John M. Balbus, senior advisor for public health at the National Institute of Environmental Health Sciences and co-chair of the Institute of Medicine Global Environmental Health and Sustainable Development Innovation Collaborative, opened the first webinar by highlighting the global burden of disease attributable to the modifiable environment. He noted that worldwide about 24 percent of all disability-adjusted life years (or years lost from both disability and death) is related to environmental factors (WHO, 2006), which range from the biological environment (such as water pollution) to the chemical environment (such as air pollution) to the built environment (including road traffic accidents). The burden of disease related to the environment is highest in the poorest countries of the world, and in these parts of the world sustainable development can provide the opportunity for a better economic life and improved health through sustainable development decisions informed by environmental health considerations.
Balbus emphasized that one of the key goals of sustainable development is to bring energy, transportation services, and other economic services to people who are lacking these resources in a way that does not compromise the needs of future generations. Substantial health benefits can be obtained from sustainable development policies around the world that focus on climate change mitigation, transportation, agriculture, food consumption, household energy, and large-scale energy production; and, in many cases, the economic benefits of these policies would significantly offset the associated costs.
However, to achieve health benefits from these policies, efforts need to take place throughout the world in ministries outside the Ministry of Health. Balbus said that in order to implement direct energy policies or change urban planning or transportation systems, the public health community needs to work in an intersectoral way to raise awareness about the health impacts from other sectors that have a strong hold on the health of future generations.
Although a siloed approach to policy development facilitates clarity in communication, it often can lead to missed opportunities to address the interrelationships among economic and social development, environmental protection, and human health (Balbus and Wasserheit, 2012). Balbus emphasized that many existing silos need to be removed, starting with the areas that have the greatest public health importance and greatest scientific rigor. In order to achieve wide acceptance across sectors and make progress, the cost of the policy or intervention needs to be reasonable, the benefits need to be measurable and sizable, the language needs to be understandable to all sectors, and all stakeholders need to strive for simplicity—simplicity in the articulation of goals, in the communication of interlinkages, and in the creation of targets and indicators.
Maria Neira, M.D.
Director, Public Health and Environment
World Health Organization
In thinking about the post-2015 development agenda, Maria Neira began by referencing a recent report to the United Nations (UN) Secretary-General, Realizing the Future We Want for All. The report outlines the importance of working with a “circle mentality” that includes environmental sustainability, inclusive social development, inclusive economic development, and peace and security—with a significant focus on sustainability, equality, and human rights—in creating the post-2015 development agenda (see Figure 2-1). This framework builds on the three pillars of sustainable development (economic, social, and environmental) and adds a fourth goal of peace and security; these four areas are all enablers of the three fundamental principles (human rights, equality, and sustainability) of the global vision (UN System Task Team on the Post-2015 UN Development Agenda, 2012a). In thinking about how to position health within the agenda, Neira noted that it is extremely important to understand the post-2015 development agenda process, particularly the architecture created under the Secretary-General.
Understanding the Post-2015 Development Agenda Process
The Secretary-General’s High-Level Panel of Eminent Persons on the Post-2015 Development Agenda was created to propose a framework for
FIGURE 2-1 Proposed integrated framework for realizing the “future we want for all” in the post-2015 development agenda.
SOURCE: UN System Task Team on the Post-2015 UN Development Agenda, 2012a.
the post-2015 development agenda and deliver a report to the UN General Assembly by the second quarter of 2013. Neira noted that the framework may include post-2015 Millennium Development Goals (MDGs) or Sustainable Development Goals (SDGs), along with data and work informed by the 2012 UN Conference on Sustainable Development (Rio+20 Conference) and ongoing countrylevel consultations of the UN Development Group (UNDG). The High-Level Panel is co-chaired by three individuals: Susilo Bambang Yudhoyono, President of Indonesia; Ellen Johnson Sirleaf, President of Liberia; and David Cameron, Prime Minister of the United Kingdom. In addition, 30 countries are assisting with the process. Neira emphasized the need to work within this structure
to ensure that health is included in the post-2015 development agenda process.
In addition to the High-Level Panel and UNDG country consultations, there are 11 thematic consultations planned, which will be led by appointed UN agencies (see Box 2-1). The architecture of all these groups can be complicated and will likely initiate competition among different topic areas and proposed goals. The health consultation will be led by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), with Sweden and Botswana playing a fundamental role in the planning process, and will conclude in January or February 2013 with a final event in Botswana. Neira highlighted the need to also use the other thematic areas, such as consultations for water or energy, to include health as an indicator and make progress in those sectors’ policies. These additional efforts will be fundamental to including health goals in the post-2015 development agenda.
