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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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?

11. 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

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

13. 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

14. 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

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

16. 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)

17. 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

18. 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.

19. 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.