The European Journal of Public Health Advance Access originally published online on July 21, 2005
The European Journal of Public Health 2005 15(5):546-551; doi:10.1093/eurpub/cki025
Miscellaneous |
The impact of the European Environment and Health Process on UK environment and health policy, plans and practice: what difference has it made?
Alexander C. Capleton, Jane Stevens and Paul T.C. Harrison** MRC Institute for Environment and Health, University of Leicester, Leicester, UK
Correspondence: Mr Alexander C. Capleton, MSc, MRC Institute for Environment and Health, University of Leicester, 94 Regent Road, Leicester LE1 7DD, UK, tel: +44 116 223 1606, fax: +44 116 223 1601, e-mail: acc8{at}leicester.ac.uk
Received January 8, 2004, accepted May 27, 2004
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Abstract |
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 Top Abstract European Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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The European Environment and Health Process (EEHP), led by the World Health Organization (WHO) Regional Office for Europe, aims to support WHO Member States as they plan and implement national and international environment and health policies. An evaluation of the impact of the EEHP in the UK was conducted in preparation for the fourth Ministerial Conference on Environment and Health in Budapest, 2004. The evaluation identified a number of impacts and influences of the EEHP. This concluded that the process had only a marginal direct influence on policy within the UK. However, it was also concluded that the process had resulted in several indirect influences, including better cooperation between government departments, greater awareness of environment and health issues from an international perspective, and a higher political profile of environment and health issues. A few outcomes of the EEHP also appear to have been taken into account in some national and local policy documents. The National Environmental Health Action Plan, which was produced as a direct result of the EEHP, appears to have had little direct impact in the UK, probably because of the lack of an implementation process and indicators, and because it was superseded by other policy initiatives relatively soon after publication. A need for better coordination and promotion of the EEHP amongst stakeholders responsible for environment and health policy areas was also identified.
Keywords: environmental health, evaluation, policy, World Health Organization
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European Environment and Health Process |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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The European Environment and Health Process (EEHP), led by the World Health Organization (WHO) Regional Office for Europe, aims to support Member States of the WHO European region as they plan and implement national and international environment and health policies. The overall goal of the process is ‘... to improve living and health conditions with sustainable approaches to ensure the right of our children to a satisfying and productive life.’1
The process has resulted in a series of 5-yearly Ministerial Conferences on environment and health. The first of these took place in Frankfurt in 1989, followed by conferences in Helsinki in 1994 and London in 1999. These conferences have resulted in several outcomes, including: the European Charter on Environment and Health, which outlined basic principles and priorities for environment and health policy; the Declaration for Action on Environment and Health in Europe, which initiated the Environmental Health Action Plan for Europe and committed Ministers to develop National Environmental Health Action Plans (NEHAPs); the Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes, which aims to protect human health and prevent water-related disease; and the Charter on Transport, Environment and Health. The fourth Ministerial Conference on Environment and Health was held in Budapest in June 2004.
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UK environment and health policy |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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Environment and health policy in the UK has a long history, stretching back to the Public Health Act of 1848, which gave Boards of Health powers to improve water supplies, drainage and sanitation with the aim of improving public health. Current UK environment and health policy is set out in a range of strategy and policy documents (table 1). Important among these is the UK Sustainable Development Strategy, A Better Quality of Life: A Strategy for Sustainable Development for the UK, which, among its objectives, aims to reduce the harm to health from poor housing and pollution, and has an overarching influence on Government policy and practice.2 Environment and health considerations are also integrated into many other diverse areas of UK policy and legislation. For example, planning regulations allow new building developments to be limited or denied on the grounds of air quality (and hence potential impacts on human health).
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The factors influencing the development of these policies will have been diverse and may have included the UK's involvement in international environment and health processes, such as the United Nations Economic Council for Europe Environment for Europe Process and the WHO's EEHP. In particular, the UK has had considerable involvement with the EEHP. It was the first country to publish an NEHAP3, and hosted the Third Ministerial Conference on Environment and Health. It is also a member of the WHO European Environment and Health Committee (EEHC) and the WHO International Steering Committee for Evaluation of Environmental Health Policies and Action Plans (ISC). However, to date, the impact of the UK's involvement in the EEHP, or other international environment and health processes, on UK environment and health policy has not been objectively evaluated.
