157 The environment and health process in Europe Henry Perlstadt and Ivan D. Ivanov As a result of the national studies described in the previous chapter, a survey instrument was designed to collect a broad range of opinions to assess the extent to which the ministerial conferences made a difference in the various countries within the WHO European Region and to provide information to the planners of the Environment and Health Process in Europe. This chapter is based on the international evaluation of the impacts of the ministerial conferences on environment and health and the other international processes. It will first present a summary of the methodology used and then systematically present the results of the data analysis on opinions and views on each of the major conference documents as well as opinions and expectations about the impacts of Fourth Ministerial Conference on Environment and Health, 23 25 June 2004 in Budapest, Hungary. The conclusion will contain a set of patterns and trends that have emerged from the data analysis. Methodology of the international evaluation The survey was organized by the WHO Regional Office for Europe with guidance from the International Steering Committee on Evaluation of Environmental Health Policies and Action Plans (ISC) and administered by Gallup International. The major topics covered in the survey are the general environmental health situation, awareness of rights to healthy environments and cases of violations (European Charter on Environment and Health, Frankfurt, 1989), environmental health planning and implementation (Environment and Health Actions Plans for Europe, Helsinki, 1994), links between transport, environment and health (Charter on Transport, Environment and Health, London, 1999), water and health (Protocol on Water and Health, London, 1999), children s health and the environment (Budapest, 2004), the environment and health information platform (Budapest, 2004) and an overall assessment of the impact of international processes. 157 2_2 environ and health process.pmd 157 01/12/2005, 13:23
158 The research was conducted using a standardized e-mail/internet survey (CAWI: Computer Assisted Web Interviewing) with the specialized web interview software during April to July 2003. The questionnaire was available in English, French, German and Russian. The sampling frame were national stake-holders of the Environment and Health Process in the WHO European Region, for example, senior experts in ministries of health and the environment, environment and health researchers, leaders of civil society organizations dealing with environment and health, experts from local authorities, experts from business and industry, journalists. The respondents were selected using non-probability, snowball sampling through opinion leaders. A list of national focal points at ministries of health and ministries of the environment in all 51 countries was provided by the WHO Regional Office for Europe. At the end of the questionnaire these focal points were requested to recommend other people who should take the survey. Eligible respondents were involved in national or international activities in health and environment and who were over 16 years old, residents of European Region Member States, involved in environmental or health activities at the national or international level and affiliated with one of the following entities dealing with health and/or environmental issues: ministries, directorates general and departments of health; ministries, directorates general and departments or committees for the protection of environment, nature or natural resources; national executive agencies, boards, sanitary and epidemiological stations and inspectorates national executive agencies dealing with the environment; economic sectors dealing with trade and development; scientific institutes and universities; news media; local authorities; and nongovernmental organizations. Usable responses were received from 406 individuals in 44 countries, 51.6% male and 48.4% female. Approximately one-third were 40 years of age or younger, onethird between 41 and 50, and one-third 51 or older. Their educational backgrounds were grouped into six categories: ecological sciences including biology, veterinary medicine and agriculture (27.2%), human medicine (25.1%), health sciences (13.9%), physical sciences including technological sciences and engineering (13.7%), social sciences (8.5%) and other (11.6%). The data was analysed in three ways: by regions, by sector and by organizational type. The regions were defined as follows: 2_2 environ and health process.pmd 158 01/12/2005, 13:23
159 Nordic: Denmark, Finland, Iceland, Norway and Sweden (2.8% of respondents); western Europe: Austria, Belgium, France, Germany, Ireland, Luxembourg, Netherlands, Switzerland and the United Kingdom (28.3%); southern Europe: Andorra, Greece, Israel, Italy, Malta, Monaco, Portugal, San Marino and Spain (14.3%); Baltic: Estonia, Latvia and Lithuania (0.9%); central Europe: the Czech Republic, Hungary, Poland, Slovakia and Slovenia (7.6%); the Balkans: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, The former Yugoslav Republic of Macedonia, Romania, Serbia and Montenegro, and Turkey (14.1%); eastern Europe: Belarus, Republic of Moldova, Russian Federation and Ukraine (23.7%); the Caucasus: Armenia, Azerbaijan and Georgia (2.0%); and central Asia: Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan and Uzbekistan (6.5%). Because of the uneven response rate, the data were first weighted by population and then adjusted for the number of respondents to increase the validity of the statistical analysis. Respondents indicated which organization they mainly represented, in order to group them in two ways. The first was into three sectors of health, environment and civil society. The health sector included respondents from a ministry of health, a public health agency, or an academic/health research institute; the environmental sector