EDITORIALS

Working across sectors for public health

Roberto Bertollini^I,1; Vivienne Taylor Gee^II

^IDirector, Division of Technical Support, Health Determinants, World Health Organization Regional Office for Europe, 8 Scherfigsvej, 2100 Copenhagen Ø, Denmark (email: ber@who.dk)
^IICommunications Officer, Health Determinants, World Health Organization Regional Office for Europe, Copenhagen, Denmark

Hippocrates wrote about the relationship between environmental conditions and health status in Airs, waters and places in about 460 BC, where he identified environmental factors affecting human health that "doctors must know to pursue their calling". Working across different sectors in public health is therefore not a new idea. The routes through which people are exposed to environmental hazards such as traffic-related air pollution or lead, for example, cut through many sectors, all of which need to be involved if change is to be achieved.

The benefits of cross-disciplinary dialogue were recognized in the Alma-Ata Declaration in 1978 (1). Nevertheless, health professionals are still more comfortable looking at patients than at the broader determinants of their health. Identifying environmental causes of diseases and implementing the measures needed to remove them is not easy, especially at local level where sectors are involved over which health policy-makers have little or no control. Such work may expose them to unfamiliar territories, budgets, vocabularies and political priorities, as well as dialogue with industry, nongovernmental organizations, planning authorities and legislators.

To facilitate this cross-sectoral cooperation, fundamental in environment and health, the WHO European Region has brought health ministers together with their counterparts in environment in quinquennial ministerial conferences, starting in 1989. The aim is to make public health a key objective for other sectors, with health impact assessment as a routine management tool. The ethical and political value of human health as a driving force persuades other sectors to give it consideration, particularly because environmental hazards do not affect everyone in the same way: people living in poverty are more exposed (2, 3). In addition, the economic argument is persuasive: at a time when the health sector is under political pressure to deliver services, it is financially attractive to reduce the demand on health services by removing some of the determinants of ill-health, so the gains may be considerable.

What progress has been made? The ministers have produced strong measures such as the legally binding Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. They have also produced declarations and charters, such as the Charter on Transport, Environment and Health, which may appear to be "soft" outcomes but can have far-reaching impact. In 1994, ministers committed their governments to developing national environment and health action plans; on the basis of a non-binding commitment in a declaration, 44 out of 51 countries did so. The conferences and the development of the action plans were evaluated in 2003 (4) and it was found that preparing the plans had indeed brought health considerations into previously closed sectors.

The success story of the action plans flows from a sense of participation and cross-sectoral discussion that resulted in ownership by the main stakeholders, with the health sector participating in many new arenas both nationally and on the local level, such as committees or initiatives on consumer protection, environment, tourism, transport and agriculture. In a survey carried out as part of the evaluation, two-thirds of respondents reported that the plans had made a difference in terms of collaboration between the environment and health sectors. Nearly 90% of ministry-level respondents had experienced a positive difference.

Working in new partnerships provides gains in terms of transparency and exchange of methodology, lessons learnt from other sectors, and understanding each other's ways of working. THE PEP (Transport, Health and Environment: the Pan-European Programme) has involved collaborating with the United Nations Economic Commission for Europe (UN/ECE) across sectors on key priorities such as the integration of environmental and health aspects into policies and decisions on transport; the shift of the demand for transport towards more sustainable mobility; and urban transport issues. This intersectoral working provides opportunities to represent health facts and figures in non-health policies; it stimulates health as a driver of policy-making processes and puts health into the calculations of economic policy; and it can result in cooperative planning and joint monitoring and evaluation. For states in socioeconomic transition, such working presents a special challenge. In the newly independent states of the former Soviet Union, for example, the duties of different ministries are often not well defined, the systems inherited from Soviet times are largely vertical and hierarchical, and budgets are constrained. Working across sectors can help because it reduces duplication and brings partners together to solve problems more effectively.

At the Fourth Ministerial Conference on Environment and Health which takes place in June 2004 in Budapest (5), the Children's Environment and Health Action Plan for Europe will be adopted. It focuses on protecting children's health from environmental hazards, informed by a precautionary and multisectoral approach. Countries will commit to four regional priority goals on air pollution, chemicals, water and sanitation and injuries. They will also undertake to produce their own national plan for children's environment and health by 2007, backed up by a suggested framework of action. This has been extensively negotiated with both the environment and the health ministries of all Member States in the region: they have jointly set the agenda and they will use the plan to push the policies that will follow at country level, whether on land use, transport, food regulation, water management or legislation. Whatever the sector, they will all be policies for health.

References

1. Declaration of Alma-Ata, 1978. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978. Geneva: World Health Organization; 1978. Health-for-All Series, No. 1, available from: http://www.euro.who.int/AboutWHO/Policy/20010827_1

2. Poverty and health: evidence and action in WHO's European Region. Copenhagen: World Health Organization Regional Office for Europe; 2002. Regional Committee for Europe Fifty-first session, Madrid, 10–13 September 2001, document EUR/RC51/8, available from: http://www.euro.who.int/Document/RC51/edoc8.pdf

3. Ziglio E, Barbosa R, Charpak Y, Turner S, editors. Health systems confront poverty. Copenhagen: World Health Organization Regional Office for Europe; 2003. Public Health Case Studies, No. 1, available from: http://www.euro.who.int/SocioEconomicDeterminants

4. See http://www.euro.who.int/document/eehc/3rddigoprepmeet_bd04.pdf

5. See www.euro.who.int/budapest2004

1 Correspondence should be sent to this author.