IMPLICATIONS OF PUBLIC POLICY ON HEALTH STATUS AND QUALITY OF LIFE
Item
- Title
-
IMPLICATIONS OF PUBLIC
POLICY
ON HEALTH STATUS AND
QUALITY OF LIFE
- extracted text
-
World Health Organization
South East Asia Regional Office
WORLD
HEALTH ORGANIZATION j
REGIONAL OFFICE FOR SOUTH EAST ASIA
ORGANISATION MONDIALE DE LA SANTE
BUREAU REGIONAL DE L'ASIE DU SUD-EST
k a ki ltd tta ta tea u a k aka kaka
Til.: 331 7804 - 23 Tilex: 31-65031 8 31-65095
RDOC(Docs)/94
20 January 1994
Your reference: Letter dated 12 January 1994
Please find enclosed copy of Document SEA/HSD/144
entitled "The Implications of Public Policy on Health
Status and Quality of Life, Bangalore 18-26 October
1989", as desired.
Dr Thelma Narayan
COMMUNITY HEALTH CELL
No.367, 'Srinivasa Nilaya'
Jakkasandra, I Main
I Block, Koramangala
Bangalore-560 034
/wl
)
This material is sent to you
k v
with the compliments of the
Reports and Documents Unit of the World Health Organization
Regional Office for South-East Asia
“712-
World Health House, NEW DELHI I 10.002. India Telcgr WHO NEW DEHLI
World Health House, NEW DELHI 1.10.002. Inde Telegr.. WHO NEW DELHI
The symposium was jointly organized by the World Health
Organization - South East Asian Regional Office and the Indian
Institute of Management, Bangalore.
The symposium benefited from the technical contributions of
many, in particular the participants themselves; the background
documentation and technical material provided by the WHO
Intersectoral Action for Health Working Group; and the exper
tise of the following institutions and individuals;
The Indian Institute of Management, Dr J.C. Bhatia,
Dr R. Dhar, Dr B. Ghosh, Dr S. Roy, Dr V.K. Tewari;
The Marga Institute, Dr E. Fernando, Dr G. Gunatilleke,
Dr N. Gunatilleke, Dr P.D.A. Perera; The University of
Indonesia, Dr A. Gani; Harvard University School of Public
Health, Dr M. Reich; Centre for Development Studies,
Trivandrum, Dr P.G.K. Panikar; Dr Aung Tun Thet, Myanmar;
and Dr U.M. Malla, Nepal.
The participants were grateful for the financial support received
from DANIDA, and would particularly like to thank the Gov
ernment of India and the State of Karnataka for having hosted
the symposium.
SEA/HSD/144
IMPLICATIONS OF PUBLIC
POLICY
ON HEALTH STATUS AND
QUALITY OF LIFE
BANGALORE, 18-26 OCTOBER 1989
WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR SOUTH EAST ASIA
NEW DELHI
Contents
Page
Introduction.................................................................................................. 5
Summary of Discussion..............................................................................9
I.
Agricultural Development Policy - Health Linkage................... 10
II.
Industrialization Policy - Health Linkage.................................... 22
III. Urbanization Policy - Health Linkage......................................... 34
Methodologies for Policy Analysis......................................................... 40
Specific Recommendations..................................................................... 47
Overall Recommendations.......................................................................61
Annexes.......................................................................................................63
Annex A - List of Participants............................................................ 64
Annex B - Method of Work.......................................... 69
Annex C - Bibliography
,-....... ........ ........................................ 71
Annex D - Programme of Work.-................. .....................................72
3
INTRODUCTION
For many years it was believed that development programmes and
projects, especially economic ones, would automatically improve health
status. While the link between economic well-being and better overall
health is certainly a strong one, an increase in income and economic
activity does not necessarily lead to improved health status. The Brundtland
*
Report
focuses attention on the state of the environment and the delete
rious effects of development activity which threaten the very survival of
our planet. The report brings into sharp focus the effects of development
projects and programmes on the environment.
There are three interrelated problems contributing to an impending
“Health Crisis’’. Each of these has worsened during the last few years,
together they draw attention to the urgent need for policy adjustment.
They are: the avoidable health hazards associated with development; the
cost of treatment of diseases caused by industrialization and urbanization;
the economic crisis which has slashed the health budgets of many
developing countries.
The Inter-Agency Regional Conference on Health Development held
in New Delhi from 20 - 24 March 1989 gave specific guidance on how to
deal with this crisis for the first time. It recommended that:
1.
(a)
the capacity of the Ministry of Health be strengthened to
analyze development projects to ensure that they do not have
a negative impact on health status;
*Our Common Future, The World Commission on Environment and Development,
Oxford University Press, 1987, Oxford, England.
5
(b)
this information be communicated to policy makers for policy
adjustment;
(c)
legal frameworks be developed for protection of health
status during development activities (e.g., in resettlement
schemes, insecticide use, food pricing, etc.);
2.
policy analysis based on existing problems be undertaken,
especially on the underlying causes of high morbidity and mortality ;
3.
(a)
health impact assessment be undertaken to identify those
aspects that have an influence on the existing situation;
(b)
modifications be suggested which would eliminate the
negative effects of development projects.
The Symposium held in Bangalore in 1989 was organized as a follow
up activity to the Regional Conference, and is the first activity of its kind
not only in the South-East Asian Region, but globally. Its principal
objective was to strengthen the negotiating skills of ministries of health
and representatives from relevant sectors for defending and protecting
health status in development programmes and projects. It focuses on a
very crucial but often neglected aspect of intersectoral action for health,
namely, “Implications of Public Policy on Health Status and Quality of
Life”.
Since it is impossible to deal with all aspects of public policy, as a first
step the relationships between development policies and health status and
quality of life were analyzed by studying three important areas in depth:
urbanization; industrialization; agricultural development.
The discussions focussed on the actions which could be taken by the
relevant sectors to reduce or eliminate health risk factors without abandon
ing their priority objectives and goals for development in their sector.
In order to facilitate this task three modules were developed. These
modules dealt with specific aspects of industrialization, urbanization, and
6
agricultural development, namely, occupational health and child labour,
housing and slums, irrigation and pesticides. Additional case studies,
together with country experiences, enriched the analyses.
During the course of discussion it became clear that health profession
als appreciated the goals of economic activity and were ready to contrib
ute to the attainment of these goals, however, they were not prepared to do
so at the expense of health status. Similarly development planners, and
those involved in formulating and implementing economic activities, ap
preciated that economic benefits can produce health gains.
There are many laws, regulations and policy statements in all the
countries which contain most of the specifications required for protecting
health status, but unfortunately these have either been partially imple
mented or not implemented at all. The case approach utilized during the
symposium enabled the participants to focus on real issues and, through
debate and discussion, to come up with alternative but feasible courses of
action.
7
SUMMARY OF DISCUSSIONS
Introduction
The Symposium was attended by key policy and decision makers,
senior implementers from health and other development sectors, experts
and researchers from institutes of development studies, development
agencies and nongovernmental organizations (NGOs). Participants from
the following eight countries attended the symposium: Bangladesh,
Bhutan, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand (see
Annex A for full list of participants).
Discussions focussed on specific issues of development activities, their
impact on health status and quality of life, and on methodological
problems faced by countries in analyzing policy issues of health relevance.
The participants felt that it was an achievement to bring together such a
highly heterogeneous, multisectoral, and multi-disciplinary group to
deliberate upon a topic which had never before been the subject of such
in-depth analysis. (See Annex B for method of work ).
Observations and policy options arrived at formed the basis of the
discussions that were held during the second phase of the symposium in
which participants were joined by policy makers from various sectors in
the participating countries. The latter attended in their personal capacities
allowing for more frank and critical analyses. It was during the second
phase that issues were more sharply identified and the feasibility of policy
options scrutinized further.
9
I. Agricultural Development Policy - Health Linkage
Case on Pesticide Use
The Issue - Pesticide use is necessary for increasing agricultural
production and productivity.
Although the case presented for discussion dealt with pesticide use in
Indian agriculture, it was felt that the situation was similar in all the
countries represented. It was agreed that agricultural production must be
increased rapidly in order to satisfy the needs of a rapidly growing
population, combat undernutrition among certain population groups and
respond to food security considerations, in addition to providing employ
ment and income to people in rural areas.