Achieving a Greater Focus on Health
In working on the health thematic consultation, Neira said that it is important to emphasize achievements and investments made in the health-related MDGs in order to sustain this work. She noted that there is a need for greater recognition and focus on the means as well as the ends.
11 Global Thematic Consultations for the Post-2015
Development Agenda Process
1. Inequalities (across all dimensions)
2. Health (including MDG 4, MDG 5, MDG 6, and noncommunicable diseases)
3. Education (primary to tertiary and vocational)
4. Growth and Employment (investment in productive capacities, decent work, and social protection)
5. Environmental Sustainability (including biodiversity and climate change)
6. Governance (accountability at all levels)
7. Conflict and Fragility (conflict and post-conflict countries, and those prone to natural disasters)
8. Population Dynamics (including aging, international and internal migration, and urbanization)
9. Hunger, Nutrition, and Food Security
For example, we as a global community need to recognize health as a human right, need stronger and more resilient health systems, need more innovation and efficiency to respond to financial constraints, and need to address the economic, social, and environmental determinants of health. All of this calls for a multisectoral response. Instead of looking for what could be the new health goals, Neira noted, the public health community should build a case for why health is a concern for all people and is influenced by, as well as contributes to, policies across a wide range of sectors. The overarching goal being proposed by WHO in order to accommodate and maintain the visibility of all the internationally agreed upon health goals is universal health coverage. The vision of universal health coverage will ensure that all people have coverage and access to health services and have financial risk protection for paying for care.
Although universal health coverage is an important overarching goal, Neira again noted the importance of including health in many of the proposed thematic consultations. For the thematic consultation on water, health-related goals should be framed to use health as a way to measure progress in the water and sanitation sectors; in this way those goals will have a very clear and positive impact on the health of people. Similarly, for energy, using health as an indicator of achievements and progress made by good energy policies will likely serve as a better outcome, which will garner popular support for policies that have more diffuse outcomes, such as reducing carbon dioxide (CO2) emissions.
Neira closed by stating that the post-2015 development agenda process is obviously a work in progress, and she hopes that at the end of the process the results will include a greater focus on health within what is sure to be a complicated post-2015 development agenda.
David Serwadda, M.B.Ch.B., M.Sc., M.Med., M.P.H.
Professor of Disease Control and Environmental Health,
Makerere University School of Public Health, Uganda
David Serwadda began his presentation by pointing out that each of the eight MDGs lays out overarching goals and specific targets for the world to work toward by 2015 (see Box 1-2 in Chapter 1 for a complete list of goals and targets). MDG 7 focuses on ensuring environmental sustainability, but this goal is linked to many other MDG outcomes. He
stated that it is important to see the interconnections between MDG 7 and MDGs 1, 2, 3, 4, and 8 to understand how the management of the environment acts on the other goals. For example, Target 7C (to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation) has connections to improved time saving for women and the promotion of gender equality (MDG 3), and reductions in waterborne diseases that can lead to reduced child mortality (MDG 4).
Coordinating Implementation of Global Development Goals
Taking a step back, Serwadda shared his experience with evaluating WHO’s Global Strategy for Health for All by the Year 2000, noting that many of the goals set for this global strategy were not achieved by 2000. One of the reasons for falling short, which is still prevalent today, is focusing implementation efforts on independent outcomes, despite the fact that the process of achieving the goals is quite interrelated. Serwadda emphasized that the MDGs are implemented in silos, with a lack of good systematic coordinated platforms for implementation.
Taking a closer look at coordinating MDG efforts, Serwadda used the topic of water sanitation to exemplify the complexity of managing resources. In Uganda, as well as many countries in Africa, water and sanitation surveillance take place in the Ministry of Health. He noted that the Ministry of Health is able to identify huge growing health problems associated with poor-quality water and sanitation, most of which is indicated by diarrheal diseases and high morbidity and mortality rates in children less than 5 years of age. However, the Ministry of Water and Sanitation—a completely separate ministry—is responsible for the management of these resources. This makes it difficult to effectively achieve Target 7C, because the public health community that tracks progress in this area has very little input in the implementation of water and sanitation resources. Serwadda pointed out that this again highlights the issue of looking at the outcomes, rather than the process of how the outcomes are achieved. In looking at the MDG process, one will quickly realize that most of the direct and indirect impacts on health and education are actually found outside the directly relevant goals. Serwadda emphasized that this is a significant problem that should be addressed moving forward with the post-2015 development agenda process.
