Health and Environment in Europe: Progress Assessment - Annexes

This text is taken from the WHO report "Health and Environment in Europe: Progress Assessment", 2010, ISBN 978 92 890 4198 0. [2]

Annex 1

Countries which responded to WHO’s survey on environment and health policies (June 2009) and survey on CEHAPE (November 2009)

List of policy topics

Intersectoral collaboration

1.1. Drinking-water quality

1.2. Sanitation and sewage

1.3. Bathing water quality

1.3.1. Coastal and freshwater quality

1.3.2. Swimming pool water quality

2.1. Road transport injuries

2.2. Unintentional injuries excluding road traffic

2.3. Physical activity

3.1. Outdoor air quality

3.2. Dampness and mould in indoor air

3.3. Second-hand tobacco smoke (SHS)

4.1. Noise

4.2. Food safety

4.3. Chemical safety − pesticides

4.4. Chemical safety − heavy metals

Country

WHO POLICY SURVEY

CHEAPE Survey

Intersectoral Collaboration

RPG I Water & Sanitation

RPG II Injuries

RPG III Air Quality

RPG IV Chemicals & Noise

Optional

1.1

1.2

1.3.1

1.3.2

2.1

2.2

2.3

3.1

3.2

3.2

4.1

4.2

4.3

4.4

UV

Radon

1

Albania

X

2

Andorra

x

x

x

x

x

x

x

x

x

x

x

x

3

Armenia

x

x

4

Austria

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

5

Azerbaijan

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

6

Belarus

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x*

7

Belgium

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

8

Bosnia and Herzegovina

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

9

Bulgaria

x

x

x

x

x

x

x

x

x

x

x

x

x

10

Croatia

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

11

Cyprus

x

12

Czech Republic

x

13

Denmark

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

14

Estonia

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

15

Finland

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

16

France

x

17

Georgia

x*

18

Germany

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

19

Greece

x

x

x

x

x

x

20

Hungary

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

21

Iceland

22

Ireland

x

x

x

x

x

x

x

x

x

x

x

x

x

x

23

Israel

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

24

Italy

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

25

Kazakhstan

26

Kyrgyzstan

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

27

Latvia

x

x

x

x

x

x

x

x

x

x

x

x

x

28

Lithuania

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

29

Luxembourg

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

30

Malta

x

x

31

Monaco

32

Montenegro

x*

33

Netherlands

x

x

x

x

x

x

x

x

x

x

x

x

34

Norway

x

x

x

x

x

x

x

x

x

x

x

x

x

35

Poland

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

36

Portugal

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

37

Republic of Moldova

x

x

x

x

x

x

38

Romania

x

x

x

x

x

x

x

39

Russian Federation

x

x

x

x

x

x

x

x

x

x

x

x

x

40

San Marino

41

Serbia

x

x

x

x

x

x

x

x

x

x

x

x

x

x

42

Slovakia

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

43

Slovenia

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

44

Spain

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

45

Sweden

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x*

46

Switzerland

x

x

x

x

x

x

x

x

x

x

x

x

x

x

47

Tajikistan

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

48

The former Ygoslav Republic of Macedonia

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

49

Turkey

x

x

x

x

x

x

x

x

x

x

50

Turkmenistan

x

51

Ukraine

52

United Kingdom

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

x

53

Uzbekistan

x

Number of answers

38

36

32

35

32

31

29

31

36

31

36

35

31

32

32

29

22

28

46

*Countries which responded to the CEHAPE survey after the deadline. These data were not, therefore, included in the analysis.

Annex 2

List of ENHIS fact sheets

Environment and health information system [web site]. Copenhagen, WHO Regional Office for Europe, 2010 ([www.euro.who.int/enhis]).