Unfortunately, the scope for increasing agricultural production through
horizontal expansion of land is very limited in many places. Cultivated
areas which have made a significant contribution in the past have regis
tered a sharp decline over time. Technology to increase yields in the form
of improved agricultural practices, use of high yielding varieties of seeds,
and increased use of fertilizers and irrigation has had a significant impact
on production levels in many places. However, crop varieties used,
intensive cultivation practices and new cropping sequences have led to an
increase in pest problems in agriculture. The practice of monoculture as
a result of the adoption of high yielding varieties has also led to an increase
in pest problems. In traditional agriculture the practice of intercropping
meant that pests, even if they attacked, did not spread as quickly, nor did
they ravage the whole crop.
Increased irrigation has added to the pest problem by creating environ
ments conducive to the reproduction of pests. All of the above factors have
resulted in increased use of pesticides. At the same time, pests are
becoming increasingly resistant to the pesticides utilized, leading to the
application of additional quantities of stronger and more harmful pesti
cides.
10
The Issue - Adverse Health Impacts of Pesticide Use.
In looking at the actual and potential impacts on health of pesticide use
it was pointed out that pesticides have varying degrees of toxicity on
different people, and in different situations. While the research findings
are not conclusive on the cause and effect linkages in pesticide use,
adverse reactions are highest among workers who are directly exposed to
pesticides. Many substances are highly contaminated with residues of
DDT, BHC, Pindane, Endrin, and other pesticides. Although the residues
appear to be within permissible levels in fruits and spices, they are above
the tolerance level in vegetables, cereals, oils and dairy products. In one
of the countries it was stated that pesticide poisoning from exposure or
involuntary ingestion was the sixth leading cause of hospital deaths in
1987.
Pesticides such as DDT and BHC once applied do not degrade easily
and can remain in the environment for as long as twenty years. The soil
becomes a reservoir for these pesticides, steadily transferring them to
edible crops, trees, and animal life, and polluting the ground water. It was
pointed out that Bangalore, once reknowned as a “garden city’’, now has
hardly any birds owing to the intensive agriculture in and around the city,
and the subsequent practice of using large amounts of pesticides which
have killed both plant and animal life.
It has been observed that adverse reactions to pesticides are highest
among workers who are directly exposed to them. Fragmentary evidence
in India points to liver injury due to toxic effects of pesticides among
workers who spray pesticides. Another study drawn from laboratory tests
conducted on animals indicates a higher susceptibility to adverse effects
of pesticides among ill nourished people when compared with the effects
on better nourished people.
In India high incidence of pesticide residues are found in food, human
fat tissue and the atmosphere. This is surprising given the limited use of
pesticides in India when compared with countries such as Japan, the
United States, and the United Kingdom. It was felt that this phenomenon
11
is largely attributable to the misuse of pesticides - wrong choice of
pesticide, misapplication, faulty storage, etc. This in tum can be ascribed
to lack of knowledge. For example, cases were reported in one country
where pesticides were stored in the kitchen along with household food
stuffs.
It might be worthwhile for each of the countries in the region to develop
a list of essential pesticides similar to the essential drug list. Essential
pesticides would be judged according to the following criteria:
harmful effects;
ii. cost effectiveness;
iii. efficacy;
iv. convenience in operation.
i.
The list which has already been published by FAO would be taken into
consideration when establishing the list of essential pesticides.
Some Policy Options
Legislation - Is it enough?
Some countries have no legislative measures en
acted, while others need to strengthen their laws to control
production or importation of pesticides and their distribu
tion. Most legislative measures are devoted solely to
control measures and little attention is paid to the effects
of human exposure to pesticide and the implementation of
monitoring activities to ensure judicious use. It was
pointed out that there is a strong need for interdisciplinary
and interinstitutional coordination to avoid duplication of
effort.
12
It was felt that controlling the use of pesticides by
legislative measures or administrative procedures alone is
not simple. The vested interests of industry, both the
manufacturers of the pesticides as well as the producers of
the agricultural commodities, are involved. If one type of
pesticide is banned, another will almost automatically
appear in the market claiming to be less harmful and more
effective.
Effective measures to prevent or decrease the ad
verse health effects of pesticides should be sought, and the
cost of these measures should be borne by the manufactur
ers. In this way the “polluters pay” principle would be
observed. At the same time, pesticide manufacturers
should provide proof that their products, which in princi
pal are less harmful or harmless to health, would not leave
behind any toxic residue in soil, agricultural products or
animals.
Research and development on pesticides should be
encouraged at country and regional levels. Relevant
departments in universities and institutes could provide the
necessary assistance in carrying out research and experi
ments in this area.
Community Involvement
While existing legislation on pesticide use is fairly
adequate in some of the countries, the actual implementa
tion of these legal provisions has not been satisfactoty.
One of the reasons for this is the limited capacity to install
an adequate supervisory mechanism due to cost implica
tions in employing sufficient staff. Another reason is as a
result of human failure.
13
In order to overcome these problems in implementa
tion and bring about the desired results in the control of
pesticides and reduction of adverse effects, pressures
exerted through society or the community would be very
effective. Community involvement and popular participa
tion in surveillance and monitoring of the use of safer
products and safety measures should be fostered. In some
countries the task could be started immediately since there
have already been successful instances of the participatory
approach to planning, implementing, monitoring and
evaluation.
Pesticide Epidemiology and Toxicology in Health
Curricula
Pesticide epidemiology and toxicology should be
introduced in health curricula to enable health personnel to
analyze and prevent additional health problems caused by
the use and misuse of pesticides. In some countries tradi
tional pest control practices exist and are used effectively
and these should be encouraged. Research on alternative
cropping patterns and biotechnology should be carried out
to develop safe and cost-effective methods of pest control.
In these endeavours cooperation of relevant international
organizations should be solicited if necessary.
Dissemination of knowledge through media
Much can be done to mitigate the ill-effects of
pesticides if people are made aware of the harmful effects.
In the face of widespread illiteracy, alternative means to
written messages should be found to inform people of the
harmful effects of pesticides, and how to apply safety
measures. The media should be utilized to inform farmers
14
and users of pesticides on how pesticides should be
handled, used and stored.
Action Research
Although the potential harmful effects of pesticide have been derived
from indirect studies of the toxic residues in food materials, atmosphere,
and soil, the ill-effects have not been firmly established with regard to
human beings. Action research is needed in at least three areas so that
decision makers will be able to examine the trade off between threatening
health hazards and increases in agricultural production and, on the basis of
this, make informed decisions. The areas suggested for action are:
i.
quantitative analysis of actual harmful effects of
pesticides including residues in food and environment;
ii.
means of substituting harmful pesticides with traditional
methods of pest control;
iii.
possibilities of reducing the cost of effective but less
harmful types of pesticides.
Case on Large Scale Water Development Projects
The Issue - Growing need for water development projects for
irrigation and energy.
The Narmada valley project was presented as an example of a large
water development project which many countries are familiar with. This
project is a controversial multipurpose project which has been receiving
a great deal of coverage lately in the press and is the subject of a debate
between the government, donors and beneficiaries.
15
Efficient utilization of water resources assumes great significance,
particularly in the context of a rapidly growing population. The Narmada
Valley Project was initiated to provide a range of benefits to large numbers
of people residing in the three Indian states of Gujarat, Madhya Pradesh
and Maharashtra. In India, as in many countries, multipurpose and other
dam projects are regarded as essential for meeting the requirements of
irrigation for agriculture, electricity for industries, as well as providing
flood control.
The Issue - Urgent need to mitigate adverse health effects caused by
changes in the environment.
It was pointed out during discussion that experience of similar projects
in other countries, while desirable for enhancing economic development,
posed a number of problems with regard to resettlement and adverse
effects on environment and health.
In the case of the Narmada Valley project cultivable land on which to
relocate the population displaced by the project was not available. Remaining
grazing lands had hardly any soil cover, were of very poor quality, and
were totally unfit for cultivation. Cash compensation provided was
inadequate in many cases and resulted in lowered living standards and
reduced quality of life among a large majority of displaced persons.
In Narmada, most of the displaced populations were tribal people. The
sudden influx of modem systems, destruction of the environment on
which their lives depended and, ultimately, displacement and resettlement
left tradition bound tribal families bewildered, powerless and on the verge
of total social, cultural and economic collapse. Many displaced people
drifted toward cities where they were unable to cope with the alien
environment and hardship. Those who have resettled still do not have
semipermanent houses and employment. Mortality rates have risen, food
reserves and incomes have fallen, and cattle are dying.
The building of irrigation dams increases the incidence of some dis
16
eases. Vector borne diseases such as malaria and schistosomiasis can be
increased through the creation of new breeding sites as a result of water
entrapment, or they can be brought into the area by the immigrant laborers.
Poor working conditions further increase the risk of malaria.