included respondents from a ministry of the environment, an environmental protection agency or an academic/environmental research institute; and the civil sector included local authorities, news media, NGOs, business and industry, and others. The health sector accounted for 37.0% of the respondents, the environmental sector 22.0% and the civil society sector 41.0%. The second group of categories were organizational types: ministries, agencies, academic/ research, local authorities, NGOs and others. Ministries accounted for 24.6% of the respondents, agencies 15.7%, academic/research 18.7%, local authorities 7.6%, NGOs 23.5% and other 9.9%. The data analysis used the Statistical Package for the Social Sciences (SPSS). Frequencies and cross tabulations were run and significance estimated using Chi- Square Tests and symmetric measures Phi, Cramer s V and Contingency Coefficient. Surprisingly, many of the results were significant at the.05 level or 2_2 environ and health process.pmd 159 01/12/2005, 13:23
160 better, and those are presented in the next section. Non significant results are generally omitted. Given the non-probability sample that was used in this survey, its results cannot be generalized to all representatives of key stake-holders. The data obtained represent the opinions of the respondents in the sample. The impact of the ministerial conferences on environment and health in Europe Overall Environmental Health Problems and Quality of Environment First, the respondents were asked whether public discussion about the environment and health has increased or decreased during the last five years and then whether the environmental health situation has actually improved or worsened. This group of questions measured the perceived change in the situation since the London Conference (see Fig. 2.1). Figure 2.1. Changes in public debate and actual environmental situation in the last 5 years 100% 80% 64% 60% 46% Public discussion 40% 28% 23% Environmental health situation 20% 23% 12% 0% Positive change No Change Negative Change Approximately two-thirds (66.3%) of all respondents reported more discussion over the past five years about health problems caused by the environment. The most saying so (82%) were respondents from central Asia and southern Europe, while the lowest percentages saying so were in the Nordic countries and western Europe (55%). The environmental sector was more likely to report an increase in discussion (77.8%) than the health sector (70.1%) and civil society (55.8%). Respondents from ministries and government agencies were most likely to report an increase in discussion (78%) while NGOs were less likely (58.9%). In terms of changes in the quality of the environment, about 40% of all respondents said it had improved over the past five years. This ranged from a high of 74.2% in central Europe to less than 20% in central Asia, eastern Europe and the Caucasus. 2_2 environ and health process.pmd 160 01/12/2005, 13:23
161 The health sector reported the most improvement in environmental quality (52.4%) followed by the environmental sector (40.7%) and then civil society (28.8%). Ministries were most likely to have seen change (55.2%) and NGOs least likely (15.8%) These results suggest that the people are getting more and more concerned about the problems of health and the environment, while the actual situation is not getting worse. European Charter on Environment and Health, Frankfurt, 1989 Ministers of health and environment got together for the first time in Frankfurt in December 1989, immediately after the destruction of the Berlin Wall. The result of the Frankfurt Conference was the European Charter on Environment and Health, which set the basis for international collaboration., setting the entitlements and responsibilities of public and private actors, the principles for public policy, the strategic elements of strategies to protect health and the environment, the priorities for pan-european action, as well as the way forward for the Member States and WHO. lth Entitlements and Responsibilities In particular, the Charter emphasized that every individual is entitled to an environment conductive to the highest attainable level of health and well-being. Therefore, the respondents in this survey were asked whether people in their countries were aware that they had the right to live in a healthy environment and if they were aware of violations of this right. Overall about 70% of respondents thought that a fair amount or a lot of people in their country were aware they had the right to live in a healthy environment. This ranged from a high of 100% in the Nordic and Baltic countries to a low of 56.2% in eastern Europe. The health sector reported the highest (82.2%), with the environmental sector next (70.1%) and civil society lowest (60.0%). Government agencies were most likely claim people were aware of this right (86.9%). Nearly 70% of the respondents were aware of cases in their country where the right to healthy environment had been violated. This ranged from highs of 87.5% in the Caucasus and 83.3% in eastern Europe to lows of 54.5% in the Nordic countries and 53.3% in central Europe. Civil society respondents were higher than either the health or environmental sectors, which had no difference between them. The civil society sector was lead by the NGOs with 85.4% indicating they were aware of such cases. The civil society sector was also most likely to report an increase in the frequency of such cases over the past five years, while ministries and government agencies were least likely to report an increase. 2_2 environ and health process.pmd 161