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Evaluation of the EEHP |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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In preparation for the fourth Ministerial Conference on Environment and Health, the EEHC requested an evaluation of the impact of the EEHP in the WHO European region.4 The evaluation had an international and a national component. The national component of the evaluation, which is the focus of this paper, aimed to look at national plans dealing with environment and health and assess the impacts and influence of the EEHP in each country. The results of the national evaluations were used to inform the European evaluation process and served as a basis for the development of Europe-wide evaluation guidelines. The UK participated in the pilot evaluation (along with Bulgaria, Estonia, Germany, Hungary, Latvia, Malta, the Russian Federation, Sweden and Switzerland) to test and develop the evaluation methodology. This is the first time that the impact of the EEHP has been evaluated in the UK; it has been followed up by the WHO with an evaluation of the EEHP among the remaining Member States of the WHO European region.
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Evaluation methodology |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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The evaluation of the impact of the EEHP in the UK was conducted during October and November 2002. The methodology used was based on an evaluation methodology developed by the ISC and EEHC, which comprised:5 (i) a questionnaire survey of key stakeholders within the field of environment and health; (ii) evaluation workshop(s); and (iii) review of key policy documents.
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Questionnaire survey and evaluation workshop |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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The questionnaire was based on that proposed by the ISC and EEHC, and aimed to identify impacts and influences of the EEHP on UK environment and health policy and practice. Key stakeholders for the questionnaire survey and evaluation workshop were identified based on expert knowledge and professional contacts within the field of environment and health policy, with the aim of obtaining a broad spectrum of views from a range of stakeholders with potential interest and involvement in the EEHP. At least one stakeholder was identified for each of the eight types of stakeholder suggested by the ISC [namely academia, business/industry, environment ministries, health ministries, local authorities, the media, non-governmental organizations (NGOs) and professional organizations]. In total, 25 stakeholders from 18 departments or organizations were invited to participate in the evaluation (table 2).
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Fourteen stakeholders responded positively from academia, business/industry, environment ministries, health ministries and professional organizations, and participated in both the questionnaire survey and evaluation workshop, held in November 2002. No responses were received from stakeholders with particular responsibility for water or transport policy, or from stakeholders representing the media, NGOs or local authority organizations.
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Review of policy documents |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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A review of policy documents was undertaken to: (i) identify references to WHO charters and declarations on environment and health in national policy documents; and (ii) identify links to the EEHP and ideas and developments that are the result of the WHO charters and declarations.
Because UK environment and health policies are laid out in a number of different policy documents, an Internet search engine (Google; http//:www.google.co.uk) was used to identify specific references to WHO charters and declarations on environment and health in UK Government documents. This approach made several assumptions, including that UK environment and health policy documents are published in full on the Internet, and that WHO charters and declarations are referenced or referred to correctly in these documents. These assumptions were thought to be reasonable given that the UK Government maintains an official online archive of documents published since 1994 (Official Documents Online; http://www.official-documents.co.uk/index.html), and that all policy documents, because they will have been extensively edited, should correctly reference the outcomes of the EEHP. The searches were conducted during November 2002 and limited to UK websites, using search terms relating to the main charters and protocols arising from the Ministerial Conferences on environment and health. The results of the searches were reviewed to identify UK Government websites and documents, and to ascertain the nature of the references to the WHO charters or declarations.
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Impacts and influences of the EEHP in the UK |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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Impact on UK policy, plans and practice. There was general consensus, from both the questionnaire survey and the evaluation workshop, that the EEHP had had little direct influence on UK policies, plans or practice. As a result, no respondents identified any specific current policies or plans that they felt had been directly influenced by the EEHP. However, one respondent felt that the UK's Sustainable Development Strategy might have been shaped by experiences with the earlier NEHAP. The Sustainable Development Strategy was suggested as having an impact by promoting awareness and encouraging Government departments to embed sustainable development (and the associated environment and health issues) into their work.
Several reasons were proposed as to why the EEHP had had little direct impact in the UK. In particular, it was considered that European Union (EU) Directives were the main driver for developing environment and health policies, and that the EEHP somewhat duplicated EU positions, although at a wider European level (i.e. beyond the EU). Indeed, one stakeholder felt that the EEHP was principally about trying to harmonize programmes and build consensus to support and develop environment and health strategies in Central and Eastern Europe. Thus, by complying with EU Directives, there sometimes remained few issues for the UK to address under EEHP initiatives. In other policy areas relevant to environment and health, such as transport, it was felt that domestic concerns would be the principal influence. However, it was acknowledged that the UK would take European initiatives, such as the EEHP, into account when developing policies and plans. Several stakeholders felt that WHO's influence on environment and health policy had occurred primarily through its research and technical assessments, e.g. the Guidelines for Drinking Water Quality, rather than through the EEHP.