The incidence of filaria, cholera, gastroenteritis, and other water
borne diseases is also likely to increase when dams are built. Analysis of
the diseases of the command areas shows that malaria, schistosomiasis and
filaria require surveillance, monitoring and control measures, although
other possible ailments such as flurosis, skin infections, and sexually
transmitted diseases have also been cited as problems requiring attention.
In the case of the Narmada Valley project the Narmada Planning Group
entrusted a study to the Department of Botany of M.S. University, Baroda
to assess the impact of the project on the health profile of the population
residing in the Gujarat portion of the catchment area both above the
Narmada dam site as well as downstream. Information regarding the
incidence of various diseases was collected and the analysis of the disease
profile in the command area showed that the three important diseases
which would require surveillance, monitoring and control measures were
malaria, schistosomiasis, and filaria. A work plan for the health sector was
prepared by the Narmada Planning Group with the following objectives:
1. To provide for systematic and continuous monitoring of the
health profile of the project area.
2. To provide for suitable infrastructure facilities to take care of
preventive and curative measures required in the project area.
Despite the above study and work plan it was noted that no represen
tative from health appeared on either the Narmada High Power Commit
tee, or the Narmada Planning Group, nor were any further studies
undertaken to assess, monitor or evaluate the health situation. The health
sector thus appears to have been excluded from the planning and imple
mentation of the project. At the same time the health sector did not take
the initiative, based on the findings of the study and work plan, to take an
17
active role in ensuring that the health status of the population was
protected during the project life span.
Some Policy Options
Health Impact Analysis Assessment
In order to prevent and control these health condi
tions epidemiological surveys of the command area must
be carried out prior to the implementation of such proj
ects. New diseases that migrant laborers and other people
coming to the area may bring with them should be taken
into account in the health profile of the area and health
interventions undertaken as required.
Health impact analysis should include the following:
(a)
epidemiological study of the affected area;
(b)
identification of probable diseases associated
with the impounding of water in big
reservoirs;
(c)
base line health profile of the migrant people
and local population to find out the possible
morbidity pattern.
The Ministry of Health should play a pivotal role in
persuading the concerned sector, or sectors, such as minis
tries of Agriculture, Water Resources, and Interior to
introduce control and prevention measures during all
phases of the project. To facilitate this process it was sug
gested that an organizational mechanism should be set up
highlighting health impact considerations in non-health
18
ministries. Representation from ministries of health has
so far been neglected in committees responsible for pro
viding guidelines for the implementation of large scale
water development projects, as well as in committees that
oversee the implementation.
In some countries committees have already been set
up with representation from all the sectors concerned.
Steps need to be established so that these sectors share the
responsibility for carrying out epidemiological and other
health studies required, the costs of which should be
incorporated in the project costs.
Surveillance and monitoring
Appropriate methods of surveillance and monitoring
of health status, including early warning of emerging
health hazards should be developed and followed through
during the implementation of the project. In this connec
tion the formation of independent watch dog groups
(social organizations, NGOs) is helpful. Every effort
should be made to promote them at the local level to assist
people in obtaining promotive, preventive, curative and
rehabilitative services, as well as in securing compensation
for displacements or suffering caused by the project.
Bearing the cost of control and remedial measures
The externalities of a project such as deterioration of
health status, loss of income, adverse environmental
effects due to massive deforestation should be included in
the costing of the project during the feasibility study. As
an example of costing, mortality and morbidity rates could
be studied and baseline data established so that curative
19
measures are calculated for the restoration of the health
status to bench mark levels at least.
In many instances in spite of the availability of
control measures and the technology to implement them,
they fail to be accommodated on the pretext that the unit
cost of production would be too high, thereby rendering
the project infeasible. Even when control and safety
measures are included in the formulation phase of the
project, these are the first to be removed when austerity
measures are applied. Many are unaware, or do not appre
ciate, that the costs incurred to cure health problems
created are sometimes higher than the costs of taking pre
ventive measures.
An example of inadequate planning occurred when
the drainage component of an irrigation dam project in a
country was removed in a drive to cut down project
expenses. No one noticed that only economic parameters
were used for monitoring, while all health status parame
ters had been omitted. A few years after the completion
of the project a serious malaria epidemic occurred of such
magnitude that the country and policy makers had, and
still have, great difficulty in containing it. The resulting
costs have proved to be very high.
When the cost of prevention and control of adverse
health impacts is not borne by the project somebody still
has to pay the cost. This is usually the health sector
operating under stringent budgets, or the individuals them
selves.
20
Role of International Organizations
International agencies should play an active role in
mobilizing the necessary resources to help countries
introduce all the safeguards required in large scale water
development projects. A good example can be seen in the
case of the Narmada Valley project where the World Bank
emphasized the need to analyze the environmental issues,
as well as the hazards to health, so that the preventive
measures required could be accommodated.
Action Research
Actions to be taken by relevant sectors during feasibility studies and
project implementation should be based on solid evidence of the potential
adverse effects of large scale water development projects. Action research
is needed to carry out epidemiological studies of command areas and to
establish baseline health profiles of both migrant and local populations in
affected areas to establish morbidity and mortality patterns.
Research and development institutes could be instrumental in estab
lishing the evidence of negative health linkages associated with large scale
water development projects by carrying out detailed studies on the
diseases associated with water impoundment.
Yi?\D0
II. Industrialization Policy - Health Linkage
Case on Occupational Health Hazards and Safety in Indus
tries
The Issue -
Whilst it is agreed that industrialization as part of the
development process may have a positive effect on
populations through the provision of increased
incomes, goods and services, industrialization also
creates health hazards and causes accidents, often
leading to disability and deaths.
A poignant example is given of the kind of health hazards that are found
in the case of the slate pencil factories of Mandsaur in Madhya Pradesh.
There are some 90 slate pencil cutting units in the area and almost the
entire population is employed in this industry. A study showed that there
is hardly a man alive over 40 years of age in the area as a result of silicosis.
The saw dust generated during the cutting process is composed of 50-55
percent silica and is breathed in directly by the cutters. The first symptoms
of silicosis are seen after six months in coughs and colds, followed by chest
pains etc. The study revealed that 55 per cent of the workers had silicosis
and 18 percent had an advanced form of the disease. Developing countries
suffer from problems of low per capita income with a highly skewed
distribution of wealth, widespread poverty and unemployment, high costs
of production, poor quality of products and a fast-growing population.
Industrialization is an important means of alleviating these economic
problems. For this reason it was unanimously felt that industrialization
should be encouraged but that the proper steps should be taken to prevent
undesirable effects on health. These steps should be taken in conjunction
with industrial development efforts, and not as an afterthought, or as a
“crisis management” response to the health problems created.
22
Some Policy Options
Occupational Health Assessments
One of the first steps to be taken by the countries of
the region is to assess the occupational health situation
using suitable indicators. Among the indicators suggested
were:
i.
ii.
iii.
iv.
v.
the average age of death of industrial
workers;
morbidity due to service in industry;
mortality due to occupational diseases in
industry;
case fatality rate due to accidents;
active days lost as a result of absentee
ism of sick workers.
The Role of Legislation
Employers already burdened with high costs and
limited markets, look upon the costs of prevention of
health hazards and treatment of health problems as an
untenable additional cost. Enterprise managers are natu
rally concerned about increasing production and produc
tivity. Removal of health hazards of industrialization in a
labour surplus economy may not add to productivity
improvements, but it increases the cost of manufacturing.
Management would therefore tend to ignore health haz
ards in such circumstances unless they are forced to do
something about it. Workers who in many cases are
already suffering from undemutrition and have very sub-
23
standard living conditions generally value getting any job,
irrespective of the likely health hazards, and would expect
employers to compensate them for any injury, death or
disability resulting from their occupation.
But simply compelling employers to adopt suitable
measures as legislated in the Factories Act, the Work
men’s Compensation Act and the Employees State Insur
ance Act, would pose problems as shown in the case
studies from India. The department of factories of every
state is empowered to enforce these laws, but success
depends on availability of information, organizational
strength of the implementing body and the judiciary, as
well as knowledge of the cost of occupational health
hazards and safety measures.
These laws should be implemented not through the
welfare system which would burden workers further
through increased taxes, but rather through the industrial
sector, making their concurrence with laws a prerequisite
for obtaining an industrial licence.
The argument can be presented to employers that
taking into consideration the health and welfare of their
employees and their families can be a good investment
rather than an extra burden. The Japanese example is
often cited here as an illustration of how very high pro
ductivity (quality and quantity) can be combined with a
complete package of health and welfare benefits for
workers and their families during their lifetime up to
death, including the provision of health services, educa
tion for children, housing, etc., provided for by the em
ployer.