162 The data indicate that while a considerable majority of Europeans were aware that they have the right to a healthy environment, this right is still too often violated, particularly in the eastern parts of the region. Prevention is better than cure The European Charter on Environment and Health also stipulated that the preferred approach in public policy should be to promote the principle of prevention. The level of implementation of this approach in the Member States was measured through a set of questions asking respondents whether prevention was given priority over cure in the areas of health and the environment. A little more than half (56.9%) of all respondents knew of cases when disease prevention was given greater priority than treatment. About 70% of respondents from southern Europe were aware of such cases while at the lower end, about 42% of western European respondents and 46% of Nordic respondents knew of such cases. The environmental sector was most likely to be aware of such cases (68.9%), followed by the health sector and then civil society. Respondents from ministries were highest in being aware of such cases (77.0%). In terms of change over past five years, at least 75% of respondents from the Baltic countries, central Europe and the Balkans reported an increase of cases where disease prevention received priority over treatment while only 35% of respondent from western Europe reported increases. Local authorities were highest in reporting increases of such cases (78.6%) while NGOs were least likely to report them (22.5%). A little more than half (58.1%) were aware of cases when prevention of environmental pollution was given greater priority than clean up. The health sector (70.0%) was most likely to be aware of such cases, followed by the environmental sector and then civil society (46.4%). Local authorities were most likely (80.6%) and NGOs least likely (36.8%) to be aware of such cases. In terms of change over last five years, about 70% of the environmental sector reported an increase, compared to both the health and civil society sectors at about 57%. NGOs and academics were least likely (45%) to report such increases. These figures suggest that realization of prevention is better than cure has not yet been fully achieved, in particular in western Europe. Health and the environment should take precedence over economy and trade The Charter also called for giving health and the environment precedence over economic and trade considerations. About 20% of respondents from civil society, NGOs and southern Europe were aware of cases where health considerations took priority over the economy and trade in development decision-making, compared 2_2 environ and health process.pmd 162
163 to about 33% of all respondents. Nordic country respondents were most likely (54.5%) to be aware of cases where health took priority over economics and trade. In terms of change over the last five years, about 40% of all respondents reported an increase. Ministries were most likely (57.9%) to report an increase, while civil society (20.6%) and NGOs (5.6%) were least likely. The principle of giving precedence to health and the environment over the economy and trade has not yet been fully implemented in the majority of the Member States. However, the results of this survey show that there are positive trends, particularly in the Nordic Countries. Vulnerable and disadvantaged groups The Charter emphasized that one of the principles of public policy should be to pay particular attention to the protection of the health and environment of biologically vulnerable and socially disadvantaged groups. The survey asked whether certain groups, such as children, women of childbearing age, people working in hazardous condition, minorities and the disabled, elderly and poor had more or less environmental protection compared to the average. Overall, 35.9% of the respondents indicated they thought children were less protected than average. This ranged from highs of about 63% in eastern Europe and central Asia to lows of less than 5% in the Baltic countries and central Europe. A higher proportion of respondents from civil society (48.8%) claimed children were less protected than average compared to 32.2% from the environmental sector and 25.0% from the health sector. Among organizations and agencies, NGOs were most likely to say children were less protected (57.3%) with about 18% of respondents from ministries or government agencies saying so. About 33% of all respondents indicated that women of child-bearing age were less protected than average. This ranged from a high of 66.3% in eastern Europe to less than 5% for the Nordic countries, the Baltic countries and central Europe. The civil sector was higher (42.9%) than the environmental sector (29.5%) followed by the health sector (23.3%). NGOs were most likely to state women of child-bearing age were less protected (54.7%), compared to about 15% of respondents from ministries and government agencies. About 40% of all respondents indicated that people with disabilities were less protected than average. The Caucasus region was highest (75.0%) and the Nordic countries lowest (9.1%) followed by central Europe (13.8%). NGOs and academics were most likely (56%) to report people with disabilities less protected. Forty-three per cent thought that workers in hazardous conditions were less protected than average. This was highest in the Caucasus (85.7%) and lowest in 2_2 environ and health process.pmd 163