One respondent thought there was more that the UK could and should take from the EEHP. However, the workshop delegates agreed that it would be unrealistic for a country to implement all the initiatives proposed by the EEHP (e.g. in developing a NEHAP) regardless of extant national policies and plans. It was suggested that the role of WHO and the EEHP should be to act as advisor, broker and catalyst in developing and disseminating useful policies and plans that can then be employed by Member States where appropriate. It was felt, however, that it was important for the UK to engage at the European level, as this helps to increase awareness amongst those who are developing environment and health policies, and provides an opportunity to learn from the experience of other countries. Furthermore, the attendance of Ministers at the Ministerial Conferences on Environment and Health would have promoted important interactions and discussions and would have helped raise the political profile of environment and health issues.
Impact of the UK NEHAP. Six of the 14 questionnaire survey respondents felt that the UK NEHAP had had little or no impact within the UK. Several stakeholders suggested that the UK NEHAP had been largely a compilation of existing or already planned actions, with only a few new initiatives that could be directly attributed to participation in the EEHP. It was also commented that the NEHAP was superseded by other policy documents before it could begin to have an impact, and that it was difficult to evaluate the impact of the plan as there were no indicators or other tools associated with it by which its impact could be measured.
A number of indirect influences of the UK NEHAP were, however, highlighted. These included the observation that the NEHAP had prompted cooperative working across Government, that it had helped to promote a better understanding of environment and health issues, and that it had helped to clarify roles and responsibilities. It was also commented that the UK had been a pilot country for the preparation of NEHAPs and, as a result, the UK NEHAP had an impact internationally, as it was used as a model by other countries, particularly in Central and Eastern Europe.
Workshop delegates suggested that there had been a missed opportunity for closer working between all levels of UK Government departments and agencies with the introduction of the NEHAP. At a national level there was perceived to be an active engagement, but it was felt that there were other drivers of environment and health, not just the NEHAP. It was also noted that there was no implementation process attached to the UK NEHAP, and that this would have been beneficial at a regional and local level for the development of local action plans. Nonetheless, it was suggested that the NEHAP might have had an indirect influence on national policies and plans, though perhaps not in a measurable way.
General impacts. The majority of stakeholders expressed the opinion that the EEHP, together with the Ministerial Conferences, provided an important focus for bringing together environment and health interests from a multi-sectoral background and for coordinating environment and health policies and initiatives at a pan-European level. The EEHP was considered to have been beneficial for the UK as a whole by allowing it to participate in European discussions and bringing it into contact with other European partners to discuss and debate the way forward. In addition, several stakeholders suggested that the process had had a number of indirect influences and impacts in the UK; for example: (i) the process had strengthened relationships and promoted cooperative working between Government departments responsible for environment and health issues; (ii) the process had influenced the approach and thinking of UK Government departments towards environment and health issues; and (iii) the process had raised awareness (particularly through the London conference), and this had had a positive impact on the political profile of environment and health issues in the UK.
The London conference was also thought to have stimulated NGO interest in the relationship between environment and health. One professional body felt that the conference had provided it with a wider perspective and links into broader environment and health policies and processes that would not have occurred had the London conference been hosted elsewhere.
Responses to questions about whether the impacts identified would have occurred without the EEHP, and whether the form of changes would have been different, were mixed. Most respondents thought that the changes would have occurred anyway, but not in the same way and with less focus. In particular, it was commented that the UK would probably have interacted with European counterparts in other ways, but that the EEHP had provided a consistent and comprehensive framework for environment and health issues, which would otherwise be absent, and that without the process, initiatives would probably have been confined to EU countries only.
Other issues. Several stakeholders commented on the difference between the needs of Western and Eastern European countries in the WHO European Region and the difficultly the EEHP faced in developing initiatives that are relevant to both groups. In particular, it was commented that the Central and Eastern European countries perhaps look more to the EEHP for a lead in environment and health policy guidance, whereas Western European countries and the EU provide support for the process and see it more as an opportunity for cooperation and collaboration rather than a source of guidance on policy. It was also suggested that there needs to be greater coordination of the EEHP with EU activities, particularly in the light of the accession of some of the newly independent states which, in the past, may have looked to the WHO and EEHP for an environment and health policy lead, but will now look more to the EU.