Ministries of health and industry should establish a
24
regular dialogue with one another to discuss means of
minimizing pollution through the siting of industries, their
spatial planning, and the adoption of preventive and
promotive measures to safeguard the health of people
already located near to factories. A coordinating body
could be set up to oversee the plan and activities of differ
ent sectors.
Providing Incentives
Employers should be stimulated to reduce the inci
dence of ill health and accidents in their companies.
Among the practical suggestions which arose during the
symposium was a yearly reduction of accident insurance
premiums as an incentive to employers to reduce acci
dents.
Employers should be encouraged to set up company
clinics and monitor the success of their management by
the degree to which health status is maintained amongst at
risk employees. Various schemes could be introduced on
an experimental basis in this area. Employers could create
a fund in the form of a health premium per employee per
unit of time, with health personnel being paid the remain
der of the premium after all charges for treating employ
ees have been deducted. In this way health personnel too
would be rewarded on the basis of the number of people
who do not fall ill.
There are difficulties in applying such a scheme
across the board as illness needs to be defined in relation
to the nature of the particular industry i.e., the health
effects of bauxite industries are different from those
associated with cement works.
25
Workers Action
Trade unions and workers associations have been
instrumental in defining workers’ rights and negotiating
for wages and compensation. These organizations should
now be encouraged to take relevant steps for the improve
ment of the health status of their members by working out
innovative proposals for negotiation with employers.
Dissemination of knowledge to the people: demystifica
tion of health
It is necessary to educate workers on the importance
of safety and prevention measures. To many, health
becomes a priority only when it interferes with their
ability to work and earn a living.
In the struggle to protect the environment many
people from a variety of backgrounds and education have
understood the basic message of the environmentalists and
have been persuaded to act to prevent environmental
damage. An example can be seen in the famous “chip
ko” movement where women protected trees by virtually
clasping them in their arms to prevent them from being
felled by unscrupulous profiteers.
The health sector could learn from what has been
accomplished by the environmental movement and launch
a large scale public campaign on occupational health
which would be simply stated in order to be understood by
all. The whole process of dissemination of knowledge and
education regarding occupational health, pollution, and
other aspects of industrial health and safety, should be
26
launched worldwide in a systematic manner. WHO
should take an active role in advocating and conducting a
community strategy in this area.
Action Research
Research institutes and individual researchers working in this area
should avoid carrying out research that has already been undertaken
elsewhere in the industrialized and in the developing countries. There is
a wealth of knowledge on such areas as occupational health hazards and
industrial hygiene which can be effectively used.
Simple and practical methods must be developed for studying both the
health of workers and the health factors of the work environment. This
will include regular monitoring of workers’ health and the working
environment, applications of the principles of industrial hygiene engineer
ing and ergonomics, accident reporting and identification of at risk groups
in different situations. The science of ergonomics which aims to relate the
fitness of machines and tools to human and physiological capacities
provides a valuable contribution to improving occupational health.
Detailed case studies of selected hazardous industries would help
pinpoint critical areas amenable to immediate change and would also
reveal areas where policy changes in different interlinking sectors would
be necessary to improve workers health.
These could be complemented by case studies of successful and inno
vative occupational health interventions in industries. Studies of the
cultural factors influencing human behaviour in industry would lead to
better understanding of the role these play in occupational health.
Case on Child Labour
The Issue - Child labour - a symptom of poverty.
Child labour was considered unacceptable because of its exploita
27
tive nature, the effect of adverse working conditions, and the denial of
educational and recreational opportunities on the health and quality of life
of children. Children working in industry suffer from physical and mental
health problems, and are often the victims of accidents at the place of
work. In response to this, relevant legislations have been enacted and
policies announced which govern the participation of children in the
labour force. It is now desirable to look at the evolution of these policies
and strategies, the organizational arrangements made to implement them,
and the managerial actions taken to benefit working children’s health.
Income from child labour plays a very important role in augmenting the
overall income of a family. According to a study conducted in Bombay,
child workers were found to contribute about 30 per cent of the total
monthly household income. A recent study in Bangalore has reported that
6 per cent of working children earned 100 per cent of the family income,
while 18 per cent generated between 50 and 100 per cent of the family
income.
An investigation of the reasons for entry of the children into the indus
trial labour force showed that 47.5 per cent of the children joined the
labour force at the insistence of their parents. Similarly, according to a
1979 ILO survey 23.4 per cent of working children cited poverty as their
reason for working.
Children are preferred to adult workers because they are docile and do
not grumble or revolt. They are agile, and are paid less than adults. At
times they are not paid at all on the pretext of training. Working children
get into a vicious circle; as their participation in the workforce continues
the drop out rate from schools increases, and as children fall further behind
with their schoolwork they find it increasingly difficult to go back to
school. This phenomenon is not solely the result of poverty, but has roots
in the inadequacies of the education system, which does not allow for
education and work to coexist. In some developing countries child labour
has been said to cause unemployment among adults. This in itself
increases the. incidence of child labour since unemployed adults force
children to work to support the family.
28
The Issue - Poor working conditions and the health status of children
Children are usually employed in industries such as match making,
beedi making, diamond polishing, sari embroidery, fish peeling, glass
*
works, plantations, tailoring, brick works, and the handloom textiles
industry. Because of the diversity of the institutions in which they work,
their working conditions vary greatly. These conditions are usually very
precarious since employers who choose children as workers are those who
do not want to pay “adult wages”, or give the amenities expected by adult
laborers.
Common characteristics of their working conditions include forced
inhalation of toxic powders, metal dust, paint or paint thinner, noxious
fumes which bum the eyes, possibility of electrocution, late night
work, exposure to high temperatures and deafening noise, frequent
industrial accidents, low wages, payment on a piece rate basis, etc.
Such working conditions lead to adverse health consequences. Hard
data on the health status of working children is scarce, but there are many
known or potential effects on children’s health which can be cited. A
series of examples were provided to the symposium participants on the
conditions of work for children. In the lock industry accidents with bodily
injury (loss of fingertips), occur as a result of exhaustion and carelessness
when carrying out the tasks of polishing, electroplating, spray painting
and working on hard presses. In this industry child workers are exposed
to the health risks of dealing with toxic chemicals and electrocution. Child
workers suffer from asthma, tuberculosis and other chest diseases, acci
dental poisoning and mental disorders.
In the slate pencil manufacturing industry the incidence of silicosis
indicates that children are more susceptible to this occupational hazard
than adults in the same industry. In the agate industry increases in the
prevalence of pneumoconiosis are directly related to the duration of
exposure. In a beedi factory, workers experience vomiting, headache,
* Beedi - small Indian cigarettes
29
giddiness, weakness and loss of appetite. In carpet weaving, workers
experience respiratory tract infection, headache, backache, and joint
pains. In tanning units the wet and slippery surface in the work area results
in numerous accidental falls into the vats, some of which are fatal. The
emanation of hydrogen sulphate from dirty tanning pots is life threatening
and many of the chemicals used in tanning cause dermatitis. In chrome
tanning, potential health threats include chrome ulceration on the hands
and occasional perforation of the nasal septum.
Children handling microscopically fine wire develope marked visual
impairments within 5-8 years. Children using handtools designed for
adults present a higher risk of fatigue and injury, while children using seats
and workbenches designed for adults have more problems in the muscu
loskeletal system.
Policy Options
The Effectiveness of Legislation
Many countries in the region have recognized the
adverse health and social effects on children who begin to
work early and have enacted laws to protect them. In
India, for example, where child labour dates back to 1881,
the Constitution, in the Directive Principle of State Policy,
states that no child below the age of fourteen years shall
be employed to work in any factory or mine, or other
hazardous employment. There are many acts which
specify different minimum ages at which children can start
work, as well as required working hours, rest, and medical
examinations. This indicates that the policy response to
the problems of child labour is adequate.
There is, however, a big gap between these policy
statements and their translation into action. Recent legis-
30
lation in India prohibits the employment of children under
fourteen in specified industries which are considered
hazardous, yet a large number of children are still em
ployed in these industries. It is clear, therefore, that the
existing legislation does not adequately protect the rights
of the child worker.
The main constraint is perhaps the lack of infrastruc
ture to enforce legislation. The enforcement of child
labour laws and regulations requires the establishment of
special monitoring bodies with staff and services specially
adapted to the total needs of children in the labour force.
The second constraint arises from the unorganized nature
of child labour in which little is officially known. It is
very difficult to penetrate these home based industries that
escape formal supervision. At the same time the home
based industries are encouraged to flourish as an important
means of generating income and employment, thereby
reducing poverty, as well as encouraging initiative and
creativity.