164 central Europe and the Nordic countries (17%). NGOs were most likely to say such workers were less protected (59.8%) and local authorities lowest (16.7%). Overall, about 45% stated that the elderly were less protected on environmental health. This ranged from a high of 83.3% in central Asia to lows of about 17% in central Europe and the Nordic countries. Civil society was most likely to say elderly less protected (51.6%) followed by the environmental sector (43.8%) and the health sector (37.5%). NGOs were highest at 68.1%. Almost half (47.6%) of respondents indicated that ethnic and racial minorities were less protected. This measure of environmental justice ranged from a high of 78.9% in central Asia to less than 30% in the Baltic countries, the Balkans, and the Nordic countries. NGOs were most likely to report environmental injustice (63.6%) and government agencies least likely (30.5%). Seventy-six per cent of all respondents said that people in poverty were less protected than average on environmental protection. Highest regions were eastern Europe (92.4%), central Asia (90.9%) and Caucasus (87.5%), while respondents from Nordic countries (50.0%) and central Europe (56.7%) were lowest. NGOs were most likely to report environmental injustice (91.6%) with local authorities the least likely (54.8%). These figures indicate that although there has been some progress in providing protection to children and women of childbearing potential, the goal of equal protection is far from being achieved with regards to hazardous working conditions, the elderly, ethnic and racial minorities, and especially the poor. Environment and Health Action Plan for Europe, Helsinki 1994 At the Second Ministerial Conference on Environment and Health in Helsinki in 1994, ministers approved the Environment and Health Action Plan for Europe and committed their governments to developing national environmental health action plans (NEHAPs). Although the pilot evaluation focused more on NEHAPs impact in the countries, this survey also asked several questions measuring the extent to which the NEHAPs made a difference at the level of the Member States. Two-thirds (66.0%) of respondents said their country had a national action plan on environmental health. The awareness of NEHAPs was highest in the Baltic countries, the Caucasus, the Nordic countries, the Balkans and central Europe, where over 80% of respondents knew of such national action plans. But only a third (31%) of respondents from southern Europe knew of them. Respondents from the health sector were more likely to answer yes (74.7%) than respondents 2_2 environ and health process.pmd 164
165 from the environmental sector (65.6%), who were more likely to do so than respondents from the civil sector (40.0%). But only about half (52.5%) of all respondents reported that such a plan was making a fair or lot of difference to the environmental and health situation in their country. Over 80% of respondents from central Europe, the Nordic countries and the Balkans said the plans made a difference compared to a third or less than 40% in central Asia, the Caucasus, western Europe and eastern Europe. Health was more likely (67.0%) than environment and civil sectors (46.4% and 40.0%). Of all groups, Local authorities were most likely to say the plans made a difference (86.7%) with NGOs the lowest (22.4%). In terms of such a plan making a difference in the development of institutions dealing with environment and health, a little more than half (55.8%) of all respondents said it did. This ranged from nearly 90% of respondents from southern Europe to about 30% from eastern Europe and central Asia. Local authorities were highest of all groups (73.3%) and NGOs the lowest (35.6%). Fig. 2.2 shows the effects of NEHAPs. Figure 2.2. Effects of NEHAPs To what extent did NEHAP make a difference? Enviornmental health situation 42% 14% Institutional building 37% 17% a fair amount a lot Collaboration between health and enviornment 49% 21% 0% 20% 40% 60% 80% 100% Overall, two-thirds (68.1%) of respondents reported that NEHAPs have made a difference in terms of collaboration between the environmental and health sectors. Over 90% of respondents from the Nordic and Baltic countries and central Europe saw such a difference, compared to about 60% from eastern Europe and the Caucasus. The environmental sector was a little more likely (78.6%) than health (72.4%), which in turn was more likely than civil society (56.0%) to report that such a plan makes a difference in terms of collaboration between the 2_2 environ and health process.pmd 165
166 environment and health sectors. Nearly 90% of ministry-level respondents saw such a difference compared to only 46.3% of the respondents from NGOs. These results reconfirm the findings from the pilot evaluation that NEHAPs had a moderate impact in the countries, mainly in improving inter-sectoral collaboration. It is interesting to note that local authorities were those most likely to perceive the impact of NEHAPs on the actual situation, while for the central governments the NEHAPs were mostly tools for improving inter-sectoral collaboration. The pilot evaluation demonstrated that the NEHAPs were mainly governmental initiatives with little input from civil society. Therefore, it is not surprising that the results of this survey show that for the NGOs they did not make any difference. Charter on Transport Environment and Health, London, 1999 The Charter on Transport, Environment and Health, approved at the Third Ministerial Conference on Environment and Health in London in 1999 had the goal of addressing the pressing transport-related problems of health and the environment. In particular, the charter called for taking health and environmental requirements into consideration in transport policies as well as to improving collaboration among the health, environmental and transport sectors. Approximately half of all respondents said health requirements were taken into consideration in transport policy-making. This ranged from above 75% for the Nordic countries, the Balkans and the Baltics to less than 15% for central Asia. About two-thirds of respondents from ministries and local authorities said health requirements were taken into consideration, compared to only one-third of NGO respondents. Fig 2.3 shows the perceived changes in transport, environment and health. Twothirds of all respondents reported that environmental requirements were taken into account in transport policy-making. This was highest in the Baltic and Nordic countries (over 90%) and lowest in central Asia (21.1%). About 70% of the health and environmental sector respondents saw this, compared to 54.7% from the civil society sector. Over 80% of those from ministries and local authorities said environmental considerations were taken into account, but only 38.8% of NGO respondents agreed. About 70% of the respondents indicated that the impact of transport on health and on the environment increased over the last five years. Central Asia and eastern Europe were highest on reporting an increase and the Nordic countries, Balkans and Caucasus the lowest. Only a quarter of all respondents thought that collaboration had improved between transport and the environment or health. Respondents from ministries and local authorities reported the highest improvement, and NGOs the lowest. 2_2 environ and health process.pmd 166