Impact of Population Growth in Africa
Serwadda then shifted to the challenges associated with African population growth. By 2050 Africa is projected to be the second most populous continent in the world, which is driven in large part by high fertility rates (UN, Department of Economic and Social Affairs,
Population Division, 1999, 2009). He explained that this population growth is increasing deforestation as the need for household energy sources expands. In addition, the increased need for housing is causing rapid development of land with poor provisions of water and sanitation. Serwadda noted that population growth is a large driver of health impacts and will require specific management to reduce its potentially significant impacts on the environment and other health outcomes. For example, efforts to reduce HIV by 50 percent are continually impacted by a denominator that is increasing all the time; this has difficult implications on the resources that are needed to move this cause forward. Looking at the MDGs, reproductive health is emphasized, but the MDGs do not specifically talk about child birth rates, and for post-2015, as far as Africa is concerned, this is going to be a huge issue that needs to be addressed moving forward.
In summary and considering the points made above, Serwadda noted the need to implement a country framework that builds, adds, and supplements each MDG goal in a coordinated manner, with a view that some MDGs, particularly those related to health, are significantly impacted by factors outside the health sector. He emphasized that population growth is an enormous driver that will have significant impacts in Africa that directly and indirectly affect the MDGs. Serwadda said this needs to be comprehensively addressed because population growth not only underpins many resource needs but also can create a vicious cycle in terms of being able to meet end targets for global development.
Zehra Aydin, M.A.
Senior Program Officer,
United Nations Environment Programme
Zehra Aydin began by noting that the Millennium Declaration, adopted in 2000, led to the development of the MDGs (see Chapter 1 for more detail). She said it would be worth looking through this document again to inspire ideas on collective responsibilities for current and future generations. For example, the Millennium Declaration recognized that “in addition to our separate responsibilities to our individual societies, we have a collective responsibility to uphold the principles of human dignity, equality, and equity at the global level … especially the most
vulnerable and, in particular, the children of the world, to whom the future belongs” (UN General Assembly, 2000).
Lessons to Learn from the MDGs
Aydin noted that there are several positive lessons to learn from the MDG experience. The two that are the most important, she said, are to have few goals to focus everyone’s attention and to have goals that shift the attention of policy makers to thinking about sustainability. With respect to the former, she said, the Millennium Summit allowed the world community to present thousands of targets and goals from numerous intergovernmental meetings and conferences, and focusing the attention on a few goals was welcomed by many people. The MDGs also moved the attention of policy makers, from looking at economic growth and development to thinking about the economy, society, and environment together in a sustainable development manner.
But some of the positive lessons also contained some negative aspects, Aydin noted. For instance, the targets and goals were selectively chosen from the text of the Millennium Declaration, and the MDGs do not reflect all of the internationally agreed-upon goals included in that document (UN System Task Team on the Post-2015 UN Development Agenda, 2012b). Important issues, such as human rights, unemployment, and peace and security (a major issue that affects all of the goals) were left out of the MDGs. In the case of MDG 7, this goal was based on environmental protection, but the associated targets and indicators do not necessarily match the intention and content provided in the Millennium Declaration. For example, the emphasis on climate change, which is present in the Millennium Declaration through the agreed-upon need to reduce greenhouse gas emissions and the number and effects of natural disasters, does not appear anywhere in the MDG 7 framework (see Table 2-1). In addition, not all of the MDG targets were well defined or included well-selected indicators (e.g., to halve poverty or reduce child mortality by two-thirds does not take into account population dynamics from 1990 to 2015). These are lessons to learn from in the post-2015 development agenda process.
Elements of the Post-2015 Development Agenda Process
Aydin explained that the post-2015 development agenda process has three elements. First, the process is expected to build on the existing MDGs, because not all of the targets of these goals have been achieved. Second, the process provides the opportunity to improve the context of the existing MDGs, perhaps with better targets and indicators. Third, the process provides an opportunity to identify new goals as a global community
TABLE 2-1 MDG 7 (Ensure Environmental Sustainability): Targets and Indicators
Target 7A: Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources
7.1 Proportion of land area covered by forest
7.2 CO2 emissions, total, per capita and per $1 gross domestic product
7.3 Consumption of ozone-depleting substances
7.4 Proportion of fish stocks within safe biological limits
7.5 Proportion of total water resources used
Target 7B: Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss
7.6 Proportion of terrestrial and marine areas protected
7.7 Proportion of species threatened with extinction
Target 7C: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation
7.8 Proportion of population using an improved drinking water source
7.9 Proportion of population using an improved sanitation facility
Target 7D: By 2020, to have achieved a significant improvement in the lives of at least 100 million slum dwellers
7.10 Proportion of urban population living in slums*
* The actual proportion of people living in slums is measured by a proxy, represented by the urban population living in households with at least one of four characteristics: (1) lack of access to improved water supply; (2) lack of access to improved sanitation; (3) overcrowding (three or more persons per room); and (4) dwellings made of non-durable material.