Poverty - the root cause
The alleviation of poverty is the principal long term
strategy that would drastically diminish child labour since
poverty appears to be the root cause. It is hoped that anti
poverty policies, educational policies, health-for-all poli
cies, nutritional policies and stepped up social services
will all help this pernicious situation.
However a number of other measures need to be
taken. Incentives or credit should be given to industries
who employ minimal child labour and provide adequate
prospects and safety measures for child workers. Special
measures should be adopted to make it less attractive for
31
families to send their children to work such as ensuring
better income generating activities for families who
depend on the income from child labour. This would
entail developing a profile of these families and educating
the community. Social pressure would help to bring about
greater change than simply relying on legislative and
administrative measures.
Different responses to different needs
The issue of child labour presents a complex picture
since it entails such elements as employment in the formal
or informal sector, and a variety of employment condi
tions. In order to deal with the different factors
preempting passage into the work force, child labour
needs to be viewed from several different perspectives and
the problems responded to accordingly.
It was suggested that child labour can be divided into three
categories:
i.
ii.
iii.
work in the informal sector;
work in the formal sector;
those working voluntarily.
There are different approaches to each of these
categories. For working children still attending schools
the schools could experiment by having special arrange
ments alongside the school curriculum for promoting
income generating activities that would help the child and
his family, e.g., special crafts. Schools could be instru
mental in helping children during school holidays, while
others could organize educational classes in the work
place for children working in the formal sector and volun
tarily, at the same time ensuring that working children
32
attain normal growth and development
For children working in the informal sector the task
is complicated as there are few, if any, indicators of where
these children are, what they are doing and how many
they are. Community-based organizations can be useful in
reaching out to these children, finding ways to help them
earn a living and at the same time mature intellectually,
socially and emotionally by encouraging income-generat
ing activities, arranging for health care and informal
schooling, and facilitating a dialogue to air concerns and
find solutions.
Action Research
Action research in this area must be innovative in order to respond
effectively to the overall complexity and social nature of this issue.
On the economic side, in-depth studies are needed on child labour in
small scale and cottage industries which often escape formal data gather
ing. A number of comparative studies are required to establish a solid
information base on the net economic effect on family income where there
are working children.
On the social side, of particular importance is the need to tailor educa
tional opportunities to the requirements of working children. Educational
programmes in the form of condensed modules need to be developed and
adapted for this purpose.
33
Urbanization
III.
Policy - Health Linkage
Cases on Housing in Urban Areas and Slums
The Issue - Rapid urban population increases are not accompa
nied by development of adequate infrastructure.
Shelter, along with food and clothing, is regarded as a basic need for
human life. The World Health Organization in one of its recent publica
tions observed that housing is intimately related to health. The structure,
location, facilities, environment and uses of human shelter have a strong
impact on the state of physical, mental and social well-being. Good
housing conditions provide a defence against death, disease and injury,
while poor housing conditions increase vulnerability to these factors.
The United Nations Center for Human Settlements (UNCHS - Habitat)
has emphasized the role of housing in healthy living. Although the
relationship between housing and health is both intimate and complex, and
is compounded by a myriad of factors such as poverty, nutrition, levels of
income and literacy which act together to defy the establishment of precise
links, it can be said that poor housing is always associated with higher
mortality and morbidity rates. It is estimated that 5 million deaths i.e. 10
per cent of all deaths worldwide, could be prevented if housing conditions
everywhere in the world could be improved.
In most developing countries rapid urbanization is occurring, but
development of various infrastructural facilities, such as adequate hous
ing, water supply, sanitation, and transport has not kept pace with the
growth of the urban population.
The Issue - Proliferation of slums in large urban settlements severely
affects the health of the urban poor.
Unsatisfactory sanitation measures in slum areas are conducive to the
spread of diseases. Damp, unsanitary ill-ventilated and overcrowded
houses expose inhabitants to a variety of health problems. Waste which
34
is indiscriminately thrown into open spaces for lack of proper disposal
facilities attract flies, which leads to food contamination and diseases such
as typhoid, cholera and dysentery.
A study of slum areas in India showed that the incidence of tuberculo
sis in an upgraded slum was ten times higher than that in a nearby non-slum
area, viral infections were two to five times greater and skin diseases twice
as high.
Slum dwellers are often poor, ignorant and, due to their difficult situ
ation, do not appreciate the implications and importance of preventive
measures to ensure good health. Very often they have a fatalistic attitude
towards diseases and consequently do not readily accept or cooperate with
programmes such as immunization schemes.
Suggested Policy Options
This situation has attracted the attention of policy
makers. It is believed that in fulfilling the basic needs of
the people, housing ranks next in importance to food and
clothing. The development of housing must be given a
high priority in society, since it fulfills many other needs
such as raising the standards of sanitation, creating addi
tional employment, dispersing economic activity and
improving urban renewal. Past policy responses have
included both slum clearance and attempts to upgrade, as
well as self-help schemes and granting of legal title to
squatters on occupied land.
Housing Legislation
Legislative measures or policy declarations alone are
not enough. The constraints posed by inadequate re
sources, urban legislation and other related policies must
35
be taken into consideration in order to ensure effective
implementation. Although the urban policy guidelines de
veloped from time to time by governments have continued
to emphasize the importance of the housing sector, the
programmes initiated and the investments made in many
countries have responded to only a small fraction of the
enormous problem of urban housing shortages in coun
tries. Attention needs to be paid to improving access to
housing inputs such as land, finance, building materials
and services. Legal, institutional and administrative
constraints which discourage people from taking housing
initiatives and force them to neglect the proper mainte
nance of existing housing stock should be minimized.
Because of the social, physical and economic com
plexity of slum formation it is very difficult to assess how
far policies and schemes introduced by governments have
been effective in checking the growth of slums, or arrest
ing any further deterioration in the health and quality of
life of slum dwellers. In examining the policies of India
one sees a pressing need to develop a comprehensive,
perhaps segmented policy for tackling the problems in
such a large country. For instance the employment profile
varies with the industrial/trade scenarios in cities, with
slum dwellers of large cities being more dependant on
regular jobs than slum dwellers of smaller cities.
The Need for Planning
It was pointed out that overcrowding in large cities
and metropolises has been the result of lack of planning to
encourage the development of smaller towns and growth
centers at appropriate distances from one another. When a
number of smaller towns exists around the main city,
movement of people is better organized and contained,
36
relieving the main city of overcrowding and congestion.
Location of industries in big cities aggravates the
problem. Development of smaller towns and industrial
growth centers at appropriate distances from cities should
be encouraged. This could be done through siting of
industrial parks and creation of special incentives such as
tax exemptions, subsidies, credits, and relaxation of input
restrictions to attract private sector investment in physical
infrastructure development.
Beyond planning - slums as a socioeconomic problem
Although slum improvement has been attracting the
notice of many governments, the policies have room for
improvement. There are few examples, if any, of a sys
tematic approach to tackling the underlying problems of
urban deprivation or of providing a comprehensive plan
for the health and well-being of all city-dwellers, includ
ing those living in slum areas. While there are short and
long-term plans that sometimes reach out to vulnerable
groups, they seldom encompass all the relevant needs,
resources, and activities and give priority to income gen
eration and education, as well as water supply, housing,
sanitation and nutrition. Achievement of the above relies
on political will to take the appropriate policy measures
and proper intersectoral coordination among all imple
menting agencies.
Tackling a problem of this complexity will involve
many sectors at all levels. The importance of the educa
tional component cannot be overemphasized. It must be
wide in scope and must operate at various levels, creating
awareness at some, changing attitudes at others, and
imparting skills in management and coordination to key
37
personnel. The poverty of slum occupants, their fatalistic
outlook and resignation are constraints to policy and
programme implementation. Social preparation and
provision of information and education of the urban poor
are essential in bringing about a positive result
Action Research
i.
a detailed survey of the urban housing situation with
emphasis on estimating existing stock, quality, demand
and affordability;
ii.
a profile of urban inhabitants and their living conditions
to determine the most vulnerable groups;
iii.
development of simple, appropriate and adequate
indicators for monitoring health status in slums through
periodic community morbidity surveys and specific
epidemiological investigations;
iv.
detailed investigation of housing finance to provide
information on types of resources available and their
sustainability;
v.
investigations of the roles of the private sector and
voluntary organizations and their resources in slum
improvement programmes;
vi.
in-depth study of legislation to identify the constraints
and barriers to implementation and action;
vii. action research that investigates existing public health
laws and regulations covering housing should be analyzed,
with a view to assessing whether these are too restrictive
38
for the poor and impossible for them to achieve. Tests
should be carried out to ascertain the effect of these laws
and regulations on the poor’s initiatives regarding their
own housing;
viii. study of the health effects of housing with special reference
to the effects of overcrowding as a result of shortage of
housing;
ix.
the effect that certain primary health care schemes would
have on the “health quality’’ of the slum, i.e., from the
standpoint of personal, communal health improvements,
to the total environment of the slum;
x.
detailed study to enable spatial planning for a viable hier
archical system of human settlements (including the
growth centers/points and satellite towns);
xi.
the effect of income-generating activities, self-help schemes,
and encouraged-entrepreneurship through the use of seed
money should be investigated.