167 In sum, while environmental issues are being relatively well-incorporated into transport policy, the potential of addressing health problems has not been yet fully achieved. The collaboration between health and environment ministries and the transport sector is not as developed as it could be. 100% Figure 2.3. Changes in transport, environment and health How has the impact of transport changed over the last 5 years? 80% 67% 60% 58% Increased 40% 31% 24% Stayed the same Decreased 20% 5% 6% 0% Impact on health Impact on the environment Protocol on Water and Health, London, 1999 The Protocol on Water and Health was the first legally binding document approved under the Environment and Health Process in Europe. Generally, it aims at improving the drinking water supply and safety and sanitation in the European Region. Fig. 2.4 shows the perceived changes in water and sanitation in the countries. From 35% to 40% of all respondents saw an improvement in the supply of drinking water to individual households, the safety of drinking water or household sanitation. The greatest improvements (generally over 60%) in all three were reported from southern Europe, central Europe and the Baltic countries. The least improvement (20% or less) was seen in eastern Europe and the Caucasus. More in the environmental sector (47.1%) thought drinking water had improved compared to the health sector (38.9%), while more in the latter (49.7%) thought that the safety of drinking water had improved than in the former (35.6%). No difference was found between the two sectors for improved sanitation, but civil society was consistently the lowest (30% or less) on water supply, water safety and sanitation. Respondents from ministries and local authorities were more likely to see improvements in all three (between 50% and 58%) while less than 20% of NGO respondents saw such improvements. 2_2 environ and health process.pmd 167
168 Figure 2.4. Changes in water and sanitation How has the situation changed in your country over the last 5 years? 100% 80% 60% 40% 40% 49% 39% 47% 44% 44% Improved Stayed the same Worsened 20% 8% 12% 7% 0% Drinking water supply Drinking water safety Sanitation Children s Environment and Health Action Plan for Europe, Budapest, 2004 The potential impacts of the Children s Environment and Health Action Plan for Europe (CEHAPE), which was approved by the Fourth Ministerial Conference on Environment and Health in Budapest in 2004, were estimated from the responses to a set of questions measuring general attitudes toward a new approach in environmental health focusing on children s health and the expectations of the respondents about the effects of the plan itself. Support for a children s approach in environmental health Overall, 69.4% of the respondents strongly agreed that environmental health hazards affect children s health differently than they do adults health. This was highest in southern Europe, central Asia and eastern Europe (80% or better) and lowest among the Nordic country respondents. The health sector felt more strongly about this (73.6%) than did civil society, (68.3%) followed by the environmental sector (63.6%). Respondents from agencies were least likely to say that environmental hazards affect children differently (53.1%). A little over one-third (36.2%) strongly disagreed with the statement that children are like little adults. This disagreement was most evident in southern Europe, central Europe and eastern Europe and lowest in the Caucasus (11%). The health sector was more likely to strongly disagree (47.2%), compared to the environmental and civil sectors, at about 30%. The NGOs were lowest in disagreeing, at 21.9%. 2_2 environ and health process.pmd 168
169 That children s health is a sensitive marker of the quality of the environment was strongly agreed to by 56.7% of the respondents. Over 80% of respondents from the Caucasus, central Asia and eastern Europe strongly agreed, while only 20% of respondents from Nordic countries agreed. NGOs and academics were most likely to strongly agree, while agencies were lowest (39.7%). On the other hand, only 22.6% strongly agreed that environmental health standards do not take the sensitivity of children into account. This was highest in eastern Europe (43.0%) and among NGOs (44.0%). ame About 40% of all respondents strongly agreed that children s health is a political argument to promote general environmental concerns and 56.1% strongly agreed that environmental health measures should protect everyone, not just children. No significant differences were found between regions, sectors or organizational types. Only one-quarter of all respondents strongly disagreed that meeting general standards for environmental protection is enough to protect children. About one-third of respondents from western Europe strongly disagreed, as did one-third of civil society. Local authorities and NGOs were most likely to strongly disagree (40%). Overall, strong support exists across the sectors and regions for a new approach to the environment and health, focusing on children. Such an approach would recognize the specific needs of children and emphasize the biological, social and political significance of environmental health effects on children and future generations. This wide support for a children s environment and health approach translated into consensus among the respondents on the expected usefulness of the CEHAPE. Almost everyone