During the questionnaire survey and workshop, several stakeholders commented on their own, and a general, lack of awareness of the EEHP. One stakeholder commented that the process is not well understood, even by those who are working in environment and health policy areas of relevance to the EEHP. As a result it was suggested that the EEHP needed to both be better promoted and made clearer to all stakeholders.
Review of policy documents. The Internet searches identified 36 UK Government documents referring directly to outcomes of the EEHP. These included transcripts of debates in the House of Commons, national policy documents and plans, Governmental reports, guidance documents, and local authority plans and strategies.
Outcomes of the EEHP were discussed in the House of Commons on seven occasions. In particular, in July 1990, the Prime Minister stated that Government policy was already consistent with the principles of the European Charter on Environment and Health and that the Government was active in all the priority areas listed in the Charter.6 The EEHP and the third Ministerial Conference were debated at length in June 1999.7 During the debate the Government stated that the Charter on Transport, Environment and Health would be complementary to the Government's integrated transport policy, and that the Protocol on Water and Health would mean the high EU and UK water quality standards would be extended throughout the European continent. The Charter on Transport, Environment and Health was also referred to in a response to a parliamentary question about the Government's commitment to achieving the targets in the Charter, when the Government confirmed its commitment and the White Paper on transport was cited as providing the national framework for creating a better, more integrated transport system; the Charter was also cited in a debate on night time flights and aircraft noise.8,9 Outcomes of the EEHP were mentioned on three other occasions, but were not discussed at any length.
The House of Commons Select Committee on European Scrutiny considered the European Community's proposal to accede to the Protocol on Water and Health.10 In a memorandum from the Minister for the Environment to the Committee, the Minister suggested that the Government considers the main benefit of the Protocol (which has yet to be ratified by the UK) as its provision of a framework within which Central and Eastern European countries can move towards the European Community's standards of water related health. The Minister also noted that the EU has already adopted legislation that meets all the substantive obligations of the Protocol.
Amongst four policy documents identified citing outcomes of the EEHP, only one, The Future of Aviation (a policy consultation document), explicitly stated that an outcome of the EEHP, the Charter on Transport, Environment and Health, would be taken into account in so far as it is relevant to air transport policy.11 In two other policy documents reference is made to a proposed revision of the NEHAP.2,12 The NEHAP itself states that it is the means to achieve the objectives of the Environmental Health Action Plan for Europe in the UK.3
The EEHP and the Third Ministerial Conference were also cited in several other Governmental reports. Several annual reports from the then Department of the Environment, Transport and the Regions (DETR) and the Department of Health, mention the EEHP in the context of these Departments' involvement and collaboration in the EEHP and in hosting the third Ministerial Conference.13–16 Other reports cite the Protocol on Water and Health as an example of UK involvement in pan-European cooperation and state that the DETR and Department of Health are actively engaged in promoting the implementation of the Charter on Transport, Environment and Health.17,18 Several other documents cite the NEHAP, stating that it built on existing strategies for sustainable development and that it was published to take forward Agenda 21.12,19
Finally, the Charter on Transport, Environment and Health is quoted in a guidance document for local authorities concerning sustainable transport, health and environment policies.20 The Charter is subsequently cited in several local authority documents concerning health improvement and local transport plans (e.g. Somerset County Council).21
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Discussion |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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The EEHP appears to have had only a marginal direct impact on UK environment and health policy in recent years. This is evidenced by the stakeholder responses and paucity of direct references to outcomes of the EEHP in policy and other Government documents on environment and health issues. However, the Charter on Transport, Environment and Health appears to have had some influence by being taken into account in the development of some transport policy, such as on aviation and at a local level. Other impacts of the EEHP in the UK appear to be mainly indirect. In particular, the process appears to have raised the political profile of environment and health issues, especially at the time of the third Ministerial Conference, and to have resulted in a closer working relationship between Government health and environment departments. It also seems to have been valuable in coordinating action on environment and health matters throughout Europe.
The general lack of significant direct impact of the EEHP in the UK appears to be for several reasons. In particular, there are other stronger influences on UK environment and health policy, such as EU Directives and domestic concerns. This is illustrated in the UK Sustainable Development Strategy, which cites the EU as being ‘especially influential’.2 Also, these policy drivers have resulted in the UK already meeting many of the environment and health standards proposed under EEHP outcomes (e.g. under the Protocol on Water and Health). However, the lack of awareness of the EEHP and its outcomes amongst stakeholders may also be a contributory factor to the lack of significant impact. This lack of awareness of the process was also apparent in other countries participating in the pilot evaluation.5 The influence of the WHO technical guidance documents was highlighted by several stakeholders. These appear to have been influential, as it has been possible to apply them in support of existing national policies, rather than requiring the promulgation of new policy or the amendment of existing policy.