39
METHODOLOGIES FOR POLICY ANALYSIS
Discussions on the six different case studies highlighted the complex
nature of the links between development policies and health outcomes.
Numerous examples were given of the ways in which health status could
be further protected from the adverse effects of development programmes,
especially economic ones.
The heterogenous mix of policy makers and senior officials from differ
ent sectors, experts and researchers from institutes of development stud
ies, development agencies and NGOs allowed for a broad range of policy
options to be tabled during discussions. The utilization of policy analysis
as an important process that contributes to an eventual policy adjustment
by analyzing the weaknesses, the outcomes and possible options was fully
discussed.
A policy can be defined as a broad statement of goals, objectives, and
means that creates the framework for government activity
.
*
Policies often
take the form of explicit written documents, but they may also be implicit
or unwritten.
Development policies are designed to encourage economic growth and
improve infrastructure, services, industry, commerce, and community
development. These may be accompanied by policies to stimulate social
and political development. Policies are formulated at the national,
regional and local levels. They may be profoundly affected by a variety
of elements both within the country itself such as the economic or
geographical situation, as well as by elements outside country borders
such as the international economic and political climate.
Policy makers in the public sector face difficult choices in deciding
how public resources are to be allocated. Policy analysis provides a tool
for carrying out careful analysis of the advantages and disadvantages of .
each course of action in order to make sensible policy choices. It is
acknowledged that certain actions are needed in some relevant sectors, so
*M. Grindle, "Policy Content and Context in Implementation", Politics and Policy
Implementation in the Third World, M. Grindle, ed. Princeton, N.J: Princeton Univer
sity Press 1980.
as to generate favorable health outcomes. The issue is how to promote
such actions within non-health sectors which have minimal adverse health
outcomes, and others which have maximal favorable health outcomes.
The strategy for achieving the latter has to include an important element
viz, how to make public policy makers in non-health sectors realize the
importance of health effect considerations in their decisions pertaining to
the concerned sector. This necessitates thorough appraisal of public
policies in non-health sectors from the special perspectives of the health
sector.
Steps for Policy Analysis
Situation Analysis
Policy makers need to be apprised of the current
situation with regard to health effects of their sectoral
policies. This calls for situation analysis. Among other
things, such an analysis will include:
(a)
identification of explicit and implicit policies
governing the sector;
(b)
assessment of elements in these policies with
likely favorable/unfavorable health effects;
(c)
evaluation of implementation of policies (such
as legislation, enforcement machinery or
organizational arrangements, public relations);
(d)
incorporation of feed-backs from policy
implementation to further policy adjustments,
planning processes and system designing;
(e)
context analysis which is an examination of
the socio-economic, political and techno
41
logical setting within which a policy is formulated.
It includes:
i.
process analysis (i.e., the understanding of the
ways in which policy decisions and plans are
arrived at and implemented or evaluated;
expected and actual roles of various Ministries
and national/intemational agencies);
ii.
risk analysis (i.e., explicit assessment of
health risks associated with development
policies based on available knowledge of life
risks, current epidemiological investigations);
iii
institution analysis (i.e., evaluation of the
strengths, weaknesses and opportunities
available in existing institutional arrangements
for policy formulation; management informa
tion systems; programme planning,
programme implementation, monitoring
and evaluation);
iv.
impact analysis i.e.,( systems of assessment
of gains/side effects of specific policies and
programmes, especially from the health and
quality of life considerations;
Policy analysis sometimes includes Social Cost
Benefit Analysis, although the latter has been considered
less useful in recent years. Nevertheless, should this step
be carried out, it consists of the appraisal of options in
terms of:
i.
42
economic costs (in money terms);
ii.
economic benefits (in money terms);
iii.
social costs (intangibles expressed in
money terms);
iv.
social benefits (tangible or intangible
non-economic benefits expressed in
money terms);
V.
weighing of overall costs and benefits
through computation of a Cost Benefit
Ratio for each available option;
vi.
comparison of these options to decide on
one or more of these.
Resource Allocation Models:
Public policy makers are often confronted with decision situations in
which choice is not in terms of “Yes” or “No” to a certain programme
option, since many such options can be justified. In such situations, the
problem can be resolved through a resource allocation model. Resource
allocation models use optimization techniques such as Linear Program
ming or input-output Analysis for allocation of scarce health sector funds
under various constraints. For example in a country a model has been
developed to examine the feasibility and economic implications of rede
signing a nation’s industrial structure on considerations of inputs, outputs,
pollution effects, technologies for pollution control etc., so that pollution
is significantly prevented or reduced.
Experimental and Quasi-Experimental Studies:
The greatest hurdle in catalyzing intersectoral action in support of
43
health is the lack of hard data demonstrating health effects of policies in
non-health sectors. The best solution to this problem lies in conducting
scientifically designed experiments and effects of specific policies and
programmes. For example, prior to construction of a dam the following
may be carried out:
(a)
a pre-study of the command area of the dam in
terms of epidemiological situation and quality of life;
(b)
a study as above in an area (control group) similar in many
characteristics but not in the command area of any major
dam;
(c)
studies similar to (a) and (b) in respect of minor irrigation
projects in comparable areas;
(d)
post-study in all the areas treated as experimental (treatment)
areas and control areas;
(e)
analysis the data collected to evaluate net health (and other)
effects of the policies of major/minor irrigation projects;
Similar experimental projects can be designed for problems such as:
(a)
estimation of net health effects of mounting a special slum
health facility or a child labour health facility;
(b)
estimation of the impact of a special health education drive
targeting farmers to mitigate adverse health effects of
pesticide use in agriculture;
Unfortunately, however, public policy makers are often not willing to
wait for long periods of time to observe the outcomes of experimental
studies before they make policy decisions. A more realistic approach is to
conduct quasi-experimental studies or analyze natural experiments.
44
Examples of such studies include:
(a)
estimation of differential health status and quality of life in
families (i) which include child labour, and (ii) which do not
contribute child labour;
(b)
determination of the health status of families living in one-room
and two-room non-slum accommodations, and others living in
slums;
(c)
estimation of the occupational health situation (morbidity
levels) in institutions with varying levels of health care
facilities;
(d)
assessment of the health status of farmers engaged in production
of different crops involving varying levels of pesticide use.
Multivariate Statistical Analysis!Area Analysis:
Association analysis using multivariate techniques with areas/institutions/groups of individuals as units of analysis provides yet another
strong methodological option. The techniques involved are multiple
regression, factor analysis, multiple classification analysis etc.
A multivariate study enables estimation of net effect of each inde
pendent variable on any one of the dependent variables, based on
secondary data sources. Examples of other studies using such ap
proaches are:
(a)
using states as units of analysis, estimating the relationship
between quantum of various pesticides used, and other rele
vant variables and morbidity rates from related diseases;
(b)
using command areas of major irrigation projects as units of
analysis, analyzing health status variables against a variety of
45
relevant independent variables such as: income level of
people, health care expenditure; health input variables
(curative and preventive); educational status of people; etc.
The above formed the basis of a fruitful discussion on the various
aspects and dimensions of policy analysis. In order to facilitate the com
prehension of the process of policy analysis and its various phases,
participants selected problems from their own country situation and
worked through the process illustrating the type of information they would
get, the variables included, the parameters they would use, and the
argumentation for changing or modifying those aspects of policies which
had a direct bearing on the problem chosen. In this way policy analysis
was seen as an invaluable analytical tool for assessing health status which
takes account of the socioeconomic and political context within which the
health situation evolves, as well as a negotiating platform for protecting
and promoting heal th status within development policies and programmes.
46
SPECIFIC RECOMMENDATIONS
The discussions following the presentation of each case aimed at iden
tifying the underlying issues, policy options and key action research.
Many of the issues were already known to policy makers, and some
countries had already taken steps to introduce safeguards. The policy
options therefore were put forward as general guidelines enabling each
country to select those most appropriate to their stage of development in
introducing safeguards for protecting health. The policy options were not
mutually exclusive. The following is a summary of the key issues, policy
options and action research required in each of the five areas discussed and
recommended for countries, WHO and the international community.