agreed that such a plan would be useful for their country. Overall, 94.2% said a fair amount or a lot of usefulness, with the lowest regions reporting 87.5% and 88.3%. Who should be the target of CEHAPE? Respondents were also asked which groups should be the future targets of a European Action Plan on Children s Health and the Environment. Children today were identified as the primary targets by 76.4% of the respondents with the only variation by region: 92.7% of eastern European respondents specified children today, at the high end, compared to 53.3% of central European and 63.6% of Nordic country respondents at the lower end. Future generations were mentioned by 71.2% of all respondents, with no significant variations by region, sector or organizational type. Overall, 58.9% of respondents would target everybody, highest in central Asia (92.3%). About 70% of local authority and NGO respondents thought everyone should be a potential target, and 68.9% of civil society and 61.1% in the environmental sector, which in turn was higher than the health sector s 46.0%. Finally, targeting parents was mentioned by 45% of the respondents, highest in eastern Europe and central Asia (58%) and lowest in central Europe, the 2_2 environ and health process.pmd 169
170 Balkans and Nordic countries (26%). No significant variations were found by sector or organizational type. Although there are some regional differences about the main target of the CEHAPE, there is clear consensus that children today should be the primary targets for the plan, with strong agreement about future generations. Possible impact of CEHAPE on different social groups Respondents were asked if they thought that the European Action Plan on Children s Health and the Environment would result in certain groups focusing on protecting children from environmental risks. A little over half of all respondents thought that politicians would change their focus (53.6%) or that government departments would change theirs (57.8%). About 70% of respondents from ministries thought that the focus of politicians and government departments would change. About two-thirds (66%) of health sector respondents thought politicians and government departments would change, compared to about 55% of the environmental sector and 50% of the civil sector. The Caucasus and central Asia were highest on thinking government departments would change their focus (over 70%). About threequarters (75%) of all respondents thought that health or environmental experts would change their focus, least in the Nordic countries (55.4%). Only a third (31%) thought that business and industry, the media or nongovernmental organizations would change their focus, with no regional distinctions. The civil sector was least likely to expect a change from business and industry (17.0%) or the media (23.9%). The health sector was least likely to expect a change from nongovernmental organizations (24.4%). Local authority respondents were least likely to expect business or industry to change (10.0%), but were very much more likely to expect the media to change its focus (83.3%). About 60% of all respondents thought children and youth would change their focus, highest in Central Asia (83.3%), and lowest in western Europe and the Nordic countries (49%). Again, local authorities held high expectations (75.0%) that children and youth would change their focus. Three quarters of all respondents thought that women s groups would change their focus, with eastern Europe highest (94.7%) and southern Europe lowest (59.6%). NGOs were the highest of the organizational groups (87.4%). In sum, the CEHAPE is expected to have highest impact on health and environment experts and women s groups, but would have little impact in the business and political circles. Usefulness and implementation Agreement was extremely high (92.3%) across sectors and organizational types concerning the extent to which a European Action Plan on Children s Health and Environment would be useful to improving the level of general environmental and 2_2 environ and health process.pmd 170
171 health protection. But differences emerged on how to best implement such an international action plan. Not surprisingly, the ministries were highest (67.0%) in favouring existing governmental action plans and strategies, while NGOs were most in favour (83.2%) of implementation through nongovernmental mechanisms, political initiatives, partnerships and networks. Civil society favoured (75.3%) nongovernmental mechanisms more than the health and environmental sectors which did not differ (57%), and civil society also favoured (68.1%) using local processes which in turn were more favoured by the health sector (57.3%) than the environmental sector (51.1%). The health sector (67.5%) favoured implementation through existing governmental action plans and strategies more than the environmental sector, which did not differ from civil society (45%). Environment and Health Information, Budapest, 2004 The Budapest Conference also approved a set of indicators to measure environmental health along with a harmonized approach for environmental health information. When asked about the usefulness of different types of information about health and the environment, approximately 75% of all respondents thought that data on human exposure to environmental hazards and data on diseases caused by environmental hazards were being used a fair amount or a lot in political decision-making about the environment and health. Use of data on human exposure was reported in the Baltics, western Europe and the Nordic countries (90% or higher) but was lowest in central Asia (42.3%). The health sector reported such data being used more (84.6%) than did the environmental sector (75.6%) or civil sector (69.9%). Respondents from ministries, government agencies and local authorities were more likely (87% or higher) to say data on human exposure was being used than academics (64.4%) or NGOs (60.9%). Three-quarters (74.2%) of