategy, including: - Macro-structural policies - Governance - Sectoral policies - Realistic costing & budgets 3. Institutional assessment Implementation of program And policies 4. Choosing EH interventions 5. Monitoring process and outcome indicators Monitoring outcomes and Evaluating impact Source: Adapted from Klugman 2002 PRSP Sourcebook

EH-Poverty Linkages in PRSPs EH Theme Example of EH-poverty linkages Water resource & sanitation Lack of water supply and sewage system in rural areas leads to increased risk of water-related diseases Indoor air pollution Burning biomass in poor households for cooking and heating leads to increased risk of acute respiratory infections Industrial & municipal waste Leaching from unsanitary landfill sites located in poor areas contaminates water resources & causes health risks Urban Air Pollution Emissions from energy plants and transport are the main cause of air pollution related respiratory diseases Institutional development Inadequate institutional capacity and legal framework underlie the specific EH-poverty issues described above Source: Adapted from Dale 2005

Understanding Poverty Linkages and Prioritizing EH objectives What is the burden of disease from EH factors? What are the underlying environmental problems (poor sanitation and hygiene, indoor air pollution, etc.)? Who are the vulnerable groups (poor, children under five, etc.)? What are the subsequent economic costs and who bears these costs? What are the EH issues that matter most from a poverty reduction standpoint?

Institutional Assessment Assessing institutional capacity & governance on EH issues Cross-sectoral collaboration Vertical collaboration (national/local) Legal and regulatory framework Enforcement Social accountability, particularly with respect to the vulnerable groups Resource allocation/PEER

Selecting EH Interventions Cost-benefit analysis Cost effectiveness studies Poverty and health impact Political will Social acceptability

Multiple inputs and outcomes in EH Some Interventions And examples Outcomes MDG target Behavior Change Health promotion Advocacy Improved health MDG 4, 5, 6 Environmental Health -global -national -local -household Governance Air pollution codes EH legislation Saving time MDG 3 Improved quality of life MDG 2, 3, 4, 5 Service delivery Water supply Refuse disposal Empowering women MDG 3 Increased attendance and better performance at school MDG 2 Infrastructure Water supplies Drainage Improved housing More sustainable livelihoods MDG 7 Finance and social marketing Promotion Credit Subsidy, if suitable Source: DFID 2003

Monitoring progress and outcome indicators Monitoring of exposure, access to services, health improvements Source of data: household surveys National and sub-national level indicators Depends on: data, cost & ease of measurement, acceptance of indicators, etc Social accountability Citizen monitoring of public services, access to information, participation in decision-making, access to justice

Cross cutting themes Participation and stakeholder involvement Awareness-raising and communication strategies Source: Tanzania’s Communication Strategy

Moving towards action: Some Tools Data sources: Census, household surveys (DHS, LSMS), exposure/epidemiological studies Economic Assessment tools: cost-of-degradation studies, cost-benefit analysis, cost-effectiveness Environment & Health Assessment tools: EIA, SEA, HIA, CEA Institutional Assessment tools: CEA, SEA, TAI, PEERs Participatory Tools: PPA, beneficiary assessments Other Tools: poverty mapping (GIS)

Moving towards action: stakeholder participation Paris Declaration: ‘increase the impact of aid in reducing poverty and inequality, increasing growth, building capacity & accelerating achievement of the MDGs’ International Multilateral institutions Bilateral institutions International NGOs International Foundations International Research Institutes National Finance Ministry Health Ministry Environment Ministry Education Ministry Infrastructure Ministries National NGOs Media Civil society organizations Universities Think tanks Local Grassroots organizations Health workers Poor communities Universities and research institutes

Moving toward action: How can PEP help? Broadening the working concept of environment by incorporating the implications of the bio-physical and socio-economic environments on people and their health. Making the case for linking environmental health and poverty reduction by highlighting the economic importance of environmental health to poverty reduction and pro-poor growth. Incorporating environmental health into existing tools, programs, and investments by PEP members to move towards results on this important agenda and consequently a continuous improvement in the quality of life of the poor.

Questions for PEP Members Content: Scope of paper: PRSPs or wider focus? Adequacy of approach/storyline What else can we include, e.g. tools? Finalization Process: Which agencies would like to sign off on it? Tell us by Sept 2007 Level of sign-off (e.g. VP Sustainable Development, WB) Receipt of comments until September 15, 2007 Final draft for agency review and sign-off, November 2007 Publication costs (ADB and others?) Dissemination plan incl. different agency responsibilities – websites, existing forums, etc.