Agricultural Development Policy and Health Status
A.
PESTICIDE USE - Key Issues
1.
The use of pesticides is necessary for improving yield of food
crops, increasing farmers’ income and protecting large invest
ments in emerging commercial agriculture.
2.
There is a growing need to minimize existing pesticide use and
to make less toxic pesticides widely available at affordable
prices.
Policy Options
(a)
a special list of essential pesticides should be identi
fied on the basis of the following criteria:
harmful effects;
cost-effectiveness;
efficacy;
operational convenience,
47
48
(b)
legislative measures should be enacted or
strengtened to control import, production and"
distribution of pesticides, and to induce producers
to invest in research and development of safer
products;
(c)
information, education and communication pro
grammes should be undertaken for pesticide users
and the general public. Agricultural extension
workers, health workers, mass media, producers
and suppliers should be involved. Focus should be
given to adverse effects of pesticide use and safe
handling methods in transportation and application
of pesticides;
(d)
use of safety measures and protective equipment
should be ensured through appropriate pricing and
distribution policy;
(e)
community involvement and popular participation
in surveillance and monitoring of the use of
products and safety measures should be encouraged;
(f)
intercountry cooperation and collaboration involving
research institutions for monitoring and evaluation
of the adverse effects of various pesticide products
should be solicited. Dissemination of this informa
tion should be promoted;
(g)
pesticide epidemiology and toxicology should be
introduced in health curricula to increase the number
health personnel who are able to analyse, prevent
and cure health problems caused by use and abuse
of pesticides;
(h)
information on traditional pest control practices should be
disseminated, the development of safe and ost-effective
methods of pest control through research on alternative
cropping patterns and bio-technology should be promoted.
cooperation of relevant international research
organizations in this regard should be solicited;
(i)
the health ministry should be equipped with the
required epidemiological skills to anticipate,
inform and control the adverse effects of pesticide
use on health.
Action Research Requirements
i.
quantitative analysis of actual harmful effects of
pesticides including residues in food and environment;
ii.
substitutes for harmful pesticides;
iii.
possibilities for reducing the cost of less harmful but
more effective types of pesticides.
B. LARGE SCALE WATER DEVELOPMENT PROJECTS - Key
Issues
1. Growing need for implementation of large scale water development
projects for increasing the supply of food and energy.
2. Urgent need to mitigate adverse effects on health caused by changes
in the environment.
49
Policy Options
(a)
health impact analysis should become an essential
part of the project appraisal process;
(b)
the cost of control measures for the protection of the
health status of relevant population groups should be
included in the project budget;
(c)
appropriate methods for surveillance and monitoring
of health status, including early warning signs of
emerging health hazards, should be developed and
followed up during project implementation;
(d)
local health workers should be trained to identify
and treat emerging health problems, and the popula
tion should be made aware of the problems through
the use of information, education and communica
tion systems;
(e)
health profiles of populations in the project area,
both migrant and local, should be maintained for
deriving appropriate health interventions;
(f)
the formation of independent watchdog groups
(social organizations, NGOs etc.) should be pro
moted at the local level for assisting individuals to
obtain compensations for displacements and health
problems caused by the project.
Action Research Requirements
■ i. - •• epidemiological studies of the affected area;
50
ii.
probable diseases associated with the impounding of
water in big reservoirs;
iii.
baseline health profile of both migrant and local
populations to establish morbidity patterns.
II. Industrialization Policy and Health Status
A. OCCUPATIONAL HEALTH - Key Issues
1.
Need for industrialization for income and employment generation
to enhance a faster rate of economic growth.
2.
Need to minimize the negative impact of industrialization on
health status.
3.
Need to maximize safety of workers and populations.
Policy Options
(a)
an objective assessment of the occupational health
situation in both quantitative and qualitative terms
should be done on a regular basis;
(b)
relevant legislation should be reviewed on a regular
basis and amended when necessary;
(c)
regular inspection of factories for potential safety
and health hazards should be carried out with close
involvement of trade unions (or similar bodies);
(d)
safety measures should be planned in different
1.
ii.
iii.
52
highly hazardous;
moderately hazardous;
least-hazardous conditions;
(e)
the involvement of social security organizations
should be sought to ensure fair allocation of
resources in support of the health of the workers
and other people in the vicinity of the industries;
(f)
greater use of trade unions (or similar bodies), mass
media, workers training centers, schools, vocational
institutions etc. to disseminate knowledge to
employees regarding the causes and consequences
of occupational health hazards. Innovative ways
should be explored to make this knowledge avail
able;
(g)
more emphasis should be laid on preventive
measures through control of the environment;
(h)
education of health professionals should be oriented
towards environmental and behavioural sciences to
enable them to cope with the factors affecting the
health status of the people;
(i)
gaps in the existing infrastructure should be identi
fied, and steps taken to rectify the deficiencies;
(j)
industrial zones should be planned and developed
for easy application of intervention and control
measures, thus minimizing unplanned
dispersion;
(k)
employers should make adequate provisions for
health insurance and health compensation to
workers and their families;
(I)
incentives (tax incentives, concessional premium,
reduced tariffs on safety equipment etc.) should be
given to industries having minimal incidence of
health hazards/accidents.
Action Research Requirements
i.
Knowledge, Attitude and Practice (KAP) studies of
various related bodies such as labour organizations,
trade unions, industrial management, etc;
ii.
case studies (in greater detail) of selected hazardous
industries;
iii.
survey of the industries using “harmful” machinery,
i. that might be either antiquated, or highly
e.,
sophisticated and beyond the capacity of operators;
iv.
case studies of successful and unsuccessful occupational
health interventions in industries;
v.
study of the cultural factors influencing human
behaviour in industrialization to better understand the
role these play in determining the situation;
vi.
experimental study to investigate the best methods of
disseminating information regarding the impacts of
industrialization on health;
53
B. CHIU) LABOUR - Key Issues
1.
Child labour, while unacceptable, is widespread in many
countries due to extreme poverty.
2.
Need to protect and promote the health status and quality of
life of working children by ensuring acceptable working
conditions.
Policy Options
54
(a)
the health status of children should be monitored in
hazardous industries at regular intervals through
epidemiological investigations;
(b)
ministries of Health, Education, Labour and Social
Welfare should be alerted to the health impacts of
child labour;
(c)
legislation on child labour should be extended and
implemented effectively;
(d)
available information should be disseminated to the
parents and public regarding the impact of child
labour on the physical and mental health of the
children;
(e)
provision should be made for longer rest periods,
reduced working hours and educational and recrea
tional facilities for working children;
(f)
special measures should be adopted to reduce school
dropouts for example through the creation of voca
tional training and the development of income
generating activitie for families who are likely to
send their children to work;
(g)
development of primary health care, especially in
the informal small scale industrial sector, as an
effective approach for improving the health status
of working children and their working environment.
Action Research Requirements
i.
study on the net economic effect of working children on
their family’s income;
ii.
nature of an educational programme (condensed
module) which could be profitably adopted to provide
educational facilities to working children;
iii.
in depth study of the child labour situation in small scale
industries.
III. Urbanization Policy, including Housing, and Health
Status - Key Issues
1. The rapid increase in the urban population due to a variety of
reasons such as rural-urban migration, expansion of the urban
industrial sector and the natural growth of the urban population, is
an inevitable fact of the development process.
2. Increasing shortage of urban housing and inadequate services and
amenities have an adverse effect on the health status of urban popu
lations.
55
3. Proliferation of slums in large urban settlements severely affect
the health of the urban poor.
Policy Options
56
(a)
the slum problem due to urbanization is a socio
economic problem and not merely a physical plan
ning issue. Therefore, specific but comprehensive
policies and programmes should be developed in
order to prevent slums from being created;
(b)
the above policies and programmes should be
developed based on an intersectoral approach with
emphasis on-
i.
short term options - community participation/self help
schemes;
- sites and services projects;
- urban community development.
ii.
intermediate options
- adult education, vocational education
and proper counselling on responsible
living;
- social preparation and organization of
the community; community incentive
schemes such as soft loans and self help
schemes;
- re-orientation of urban
health care on the basis of the
Primary Health Care approach.
iii.
Long term options - industrial siting;
encouragement of infrastructure
development by the private sector
through special incentives (such as tax
exemptions, subsidies, credit facilities,
trade etc.).
The above options should be considered as an effort to avoid over
crowding in large cities and encourage development of smaller towns.
