INTRODUCTION

6.1.	Health and development are intimately interconnected.  Both 
insufficient development leading to poverty and inappropriate development 
resulting in overconsumption, coupled with an expanding world population, 
can result in severe environmental health problems in both developing and 
developed nations.  Action items under Agenda 21 must address the primary 
health needs of the world's population, since they are integral to the 
achievement of the goals of sustainable development and primary 
environmental care.  The linkage of health, environmental and 
socio-economic improvements requires intersectoral efforts.  Such efforts, 
involving education, housing, public works and community groups, including 
businesses, schools and universities and religious, civic and cultural 
organizations, are aimed at enabling people in their communities to ensure 
sustainable development.  Particularly relevant is the inclusion of 
prevention programmes rather than relying solely on remediation and 
treatment. Countries ought to develop plans for priority actions, drawing 
on the programme areas in this chapter, which are based on cooperative 
planning by the various levels of government, non-governmental 
organizations and local communities.  An appropriate international 
organization, such as WHO, should coordinate these activities.


PROGRAMME AREAS

6.2.	The following programme areas are contained in this chapter:  

	(a)	Meeting primary health care needs, particularly in rural areas;

	(b)	Control of communicable diseases;

	(c)	Protecting vulnerable groups;

	(d)	Meeting the urban health challenge;

	(e)	Reducing health risks from environmental pollution and hazards.



PROGRAMME AREAS

              A.  Meeting primary health care needs, particularly in
                  rural areas

Basis for action

6.3.	Health ultimately depends on the ability to manage successfully the 
interaction between the physical, spiritual, biological and economic/social 
environment.  Sound development is not possible without a healthy 
population; yet most developmental activities affect the environment to 
some degree, which in turn causes or exacerbates many health problems.  
Conversely, it is the very lack of development that adversely affects the 
health condition of many people, which can be alleviated only through 
development.  The health sector cannot meet basic needs and objectives on 
its own; it is dependent on social, economic and spiritual development, 
while directly contributing to such development.  It is also dependent on a 
healthy environment, including the provision of a safe water supply and 
sanitation and the promotion of a safe food supply and proper nutrition.  
Particular attention should be directed towards food safety, with priority 
placed on the elimination of food contamination; comprehensive and 
sustainable water policies to ensure safe drinking water and sanitation to 
preclude both microbial and chemical contamination; and promotion of health 
education, immunization and provision of essential drugs.  Education and 
appropriate services regarding responsible planning of family size, with 
respect for cultural, religious and social aspects, in keeping with 
freedom, dignity and personally held values and taking into account ethical 
and cultural considerations, also contribute to these intersectoral 
activities.

Objectives

6.4.	Within the overall strategy to achieve health for all by the year 
2000, the objectives are to meet the basic health needs of rural peri-urban 
and urban populations; to provide the necessary specialized environmental 
health services; and to coordinate the involvement of citizens, the health 
sector, the health-related sectors and relevant non-health sectors 
(business, social, educational and religious institutions) in solutions to 
health problems.  As a matter of priority, health service coverage should 
be achieved for population groups in greatest need, particularly those 
living in rural areas.

Activities

6.5.	National Governments and local authorities, with the support of 
relevant non-governmental organizations and international organizations, in 
the light of countries' specific conditions and needs, should strengthen 
their health sector programmes, with special attention to rural needs, to:

	(a)	Build basic health infrastructures, monitoring and planning 
systems:

	(i)	Develop and strengthen primary health care systems that are 
practical, community-based, scientifically sound, socially 
acceptable and appropriate to their needs and that meet basic 
health needs for clean water, safe food and sanitation;

    	(ii)	Support the use and strengthening of mechanisms that improve 
coordination between health and related sectors at all 
appropriate levels of government, and in communities and 
relevant organizations;

   	(iii)	Develop and implement rational and affordable approaches 
to the establishment and maintenance of health facilities;

   	(iv)	Ensure and, where appropriate, increase provision of social 
services support;

	(v)	Develop strategies, including reliable health indicators, to 
monitor the progress and evaluate the effectiveness of health 
programmes;

    	(vi)	Explore ways to finance the health system based on the 
assessment of the resources needed and identify the various 
financing alternatives;

   	(vii)	Promote health education in schools, information 
exchange, technical support and training;

  	(viii)	Support initiatives for self-management of services by 
vulnerable groups;

    	(ix)	Integrate traditional knowledge and experience into national 
health systems, as appropriate;

	(x)	Promote the provisions for necessary logistics for outreach 
activities, particularly in rural areas;

    	(xi)	Promote and strengthen community-based rehabilitation 
activities for the rural handicapped.

	(b)	Support research and methodology development:

	(i)	Establish mechanisms for sustained community involvement in 
environmental health activities, including optimization of the 
appropriate use of community financial and human resources;

    	(ii)	Conduct environmental health research, including behaviour 
research and research on ways to increase coverage and ensure 
greater utilization of services by peripheral, underserved and 
vulnerable populations, as appropriate to good prevention 
services and health care;

   	(iii)	Conduct research into traditional knowledge of prevention 
and curative health practices.