1.1	Outbreaks of waterborne diseases
1.2	Public water supply and access to improved water sources
1.3	Wastewater treatment and access to improved sanitation
1.4	Bathing water quality
2.1	Mortality from road traffic injuries in children and young people
2.2	Mortality in children and adolescents from unintentional injuries (falls, drowning, fires and poisoning)
2.3	Prevalence of excess body weight and obesity in children and adolescents
2.4	Percentage of physically active children and adolescents
3.1	Prevalence of asthma and allergies in children
3.2	Infant mortality from respiratory diseases
3.3	Exposure of children to outdoor air pollution (particulate matter)
3.4	Exposure of children to second-hand tobacco smoke
3.5	Children living in homes with problems of dampness
3.6	Proportion of children living in homes using solid fuel
3.7	Policies to reduce the exposure of children to second-hand tobacco smoke
4.1	Incidence of childhood leukaemia
4.2	Incidence of melanoma in people aged under 55 years
4.3	Persistent organic pollutants (POP) in human milk
4.4	Exposure of children to chemical hazards in food
4.5	Levels of lead in children’s blood
4.6	Radon levels in dwellings
4.7	Work injuries in children and young people

Annex 3

Policy survey and policy analysis methods

Data collection

Information concerning the policy framework and measures in each Member State was collected through a survey instrument. The questionnaire was in 16 parts, each focusing on separate EH topics across the four regional priority goals. Each part consisted of 13 questions designed to collect information about national policies addressing policy framework, type of policy, scope, objectives, policy targets, equity considerations, implementation, enforcement, monitoring and evaluation of policy, health sector involvement and the provision of information to the public. The general part of the questionnaire collected information about collaborative structures supporting health policy integration.

The questionnaire (in English or Russian) was distributed to all 53 Member States in the Region, of which 40 replied. Once all questionnaires had been received, some initial results were put together and presented at a meeting of all participating countries (in Bonn on 22 and 23 June 2009). During the meeting, some concerns were raised about the ambiguity of some questions. These concerns were addressed and once all participants had a clear understanding of all questions, time was given for countries to make appropriate revisions to their replies.

At the same meeting, participants discussed and adopted the model for the policy analysis, which incorporated answering options from the policy questionnaire.

Data analysis

The analysis used for this policy assessment is rooted theoretically in three constructs: public governance, healthy public policy, and transparency and communication. All constructs were developed in order to retrieve valuable information about policy development while emphasizing the importance of health in policy and the health impacts related to policy. From these constructs, six dimensions were created to highlight key policy aspects. For each dimension, answering options from the questionnaire were selected and used as indicators to measure a country’s strength within a given dimension.

Public governance

The construct of public governance focused mainly on the development, implementation and enforcement of public policy and compliance with it. The following is a brief explanation of the dimensions within this construct.

Dimension 1: Policy development

The purpose of this dimension is to explore which types of policy have been implemented and at which political level policy regulation is governed. Country replies allowed for an assessment of policy development in order to determine which policies had been implemented in a systematic and consistent manner.

Dimension 2: Implementation and enforcement

This dimension was established to investigate methods set in place to monitor compliance with policy. It assesses what techniques are used such as standardized criteria for monitoring, regular reporting and the designation of a competent authority to control compliance. Action taken in the event of non-compliance is also relevant to this dimension.

Healthy public policy

Healthy public policy is a rather novel concept which has yet to be clearly defined. Its purpose is to increase the involvement of the health sector throughout policy development and across all sectors of government. Furthermore, healthy public policy aims to make policy more accountable for its health impacts in relation to the whole population and in particular to vulnerable population groups, such as children. The aspects included in the concept are presented in.

Dimension 3: Accountability for health

This is a broad dimension which focuses on policy-makers’ ability to incorporate health accountability into policy development. It investigates the use of evidence and information about health risks in the setting of policy targets and in monitoring progress towards those targets. Monitoring and surveillance measures must be based on health-relevant indicators (such as a valid population exposure) in order to be accountable for health. This dimension also considers action and measures for making policy accountable for its health impact, as well as information provided to the public about the current situation of health risks or possible health benefits.

Dimension 4: Involvement of the health sector

The aim of this dimension is to investigate the involvement of the health sector at each stage of policy development. Assessment is based primarily on mechanisms in place to ensure such involvement throughout policy formulation, implementation, evaluation and the preparation of information concerning related health risks. Control and enforcement are also taken into account, but with less direct relation to the health sector.

Dimension 5: Equity considerations

The rationale for this dimension is to determine which population groups are taken into account during policy development. Consideration of various population sub-groups and action taken to protect such groups are measured and assessed. The primary focus in this analysis is on children although other relevant groups are also taken into account.