all respondents thought that data on diseases caused by environmental hazards was being used in political decision-making. People in the Nordic countries and the Balkans were most likely (over 87%) to say this, while central Asians (37.5%) were least likely. The health sector was more likely (89.4%) to agree than the environmental sector (75.0%), with the civil sector least likely to do so (60.8%). Almost all respondents from local authorities, ministries and agencies were likely to report such data use (over 85%) while NGOs were least likely (40.4%). About 75% of all respondents thought that public opinion played a role in political decision-making on environmental health. This was highest in the Nordic countries and western Europe (89%) and lowest in central Asia. The three sectors did not vary on this. Almost all local authorities (93.3%) thought that public opinion was used in such decision-making while only two-thirds (66%) of the academics and NGOs thought so. 2_2 environ and health process.pmd 171
172 Approximately 80% of all respondents reported that international environmental conventions and regulations were used a fair amount or a lot in political-decisionmaking about environmental health. This was highest in the Baltics, Balkans and Nordic countries (over 90%) and lowest in southern Europe (66%). The health sector was more likely (90.7%) to say that international conventions and regulations were used compared to the environmental sector (83.9%) and civil sector (69.7%). Almost all respondents from ministries (93.9%) and agencies (88.1%) thought such conventions and regulations were used while only two-thirds (66%) of NGOs did. More specifically, about 75% of all respondents stated that decisions of the European ministerial conferences on environment and health were being used in political decision-making. This was highest in the Baltics, Balkans, central Europe and the Nordic countries (over 90%) and lowest in central Asia (50.0%). Approximately 80% of both the health and environmental sectors thought the ministerial conferences were used compared to the civil sector s 68.7%. Respondents from ministries and agencies were more likely (86%) to report such use with NGOs the least likely (62.2%). Almost all respondents (over 90%) thought that indicators measuring environmental health risks and outcomes would be very or somewhat useful and that such indicators would enable governments to deal better with environmental health issues a fair amount or a lot. Very little variation was found by region, sector or type of organization. Overall evaluation of the impact of international processes The last items asked about an overall evaluation of the international processes and relationships between the environmental and health sectors. A little less than 60% of all respondents said that the collaboration between the two sectors had improved over the last ten years. No differences were found by region or sector, but respondents from ministries (76.8%) and local authorities (71.0%) were most likely to report improvement, while academics and NGOs were least likely (49%). About 80% of all respondents said that international processes had a fair amount or a lot of influence on the collaboration between the environmental and health sectors. High regions were the Baltics, central Asia, the Balkans and central Europe (all 90% or greater) and the low regions were western Europe and southern Europe (74%). The health and environmental sectors both were more likely to see the influence of international processes (85%) compared to the civil sector (73.0%). Respondents from central governments were most likely to report the influence of international processes (89.7%) followed by academics (85.5%). 2_2 environ and health process.pmd 172
173 The use of human health as a justification for environmental action increased according to 57.5% of all respondents. This did not differ by region or sector. Local authorities were more likely to state this (76.7%) while academics (45.3%) and NGOs (40.2%) were least likely. But almost 80% of all respondents said that international processes influenced the use of health as a justification a fair amount or a lot. Almost all respondents (90% or more) from the Baltic countries, central Asia, the Balkans, and central Europe thought international processes influenced the use of health as a justification while eastern Europe was the lowest at 63.3%. This international influence was reported by more respondents from the health sector (86.7%) and the environmental sector (81.6%) than the civil sector (68.2%). Ministries and agencies were highest (88%) and NGOs the lowest (63.3%). Approximately 60% of all respondents thought that consideration of environmental factors in health protection programmes had increased over the last ten years. This was highest in central Europe (79.3%) and lowest in central Asia and eastern Europe (46%). The health sector was more likely (74.1%) to report such considerations had increased than the environmental sector (63.1%), which was in turn more likely than the civil sector (46.2%). Ministries, agencies and local authorities were more likely (over 70%) to say such considerations had increased, while NGOs were least likely (41.9%). On the other hand about 80% of all respondents answered that international processes had a fair amount or a lot of influence on the change involving the use of environmental factors in health protection. This was very high (over 90%) in the Baltic countries, the Balkans, central Europe and central Asia. Western Europe was least likely (64.2%) to attribute such change to international processes. The health sector was more likely (86.4%) to agree than the environmental sector (80.8%) which was more likely to do so than the civil sector (73.4%). Ministries, agencies and local authorities were more likely (88%) to say such considerations had increased. Summary of findings The findings can be summarized by the amount of consensus expressed. There was clear support for the major outcomes of the Budapest Conference. Nearly everyone (over 90%) indicated that: CEHAPE would be useful to improve the level of general environmental protection and general health protection in their country. A common set of indicators measuring environmental health risks and outcomes would be very or somewhat useful. Such a set of indicators would enable governments to deal better with environmental health issues. 2_2 environ and health process.pmd 173