The most obvious impact of the EEHP in the UK was that it precipitated the development of the UK NEHAP, although this seems to have had only a limited impact nationally. This is probably as a result of the NEHAP being superseded by other policy documents relatively soon after it was published, and the lack of an implementation process and indicators associated with the plan. These can help to drive policy and decision-making and provide a basis for monitoring and evaluation.22 The implementation of NEHAPs in most countries is seen as a process that may take up to 20 years.23 Therefore, it is not surprising that the UK NEHAP did not result in significant impacts during the relatively short time it was extant. Furthermore, the suggestion that a weakness of the UK NEHAP was the lack of means to measure its impact reflects the experience of other countries. For example, Switzerland has encountered similar challenges in the implementation of its NEHAP, where a lack of indicators has hindered the measurement of its impact.24 Indeed, it has been noted that the importance of NEHAPs does not lie so much in the plans themselves, but in the processes which have to be set up to develop and apply them.23 To address this weakness, the WHO has recently developed a comprehensive set of environmental health indicators for use in NEHAPs.25 However, whilst being beneficial for monitoring processes and international comparisons, such indicators are not always suitable for monitoring the implementation of NEHAPs in individual countries.26 Despite the lack of a national impact, the UK NEHAP does appear to have had an international impact by being a model upon which other countries, particularly Eastern European countries, have based their own NEHAPs.27
Given that this evaluation was conducted over a relatively short period of time and that some stakeholders suggested by the ISC were not able to participate, it is possible that some impacts of the EEHP in the UK may not have been identified. This is supported by comments from several participants that the corporate memory in their organization was not always sufficient to identify impacts of the EEHP that may have occurred several years previously. As a result, the EEHP may have had a wider influence in the UK than identified here. Furthermore, it should be borne in mind that the EEHP is an ongoing process and that some of its outcomes, such as the Charter on Transport and Health, and the Ministerial Conference in Budapest, may yet result in further influences and impacts on UK policy and plans and, subsequently, on environmental and public health. The EEHP may also have had, or be having, an impact internationally; for example, the EEHP appears to have influenced the EU's Environment and Health Strategy, which, in turn, may have important influences throughout EU Member States.
In conclusion, the EEHP appears to have had little direct impact on UK environment and health policy and plans. However, the UK's involvement in the EEHP has been beneficial in raising political awareness of environment and health issues and providing a valuable international forum within which to collaborate and coordinate environment and health policy.
Key points
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Acknowledgments |
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We would like to thank those who gave their time to respond to the questionnaire or be interviewed and those who attended the workshop. We also thank the UK Department of Health for funding this evaluation, and particularly Gareth Jones and Eileen Lawrence for their support of the project. The views expressed here are those of the authors, and do not necessarily represent those of any UK Government department or agency.
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References |
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TopAbstractEuropean Environment and Health...UK environment and health...Evaluation of the EEHPEvaluation methodologyQuestionnaire survey and...Review of policy documentsImpacts and influences of...DiscussionReferences |
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1 WHO Regional Office for Europe. Contribution of Health to the Agenda of the Fifth "Environment for Europe" Conference, Kiev, May 2003. Working Paper No. WGSO/EXECOM-4/2002/5. Kiev: Ad Hoc Preparatory Working Group of Senior Officials "Environment for Europe" Executive Committee, 2002.
2 DETR. A Better Quality of Life. A Strategy for Sustainable Development in the UK. London: The Stationery Office, 1999.
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11 DETR. The future of aviation—consultation on air transport policy. London: Department for the Environment, Transport and Regions, 2000.
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25 WHO European Centre for Environment and Health. Environmental Health Indicators for the WHO European Region: Update of methodology. Report No. EUR/03/5039762. Copenhagen: World Health Organization 2002.
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27 Cizkova H, Kazmarovà, Dumitrescu A, Janikowski R. The NEHAP experience in the Czech Republic, Romania and Poland. In: Briggs DJ, Stern R, Tinker TL, editors. Environmental health for all. Risk assessment and risk communication for National Environmental Health Action Plans. Dordecht: Kluwer Academic Publications, 1999:17–34.
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