Transparency and communication

Dimension 6: Information to the public

The answering options selected to evaluate strength in this dimension are indicators of how easily the public has access to important policy information. This dimension also assesses information given to the public with the purpose of promoting health, educating them about the benefits of given interventions and raising awareness of relevant health risks and policy action plans. It is important to note that information which is publicly available should also be provided in a manner which is comprehensible to everyone.

Calculation of scores

Once the dimensional model had been developed and approved by all participants, country scores were calculated. For each answering option, countries were awarded 1 point if they answered “yes” or 0 points if they answered “no”. All points were then added up for each dimension, divided by the maximum possible score in each dimension and multiplied by 100. Using scores out of 100 gave consistency to all dimensions and allowed scores for all dimensions to be displayed using radar plots. Country scores were then aggregated in country group scores, which were the averages of scores for all countries in a given group.

Aspects covered by the dimensions of public governance

Policy aspects covered by the dimensions in healthy public policy

Policy aspects covered by the dimensions in transparency and communication

In a few cases, scores other than 0 or 1 were given. Answering options which displayed a lack of crucial measures were given -1 point. For example, countries which reported no measures in place to ensure compliance for road traffic injuries lost 1 point from the overall score of implementation and compliance. On the other hand, answering options which represented strong policy measures were given 2 points. For example, countries which reported having policies for bathing water quality which followed EU legislation or were covered by national statutory policies were awarded 2 points. Lastly, to avoid double-counting, some scores were merged. For example, countries which reported policy objectives and/or targets based on international commitments were only awarded 1 point, regardless of whether they had answered yes to one or both options.

Example of answering options used in scoring drinking-water quality

Drinking-water quality	Ideal score	Country X
Policy developments
National/federal policy in place
Mostly following EU legislation	1	1
Covered by national statutory policies	1	1
Covered in non-statutory initiatives	1	0
Policy objectives
Compliance with drinking-water quality standards/regulations for:
microbiological and chemical indicator parameters	1	1
continuity of supply	1	1
control/reduction/abatement of pollutants at the water supply source	1	1
building infrastructure and management of drinking-water supply	1	1
health risk reduction/prevention	1	0
preparedness and response to emergencies ensuring health protection	1	1
Basis for target-setting
International/EU commitments	1	1
National: sectoral policy strategy, experience gained in the country	1	1
Total	11	9
Score ((XX/11)*100)	100.0	81.8
European Region average	74.2
Implementation and enforcement
Polocy compliance defined and reported
Legally binding according to pre-defined criteria	1	1
Mandatory reporting on pollution level according to pre-defined format	1	0
Existence of a designated competent authority	1	1
Measures in case of non-compliance
Prohibition or restricted use of contaminated water supply dangerous to health	1	0
Penalties for infringements of the legal provisions to ensure their implementation	1	1
Appropriate remedial measures to minimize the risk of non-compliance and restore the water quality with priority given to rectifying problems at the source	1	1
Specific action aimed at the protection of the population at risk	1	1
Methods/criteria for monitoring
As in EC legislation, international standards, guidelines	1	0
As prescribed in national standards, guidelines	1	1
Total	9	6
Score ((XX/9)*100)	100.0	66.7
European Region average	70.0
Accountability for health
Basis for target-setting
Information on health risks related to pollution of drinking-water	1	1
Health impact assessment	1	0
Monitoring progress towards policy targets
Monitoring network for drinking-water quality, including data collection	1	0
Periodic reports available and used to review policy obligations and targets	1	0
Specific indicators coupled with targets to measure progress towards the attainment of policy objectives	1	0
Introducing water safety plans that monitor water quality throughout the chain from source to consumtion	1	0
Measures in place to ensure health accountability
Permanent health surveillance, e.g. outbreaks and diseases related to drinking-water	1	1
Mandatory periodic evaluation and follow-up on the health consequences	1	0
Health impact assessment to define policy effectiveness	1	0
Total	9	2
Score ((XX/9)*100)	100.0	22.2
European Region average	54.8
Health sector involvement
Mechanisms to ensure health sector involvement throughout policy cycle
Policy formulation – defining the health impact	1	0
Policy implementation – relevant monitoring/surveillance	1	0
Policy evaluation – assessment and reporting back	1	0
Control and policy enforcement	1	1
Dissemination of information on health risks of drinking-water pollution	1	1
Total	5	2
Score ((XX/5)*100)	100.0	40.0
European Region average	84.1
Equity considerations
Population groups considered in policy
Potentially highly affected	1	0
Groups at high risk from small water supplies	1	0
Children	1	0
Deprived population subgroups	1	0
Total	4	0
Score ((XX/4)*100)	100.0	0.0
European Region average	30.9
Transparency and communication
Information provided to the public
Current quality information on drinking-water readily available through easily accessible media	1	1
Information on action programmes and water safety plans	1	0
Regular public reports on drinking-water quality	1	0
Reports describing health impact of pollution in drinking-water	1	0
Promotion of action and sustainable use of water supply zones	1	0
Total	5	1
Score ((XX/5)*100)	100.0	20.0
European Region average	62.3