174 At least three-quarters (75%) of all respondents indicated that: People in poverty had less than average environmental health protection. Children today should be the target of the European Action Plan on Children s Health and the Environment. Environmental experts will increase their focus on protecting children as a result of European Action Plan on Children s Health and the Environment. Women s groups will increase their focus on protecting children as a result of European Action Plan on Children s Health and the Environment. Data on human exposure to environmental hazards is being used in political decision-making about environmental health a fair amount or a lot. Data on diseases caused by environmental hazards is being used in political decision-making about environmental health a fair amount or a lot. Public opinion is being used in political decision-making about environmental health a fair amount or a lot. International environmental conventions and regulations are being used in political decision-making about environmental health a fair amount or a lot. Decisions of the ministerial conferences on environment and health are being used in political decision-making about environmental health a fair amount or a lot. International processes on the environment and health have influenced the collaboration between the environmental and health sectors a fair amount or a lot. International processes on the environment and health have influenced the use of health as a justification for environmental action a fair amount or a lot. International processes on the environment and health have influenced the change in consideration of environmental factors in health protection programmes over the last ten years a fair amount or a lot. About two-thirds (at least 64%) of all respondents indicated that: More discussion of health problems caused by environment has occurred over the past five years. People are aware that they have the right to live in a healthy environment a fair amount or a lot. They are aware of cases when the rights of individuals to a healthy environment have been violated. They know that their country has a national action plan on environmental health. 2_2 environ and health process.pmd 174
175 NEHAPs make a difference in collaboration between the environment and health sectors. Environmental requirements are taken into consideration in decisionmaking on transport policies a fair amount or a lot. The impact of transport on health has increased over the past five years The impact of transport on the environment has increased over the past five years. Environmental hazards affect children s health in ways different from adults. Future generations (for example, 25 years from now) should be the target of the European Action Plan on Children s Health and the Environment. Health experts will increase their focus on protecting children as a result of European Action Plan on Children s Health and the Environment It is best to implement international action plans on children s health and the environment through nongovernmental mechanisms such as political initiatives, partnerships and networks. Patterns The major differences between regions often have the Nordic and Baltic countries sometimes joined by the Balkans at one end with the Caucasus and central Asia sometimes joined by eastern Europe at the other. Occasionally either central Europe or southern Europe appear at an extreme. Civil society was significantly different from the health and the environment sector on 39 of the 76 items, that is, 51.3%. It was the lowest on 28 items and highest on 11. The health sector was higher than the environmental sector on 22 items while the environmental sector was higher than health on 12 items. Nongovernmental organizations were significantly different from the other organizational types on 29 items and were different along with academic/research on another 5. The NGOs were lowest on 19 items and with academic/research on 3. NGOs were highest on 10 and with academic/ research on another 2. Ministries were significantly different on 12 items, 11 times higher and once lower. Finally local authorities were significantly higher than other organizational types six times. Conclusion In conclusion, the assessment of the Environment and Health Process in Europe confirmed that the ministerial conferences on environment and health have had a 2_2 environ and health process.pmd 175
176 positive influence on policies and processes at national level. The process itself was successful in fostering collaboration between the environment and health sectors, as well as in promoting health as a justification for environmental action, and the study of environmental risk factors as part of health protection programmes. This has resulted in an increased awareness of the health problems caused by environmental risk factors. The ministerial conferences have also been useful in presenting policy guidelines and knowledge on issues, as well as in facilitating networking and the exchange of information. The London Conference, in particular, led to greater collaboration and joint action between the environment, health and transport sectors. However, it was recognized that in general the process was more effective in addressing environmental than health aspects, and that it did not sufficiently involve the other economic sectors in joint action on environment and health. 2_2 environ and health process.pmd 176
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