SOURCE: UN, 2008.
and confront emerging challenges (such as inequality) affecting both developed and developing countries.
Moving to the UN process, Aydin highlighted two key elements. The first element, also mentioned by Neira during her presentation, is the UN System Task Team report to the Secretary-General on the post-2015 development agenda. Aydin noted that the three fundamental principles—equality, sustainability, and human rights—proposed in Realizing the Future We Want for All should be the basic building blocks of the framework for the next development agenda (see Figure 2-1). The second element in the UN process includes national consultations that
will take place in up to 100 countries and global thematic consultations on 11 specific themes (see Box 2-1). The national consultations are supported by the UN Development Group and are being organized through collaboration with the UN Office of the Resident Coordinator and the national governments. These consultations could provide an entry point for colleagues and counterparts at other national science academies to contribute to the national discussion. Aydin suggested that mobilizing these groups could enhance the scientific basis of the process.
Although the global thematic consultations reference 11 separate themes, with crosscutting issues looking at human rights and gender equality, these consultations will not occur in silos. Aydin said there are efforts under way to encourage linkages among the themes (such as discussing environmental sustainability along with education, health, food security, or population dynamics) to assess relationships among these issues. All of the thematic consultations will start with a call for papers and virtual conversation, followed by an expert or leadership meeting, and then a final report that synthesizes all the findings. When these contributions are completed, the process goes into the intergovernmental stage from June 2013 through the end of 2015, and discussions will focus on producing a globally agreed-upon new development agenda that will take effect in 2016.
In closing, Aydin noted that she hopes that by working together, the national science academies can mobilize their networks and colleagues from all parts of the world to contribute to this process.
A brief discussion among the speakers and participants followed the presentations. Their remarks are summarized in this section.
An Intersectoral Approach to Achieving Global Development Goals
Balbus began the discussion session by noting the interesting process issues that were described in the presentation from Aydin, including the idea of points of entry into the process and the role of the national science academies at the country level. He also highlighted a point from Serwadda, the idea that breaking down silos should not come from the very top down to the country level, but that each country needs an intersectoral approach to achieving global development goals that can work within the context of each individual country’s culture and government structure. Balbus then presented the first question to the group, asking for additional ideas on how to operationalize this proposed approach at the country level.
Serwadda began by noting that most of the MDGs were framed at the 10,000-foot level and that adoption of the MDGs were more or less agreed upon through the UN system, rather than having bottom-up input from the country level. He stated that the process lacked a rigorous country discussion to determine exactly how the MDGs should be implemented and whether the goals were realistic. Serwadda went on to say that the consultation process referenced in Aydin’s presentation is probably trying to rectify this, because the discussions are starting from the country level and moving up. He thinks that this process facilitates more dialogue and more awareness of what is required to implement the global goals and the process to achieve the outcomes.
Aydin stated that she was also intrigued by the suggestion that there could be an approach to achieve the global development goals in every country and noted that there has been an effort in that direction that could perhaps be built upon in the post-2015 development agenda process. She explained that after the 1992 Rio Summit there was a decision that the countries would develop their sustainable development frameworks (for example, some called it National Agenda 21, and quite a few countries developed frameworks), but then attention was diverted to the Millennium Summit. However, she said, the existing country frameworks—whether called National Agenda 21, National Council for Sustainable Development, or something else—could survive, and include not only the three pillars of sustainable development but also other global concerns related to peace and security. Aydin noted that the additional dimension of peace and security presented in the integrated framework in Realizing the Future We Want for All (see Figure 2-1) completes the cycle of sustainable development because, as learned over time, when a conflict breaks out, all efforts to address sustainable development are lost. There is an opportunity for the country level to become better coordinated, she said, because part of the problem at the country level is lack of coordination across the different ministries. She emphasized that the four basic building blocks of the vision for the post-2015 development agenda—environmental sustainability, inclusive social development, inclusive economic development, and peace and security—will provide incentives for ministries to increase communication at the country level, which in turn will hopefully eliminate confusing mandates or mixed messages that often arise from not communicating across ministries.