 Means of implementation

(a)	Financing and cost evaluation

6.6.	The Conference secretariat has estimated the average total annual 
cost (1993-2000) of implementing the activities of this programme to be 
about $40 billion, including about $5 billion from the international 
community on grant or concessional terms.  These are indicative and order 
of magnitude estimates only and have not been reviewed by Governments.  
Actual costs and financial terms, including any that are non-concessional, 
will depend upon, inter alia, the specific strategies and programmes 
Governments decide upon for implementation.

(b)	Scientific and technological means

6.7.	New approaches to planning and managing health care systems and 
facilities should be tested, and research on ways of integrating 
appropriate technologies into health infrastructures supported.  The 
development of scientifically sound health technology should enhance 
adaptability to local needs and maintainability by community resources, 
including the maintenance and repair of equipment used in health care.  
Programmes to facilitate the transfer and sharing of information and 
expertise should be developed, including communication methods and 
educational materials.

(c)	Human resource development

6.8.	Intersectoral approaches to the reform of health personnel 
development should be strengthened to ensure its relevance to the "Health 
for All" strategies.  Efforts to enhance managerial skills at the district 
level should be supported, with the aim of ensuring the systematic 
development and efficient operation of the basic health system.  Intensive, 
short, practical training programmes with emphasis on skills in effective 
communication, community organization and facilitation of behaviour change 
should be developed in order to prepare the local personnel of all sectors 
involved in social development for carrying out their respective roles.  In 
cooperation with the education sector, special health education programmes 
should be developed focusing on the role of women in the health-care 
system.

(d)	Capacity-building

6.9.	Governments should consider adopting enabling and facilitating 
strategies to promote the participation of communities in meeting their own 
needs, in addition to providing direct support to the provision of 
health-care services.  A major focus should be the preparation of 
community-based health and health-related workers to assume an active role 
in community health education, with emphasis on team work, social 
mobilization and the support of other development workers.  National 
programmes should cover district health systems in urban, peri-urban and 
rural areas, the delivery of health programmes at the district level, and 
the development and support of referral services.


B.  Control of communicable diseases

Basis for action

6.10.	Advances in the development of vaccines and chemotherapeutic agents 
have brought many communicable diseases under control.  However, there 
remain many important communicable diseases for which environmental control 
measures are indispensable, especially in the field of water supply and 
sanitation.  Such diseases include cholera, diarrhoeal diseases, 
leishmaniasis, malaria and schistosomiasis.  In all such instances, the 
environmental measures, either as an integral part of primary health care 
or undertaken outside the health sector, form an indispensable component of 
overall disease control strategies, together with health and hygiene 
education, and in some cases, are the only component.

6.11.	With HIV infection levels estimated to increase to 30-40 million by 
the year 2000, the socio-economic impact of the pandemic is expected to be 
devastating for all countries, and increasingly for women and children.  
While direct health costs will be substantial, they will be dwarfed by the 
indirect costs of the pandemic - mainly costs associated with the loss of 
income and decreased productivity of the workforce.  The pandemic will 
inhibit growth of the service and industrial sectors and significantly 
increase the costs of human capacity-building and retraining.  The 
agricultural sector is particularly affected where production is 
labour-intensive.

Objectives

6.12.	A number of goals have been formulated through extensive 
consultations in various international forums attended by virtually all 
Governments, relevant United Nations organizations (including WHO, UNICEF, 
UNFPA, UNESCO, UNDP and the World Bank) and a number of non-governmental 
organizations.  Goals (including but not limited to those listed below) are 
recommended for implementation by all countries where they are applicable, 
with appropriate adaptation to the specific situation of each country in 
terms of phasing, standards, priorities and availability of resources, with 
respect for cultural, religious and social aspects, in keeping with 
freedom, dignity and personally held values and taking into account ethical 
considerations.  Additional goals that are particularly relevant to a 
country's specific situation should be added in the country's national plan 
of action (Plan of Action for Implementing the World Declaration on the 
Survival, Protection and Development of Children in the 1990s 1/).  Such 
national level action plans should be coordinated and monitored from within 
the public health sector. Some major goals are:

 	(a)	By the year 2000, to eliminate guinea worm disease 
(dracunculiasis);

	(b)	By the year 2000, eradicate polio;

	(c)	By the year 2000, to effectively control onchocerciasis (river 
blindness) and leprosy;

	(d)	By 1995, to reduce measles deaths by 95 per cent and reduce 
measles cases by 90 per cent compared with pre-immunization levels;

	(e)	By continued efforts, to provide health and hygiene education 
and to ensure universal access to safe drinking water and universal access 
to sanitary measures of excreta disposal, thereby markedly reducing 
waterborne diseases such as cholera and schistosomiasis and reducing:

	(i)	By the year 2000, the number of deaths from childhood diarrhoea 
in developing countries by 50 to 70 per cent;