Radar plot displaying scores calculated for country X and the European Region average for drinking-water quality

Radar plot displaying scores calculated for country X and the European Region average for second-hand tobacco smoke

Example of answering options used in calculating scores for second-hand tobacco smoke

Second-hand tobacco smoke	Ideal score	Country X
Policy development
National/federal policy in place
Covered by national statutory policies	1	1
Covered in non-statutory initiatives	1	0
Policy objectives
Specified population subgroups
Whole population	1	1
Creation of smoke-free environments:
at homes	1	0
private cars	1	0
Smoking ban in public places:
bars and restaurants	1	1
hospitals	1	1
education facilities	1	1
offices	1	1
shops	1	1
arenas for sport or leisure activities	1	1
public transport and terminals	1	1
Reduction of (active) smoking prevalence	1	1
Basis for target-setting
International/EU guidelines	1	1
National/sectoral policy strategy, experience gained in the country	1	0
Total	15	11
Score ((XX/15)*100)	100.0	73.3
European Region average	66.5
Implementation and enforcement
Policy compliance defined and reported
Legally binding according to pre-defined conditions	1	0
Mandatory reporting according to pre-defined format	1	1
Existence of a designated competent authority	1	1
Measures in case of non-compliance
Penalties for infringements of the legal provisions to ensure their implementation	1	1
Prohibition or restricted use to eliminate the risk of non-compliance	1	0
Methods/criteria for monitoring
As in EC legislation, international standards guidelines	1	0
As prescribed in national standards, guidelines	1	0
Total	7	3
Score ((XX/7)*100)	100.0	42.9
European Region average	47.8
Accountability for health
Health impact assessment	1	1
Scientific development in the field of health risks to seond-hand tobacco smoke (ETS)
Monitoring progress towards policy targets
Systematic monitoring of actual smoke-free environments	1	0
Periodic reports available and used to review policy obligations and targets	1	1
Specific indicators coupled with targets to measure progress towards the attainment of policy objectives	1	0
Measures in place to ensure health accountability
Permanent health surveillance	1	0
Mandatory periodic evaluation and follow-up on health consequences	1	0
Health impact assessment to monitor policy effectiveness	1	0
Total	7	2
Score ((XX/7)*100)	100.0	28.6
Health sector involvement
Mechanisms to ensure health sector involvement throughout policy cycle
Policy formulation - defining the health impact	1	1
Policy implementation - relevant monitoring/surveillance	1	1
Policy evaluation - assessment and reporting back	1	1
Control and enforcement of policy	1	1
Dissemination of information on health risks of second-hand tobacco smoke	1	1
Total	5	5
Score ((XX/5)*100)	100.0	100.0
European Region average	79.1
Equity considerations
Population groups considered policy
Specified population subgroups
High-exposure groups	1	1
Children	1	1
Pregnant women	1	1
Deprived population subgroups	1	1
Workers	1	0
Total	5	4
Score ((XX/5)*100)	100.0	80.0
European Region average	39.7
Transparency and communication
Information provided to the public
Information on extent of second-hand tobacco smoke readily available through any easily accessible media	1	1
Regular public reports on smoke-free environments	1	0
Promotion of action to achieve 100% smoke-free environments	1	1
Reports describing health risks of second-hand tobacco smoke	1	1
Total	4	3
Score ((XX/4)*100)	100.0	75.0
European Region average	55.9