Maximum returns on development investment

Even while his country was still recovering from the impact of the devastating tsunami that hit southeast Asia late last year, Maumoon Abdul Gayoom, President of the Maldives, urged the international public health community to think ahead about less apparent but equally critical long term threats to health and well-being.
By Diarmid Campbell-Lendrum, HELI secretariat, World Health Organisation; Hamed Bakir, WHO Regional Centre for Environmental Health Activities, Amman, Jordan; and Pierre Quiblier, HELI secretariat, UNEP

Opening the World Health Assembly in May 2005, President Gayoom noted that while natural disasters and global pandemics such as Aids grab headlines, local forms of environmental pollution, as well as global environmental changes, can also have profound impacts on health. In the case of Small Island States like the Maldives, trends such as climate change, can threaten the “very survival of the nation”.

“Rising temperatures could kill the coral which forms the basis of our habitat. We would indeed suffer economic ruin if corals die, but it would also starve the nation of essential supplies of fish which forms part of the staple. Moreover, global warming would also alter the epidemiological pattern, with an increase in vector-borne diseases and the emergence of more virulent forms of tropical diseases. And perhaps what is worse, as the seas rise, the water aquifers and the soil are likely to be poisoned by excess salination,” he told an Assembly focused on tackling the most urgent threats to health.

“The links between the environment and health show that addressing the challenges in both areas calls for a global partnership, where everyone becomes part of the solution and none a problem... at the end of the day, prevention is still better than cure. And let that be our goal in promoting environmental health,” he added.

There are some grounds for hope; partnerships are beginning to be formed that view environment and health as integrally linked, and consider the threats posed by emerging issues, such as global environmental change, in an integrated manner. The recent Millennium Ecosystem Assessment, carried out by the UN and specialised agencies from climate stabilisation to food production, underpin all aspects of human health and well-being. The report stresses that the Earth’s natural resources are being strained to capacity and the harmful consequences of this degradation to human health are already being felt. Impacts could grow signifi- cantly worse over the next 50 years.

The assessment’s health synthesis report notes, for example, that at least five out of the top 10 infectious disease killers globally, from malaria to dengue to diarrhoea, are closely related to environmental factors, such as water availability and climate conditions. While such relationships are well established at a local level, the report also shows how global changes, such as the widespread degradation of freshwater supplies, and the fact that global temperatures are increasing at their fastest rates for at least the last 10,000 years can impact on local effects. It documents interconnections too, pointing out how actions to improve certain aspects of human wellbeing can have a wide range of important consequences, including for health. For example, it is becoming clear that certain consumption habits probably helped diseases such as Sars to cross over to human populations. Similarly agricultural practices that create new ecological interactions, have increased the risk of avian influenza becoming a global pandemic, with potentially devastating consequences.

Demonstrating a threat does not provide a solution in itself. As many health risks arise from complex, competing needs, they cannot always be solved by simple fixes. For example, irrigation schemes can increase agricultural production and local incomes, but can also provide habitats for mosquitoes and snails, enhancing transmission of diseases such as malaria and bilharzia (schistosomiasis). These kinds of situation require integrated decision- making, taking full account of the services that the environment provides to all aspects of well-being, from health, to security and personal wealth.

The need for such cross-sectoral solutions is also increasingly recognised at an international level. The final report of the United Nations Millennium Project, “Investing in Development,” outlines a practical plan for allowing the poorest countries to achieve the Millennium Development Goals by 2015. Underlining the vital link between the environment and defeating poverty, it notes that interventions that are implemented outside the health sector, such as improving the quantity and quality of water, or environmental conditions, provide the double benefit of addressing the MDGs on child mortality and environmental sustainability.

There are now some examples of an integrated approach to health, environment and development: the Canadian International Development Research Centre is promoting an Ecohealth approach; and a range of impact assessment procedures are being used in large-scale, donor-driven developments. But they are few and far between. Intersectoral actions are sometimes said to be “Blessed by everyone, and funded by no-one”. The two most effective ways of convincing a sceptical decision-maker are, first, to demonstrate that integration makes sound economic sense, and second, to quote case studies in which a cross-sectoral partnership has actually worked on the ground, providing more convincing recommendations.

Recent work within the joint UNEP/ WHO Health and Environment Linkages Initiative has shown that such partnerships can work, and that efficient integrated management of ecosystem services can show a big return on investment. One country assessment under this initiative is addressing water demand management in Jordan. It is one of the world’s most water-stressed countries, and the water it does have comes from underground aquifers with finite reserves. At the same time water-efficiency in farming is low, and approximately 30% of the domestic supply is lost through leakages. Although the entire population is connected to a high quality piped water supply, many poorer households use very little water each day. The net result is wastage of a precious resource, with far-reaching implications. Along with the direct economic cost of lost water, rapid water extraction requires imported energy for pumping and brings forward the date at which aquifers will dry up. An initial assessment has shown that households with low levels of domestic water consumption also tend to have higher diarrhoea rates (a complete analysis of this relationship is still under way).

The WHO Centre for Environmental Health Activities in Amman formed a national team of academic researchers along with representatives of the national Ministries of Health, Water, and Environment to examine the costs and benefits of a series of government proposals for investment in water efficiency. The assessment identified a wide range of benefits, but assigned money value to only a few of these: economic gains from reduced water loss, health gains from fewer cases of diarrhoea, and environmental benefits in terms of reduced costs of water-pumping. A series of conservative assumptions were also made: a high discount rate on the investment (decreasing the apparent value of future benefits), and ignoring the probability that both water and energy costs may well increase in the future.

Even this “complete cost, incomplete benefit” analysis suggests that water ef- ficiency measures are a good deal. Each dollar invested towards reaching the most ambitious water efficiency target should bring a return of $1.71 to $1.84 from the economic, environmental and health benefits examined, with the precise value depending on the degree to which it is assumed that increasing domestic water supply has a direct causal effect on reducing diarrhoea rates. A more complete account of benefits would make the investments look even more attractive; but this group reckoned they could already conclude that investing in water efficiency was money well spent.

The intersectoral group recommended that the Government adopt the most ambitious of its options for improving water efficiency, and that it should consider accelerating implementation to maximise the return on its investment. They also went beyond the economic assessment, proposing that measures be introduced to ensure that water savings are directed to the poorest populations, in order to reap the greatest benefits.

Working across sectors is notoriously difficult, and requires flexibility and understanding from all concerned. But the fact that all of the major government agencies, along with other actors, were involved from the beginning of the process, increased the scope and quality of the assessment. The fact too that they shared data, and were able to agree a set of consensus recommendations, strengthens the case for coherent and cost-effective government action. In the Jordanian experience, all the partners involved are now convinced that it is only by addressing health and environment issues together that the real value of each can be fully appreciated. Through their efforts and results they demonstrate that, in the long run, investing time and understanding to build partnerships can also pay dividends.

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