Neira noted that there are multiple consultative and delegative processes occurring at the moment, each with complicated mechanisms, and suggested the need to propose very pragmatic solutions to address the difficult processes. She highlighted the importance of involving all stakeholders and relevant groups in the process, but in a pragmatic way to move toward consensus. She said the process at the country level has been extremely clear and straightforward and ensuring this multisectoral
approach is fundamental to the process, as well as facilitating countrylevel involvement with all the thematic consultations.
William Sontag, global environmental informatics specialist with the Office of International and Tribal Affairs at the U.S. Environmental Protection Agency, provided a few additional points. He said it seems that the successful MDGs around human health aspects (such as cardiopulmonary disease, clean drinking water, and chemical exposure) will likely continue in the next agenda, but the new or somewhat different types of measures and goals that are needed should be explored in the post-2015 context. These could include looking at population health in urban areas, the connection of ecosystem services provisioning to human health, or the connection between biodiversity and human health. Following a point made by Aydin during her presentation, Sontag noted that consultation efforts should focus on the development of appropriate indicators under MDG 7 or under the SDGs, in order to assess the major impacts that connect the environment with human health. In addition, current work to develop early-warning or assessment information systems could be helpful to this process, as well as the possibility of utilizing crowd source citizen participation to help identify information on population and public health.
Highest-Priority Goals for
the Post-2015 Development Agenda or SDGs
Balbus presented the second question for the group. If one were writing these SDGs or post-2015 development goals, he asked, which one would be placed at the top of the list, or which goal is the most important?
Serwadda noted that it is very difficult to pick one important goals that overrides the others, because so many of the variables that produce the desired outcomes are interrelated. He said that it is important to work on multiple fronts in order to make an impact.
Neira also noted that this is an extremely difficult question, but WHO is exploring the potential for using universal health coverage as a way to accommodate a wide range of health concerns (such as polio, AIDS, tuberculosis, malaria, and mortality related to noncommunicable diseases (NCDs), which is becoming a major issue). WHO is proposing universal health coverage as an overarching goal and a way to utilize the benefit of health policies in other sectors, including transportation, energy, urban planning, water and sanitation, and many others, where health can be a good indicator of progress.
Aydin noted that she would like to see a goal on climate change with corresponding indicators that would make linkages to the four pillars that are emerging for the next development framework; there would be an indicator on how much the economy is greening, how much the society
is learning to be green, and how improved management of natural resources is preventing conflict. A second high priority for Aydin would be a goal on inequality, because research shows that when a society is more equal, many of the illnesses and problems are more manageable (from health to education to the environment); however, when inequality grows, a negative cycle that feeds into more problems and inequality is established.
Paulo Buss, former president of the Oswaldo Cruz Foundation (also known as FIOCRUZ), noted his agreement with the WHO choice of universal health coverage, but said it is important to ensure the definition is broad and goes beyond the provision of clinical health services to a more comprehensive idea of universal health systems, which would incorporate public health more broadly.
Sontag noted the need for a very strong connection between whatever indicators are chosen and urban sustainability, as the urban sustainability agenda is extremely important.
Making Intersectoral Linkages in the Post-2015 Development Agenda Process
Judy Wasserheit, vice chair of the Department of Global Health at the University of Washington School of Public Health, provided the third question for the group, asking how the call for papers and other components of the post-2015 development agenda process will be structured in order to build intersectoral linkages between health and nonhealth sectors from the foundation up.
Aydin said many lessons have been learned from the MDGs process that will help to improve the next development agenda. One of the lessons learned at the UN is the need for UN coherence at the country level to prevent working in silos. This approach is being piloted in 30 countries, where the focus is on working together as one at the country level rather than in separate agencies. She noted that this process has been beneficial; even though it requires more give-and-take, this ultimately leads to better results for everyone involved, making it a win-win approach. By applying the lessons from this “one-UN process” to the new development agenda at least at the country level, there will be more coherence and less possibility for a siloed approach. Aydin emphasized that during the past several decades, UN teams have learned that the more they connect and the more they collaborate, the better the results, which is perhaps the simplest answer.
Neira then said she is not sure if the call for papers will force stakeholders to work on intersectoral collaboration. She noted that if indicators are developed under each thematic category to measure how much intersectoral collaboration is taking place, this may create a
mechanism that will force these collaborations and prevent a siloed approach.
Balbus reminded people to reference the WHO website on health in the green economy (http://www.who.int/hia/green_economy/en [accessed October 18, 2012]) to review discussion papers on indicators for other sectors that emphasize health content to better understand how these indicators may facilitate intersectoral collaboration.
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