    	(ii)	By the year 2000, the incidence of childhood diarrhoea in 
developing countries by at least 25 to 50 per cent;

	(f)	By the year 2000, to initiate comprehensive programmes to 
reduce mortality from acute respiratory infections in children under five 
years by at least one third, particularly in countries with high infant 
mortality;

	(g)	By the year 2000, to provide 95 per cent of the world's child 
population with access to appropriate care for acute respiratory infections 
within the community and at first referral level;

	(h)	By the year 2000, to institute anti-malaria programmes in all 
countries where malaria presents a significant health problem and maintain 
the transmission-free status of areas freed from endemic malaria;

	(i)	By the year 2000, to implement control programmes in countries 
where major human parasitic infections are endemic and achieve an overall 
reduction in the prevalence of schistosomiasis and of other trematode 
infections by 40 per cent and 25 per cent, respectively, from a 1984 
baseline, as well as a marked reduction in incidence, prevalence and 
intensity of filarial infections;

	(j)	To mobilize and unify national and international efforts 
against AIDS to prevent infection and to reduce the personal and social 
impact of HIV infection;

	(k)	To contain the resurgence of tuberculosis, with particular 
emphasis on multiple antibiotic resistant forms;

	(l)	To accelerate research on improved vaccines and implement to 
the fullest extent possible the use of vaccines in the prevention of 
disease.

Activities

6.13.	Each national Government, in accordance with national plans for 
public health, priorities and objectives, should consider developing a 
national health action plan with appropriate international assistance and 
support, including, at a minimum, the following components:

	(a)	National public health systems:

	(i)	Programmes to identify environmental hazards in the causation 
of communicable diseases;

    	(ii)	Monitoring systems of epidemiological data to ensure adequate 
forecasting of the introduction, spread or aggravation of 
communicable diseases;

   	(iii)	Intervention programmes, including measures consistent 
with the principles of the global AIDS strategy;

    	(iv)	Vaccines for the prevention of communicable diseases;

	(b)  	Public information and health education:

		Provide education and disseminate information on the risks of 
endemic communicable diseases and build awareness on 
environmental methods for control of communicable diseases to 
enable communities to play a role in the control of 
communicable diseases;

	(c)  	Intersectoral cooperation and coordination:

  	(i)	Second experienced health professionals to relevant sectors, 
such as planning, housing and agriculture;

    	(ii)	Develop guidelines for effective coordination in the areas of 
professional training, assessment of risks and development of 
control technology;

	(d)	Control of environmental factors that influence the spread of 
communicable diseases:

		Apply methods for the prevention and control of communicable 
diseases, including water supply and sanitation control, water 
pollution control, food quality control, integrated vector 
control, garbage collection and disposal and environmentally 
sound irrigation practices;

	(e)  	Primary health care system:

	(i)	Strengthen prevention programmes, with particular emphasis on 
adequate and balanced nutrition;

    	(ii)	Strengthen early diagnostic programmes and improve capacities 
for early preventative/treatment action;

   	(iii)	Reduce the vulnerability to HIV infection of women and 
their offspring;

	(f) 	Support for research and methodology development:

	(i)	Intensify and expand multidisciplinary research, including 
focused efforts on the mitigation and environmental control of 
tropical diseases;

    	(ii)	Carry out intervention studies to provide a solid 
epidemiological basis for control policies and to evaluate the 
efficiency of alternative approaches;

   	(iii)	Undertake studies in the population and among health 
workers to determine the influence of cultural, behavioural and 
social factors on control policies;

	(g)  	Development and dissemination of technology:

	(i)	Develop new technologies for the effective control of 
communicable diseases;

    	(ii)	Promote studies to determine how to optimally disseminate 
results from research;

   	(iii)	Ensure technical assistance, including the sharing of 
knowledge and know-how.

Means of implementation

(a)	Financing and cost evaluation

6.14.	The Conference secretariat has estimated the average total annual 
cost (1993-2000) of implementing the activities of this programme to be 
about $4 billion, including about $900 million from the international 
community on grant or concessional terms. These are indicative and order of 
magnitude estimates only and have not been reviewed by Governments.  Actual 
costs and financial terms, including any that are non-concessional, will 
depend upon, inter alia, the specific strategies and programmes Governments 
decide upon for implementation.

(b)	Scientific and technological means

6.15.	Efforts to prevent and control diseases should include 
investigations of the epidemiological, social and economic bases for the 
development of more effective national strategies for the integrated 
control of communicable diseases.  Cost-effective methods of environmental 
control should be adapted to local developmental conditions.

(c)	Human resource development

6.16.	National and regional training institutions should promote broad 
intersectoral approaches to prevention and control of communicable 
diseases, including training in epidemiology and community prevention and 
control, immunology, molecular biology and the application of new vaccines.  
Health education materials should be developed for use by community workers 
and for the education of mothers for the prevention and treatment of 
diarrhoeal diseases in the home.