Action Research Requirements
i.
a detailed survey of the urban housing situation with
emphasis on estimating existing stock, quality, demand
and affordability;
ii.
a profile of urban inhabitants and their living conditions
to determine the most vulnerable groups;
iii.
development of simple, appropriate and adequate
indicators for monitoring health status in slums through
periodic community morbidity surveys and specific
epidemiological investigations;
iv.
detailed investigation of housing finance to provide
information on types of resources available and their
sustainability;
v.
investigations of the roles of the private sector and
voluntary organizations and their resources in slum
improvement programmes;
vi.
in-depth study of legislation to identify the constraints
57
and barriers to implementation and action;
58
vii.
action research that investigates existing public health
laws and regulations covering housing should be
analyzed, with a view to assessing whether these are too
restrictive for the poor and impossible for them to
achieve. Tests should be carried out to ascertain the
effect of these laws and regulations on the poor’s
initiatives regarding their own housing;
viii.
study of health effects of housing with special reference
to the effects of overcrowding as a result of shortage of
housing;
ix.
the effect that certain primary health care schemes
would have on the “health quality” of the slum, i.e.,
from the standpoint of personal, communal health
improvements, to the total environment of the slum;
x.
detailed study to enable spatial planning for a viable
hierarchical system of human settlements (including
the growth centers/points and satellite towns);
xi.
the effect of income-generating activities, self-help
schemes, and encouraged-entrepreneurship through the
use of seed money should be investigated.
SPECIFIC RECOMMENDATIONS FOR WHO AND
OTHER INTERNATIONAL ORGANIZATIONS
1.
To set up an interdisciplinary scientific group at
regional level to advise and support WHO and
countries on:
(a)
the implementation of recommendations
related to health in public policy, emanating
from the regional and global levels;
(b)
the production of documents and publications
on themes related to health in public policy for
advocacy purposes;
(c)
the involvement of policy makers and repre
sentatives of bilateral and other funding
agencies on issues of concern to the countries
of the region through round-table negotiations
and discussions.
2.
WHO should support the development of a network
of institutions which could undertake training
activities, research studies, information gathering
and documentation on issues in the area of
public policy as identified above, especially
regarding the issues of health status protection and
promotion in agricultural development, industrializ
ation policy, urbanization policy including
housing, as well as the development and dissemina
tion of methodologies that could be used for health
impact analysis during project formulation.
3.
WHO and the ILO should liaise with the countries
and relevant labour organizations to strengthen and
59
support mechanisms that develop safety measures.
4.
60
WHO, in collaboration with relevant UN Organiza
tions and other agencies, should intensify its support
to member countries for implementing the general
and specific recommendations and in their efforts to
mobilize resources for strengthening appropriate
national institutions for the implementation of the
above.
OVERALL RECOMMENDATIONS
The following overall recommendations were adopted by the Sympo
sium.
Recognition should be given to development policies in non-health
sectors as they have wide ranging implications for, and impact on health
status and quality of life.
Health impact analyses are a valuable component for feasibility and
appraisal studies, the results of which can be used to eliminate or reduce
adverse effects of development programmes and projects.
In view of the World Health Assembly Resolution WHA 39.22 and the
recommendations of the South-East Asia Regional Conference on Health
Development, this Symposium recommends that action be taken by the
countries, WHO and other international agencies to:
1.
Advocate, sensitize and create awareness
among policy and decision makers,
administrators, health and other professional
groups and NGOs on the health implications
of development policies and projects by
holding symposia, seminars and workshops at
appropriate levels in the countries and in the
region.
2.
Promote and carry out health impact analyses
with regard to development policies and
programmes relevant to specific country
situations.
3.
Support and encourage institutions to under
take the training of development planners,
senior management personnel and researchers
to augment their skills in the analysis of the
61
implications of development policies and projects on
health status.
62
4.
Select institutions to commence action
research in collaboration with local experts
and other concerned agencies on relevant,
identified themes.
5.
Promote the exchange of information and
experiences amongst health planners, policy
analysts and programme managers through
the organization of study tours and meetings
both within and outside countries.
6.
Strengthen the existing research institutions
and mechanisms to undertake research studies
to identify and analyze areas and issues of
vital concern to health status in development
policies and projects (at least one issue per
year).
7.
Use these studies as the technical basis of
meetings held with relevant agencies, and
publish and disseminate results of studies
and meetings.
8.
Strengthen the infrastructure in the countries
of the Southeast Asian region to collect,
analyze and document information on a
regular basis, and facilitate decision-making
on issues related to the implications of
development policies on health status.
ANNEXES
A.
List of Participants
B.
Programme of Work
C.
Bibliography
D.
Method of Work
63
ANNEX A.
LIST OF PARTICIPANTS
Dr Mahboob Hussain
Director-General
Bangladesh Institute of Development Studies
Dhaka, Bangladesh
Dr S.Y. Anayat
Director
Health Division
Ministry of Social Services
Bhutan
Mr R.P. Kapoor
Director-General
National Institute of Rural Development
Hyderabad, India
Mr R. Srinivasan
Secretary
Ministry of Health and Family Welfare
Government of India
New Delhi, India
Dr Widyastuti Wibisana
Director
Community Participation
Ministry of Health
Jakarta, Indonesia
64
Dr S.-L. Leimena
Director-General
Community Participation
Ministry of Health
Jakarta, Indonesia
Dr M. Alwi Dahlan
Assistant to Minister of Population and Environment
Jakarta, Indonesia
Dr U. Myint Thein
Director
Department of Health
Yangon, Myanmar
Dr U. Thet Lwin
Lecturer
Statistics Department
Institute of Economics
Yangon, Myanmar
Mr Subama Jung Rana
Additional Health Secretary
Ministry of Health
His Majesty’s Government of Nepal
Kathmandu, Nepal
Dr B.D. Chataut
Chief of Policy, Planning, Monitoring
and Supervision Division
Ministry of Health
His Majesty’s Government of Nepal
Kathmandu, Nepal
65
Ms Padma Mathema
Assistant Secretary
Chief-Social Service Division
National Planning Commission
Singh Durbar
Kathmandu, Nepal
Ms K.C. Gauri
Member-Secretary
Health Service’Coordination Committee
Social Service National Coordination Council
Lainchaur, Nepal
Dr Godfrey Gunatilleke
Executive Vice Chairman
Marga Institute
Sri Lanka Center for Development Studies
Colombo, Sri Lanka
Dr E. Rajanathan
Deputy Director-General
Public Health Services
Colombo, Sri Lanka
Dr P.M.B. Cyril
Minister of State for Health
Democratic Socialist Republic of Sri Lanka
Colombo, Sri Lanka
Mr Narong Nitayaphorn
Director
Social Project Division
NESDB
Bangkok, Thailand
66
Mr Panya Rangsipiphat
Planning and Policy Analyst
Division of Rural Development
NSEDB
Bangkok, Thailand
Dr Supasit Pannarunothai
Head, Planning and Project Section
Provincial Hospital Division
Ministry of Public Health
Bangkok, Thailand
Dr Pricha Deesawasdi
Deputy Permanent Secretary
Ministry of Public Health
Bangkok, Thailand
WORLD HEALTH ORGANIZATION
Dr A. El Bindari Hammad
Responsible Officer
Intersectoral Action for Health
WHO Headquarters
Geneva, Switzerland
Dr Uton M. Rafei
Director
Health Systems Infrastructure
WHO Regional Office for South-East Asia (WHO/SEARO)
New Delhi
Dr Sonja Roesma
Regional Adviser - Primary Health Care
WHO Regional Office for South-East Asia (WHO/SEARO)
New Delhi
67
Dr Palitha Abeykoon
Medical Officer - Medical Education
WHO Regional Office for South-East Asia (WHO/SEARO)
New Delhi
Professor U.M. Malla
Temporary Adviser to the Regional Director
New Delhi
INDIAN INSTITUTE OF MANAGEMENT
Dr Basu Ghosh
Professor of Health Services Management
Faculty Leader
Dr Jagdish C. Bhatia
Professor of Health Services Management
Dr Ranajit Dhar
Professor of Economics
Dr Shyamal Roy
Professor of Agricultural Economics
Dr Vinod K. Tewari
Professor of Human Settlements Studies
OBSERVER
Dr Iain Aitken
School of Public Health
Harvard University
USA
68
ANNEXB
METHOD OF WORK
The Symposium was conducted using a well structured programme
with a participatory approach. To facilitate in-depth analysis and
initiate discussion two small groups were formed to discuss specific
cases. The groups included at least one country participant. These
groups analyzed the modules thoroughly and reported back in plenary
sessions. During the plenary sessions all the participants had a chance
to share their views and come to some consensus.
The areas of public policy and their impact on health status and
quality of life were presented in three modules. These were:
(a)
Agricultural development policies;
(b)
Industrialization policies;
(c)
Urbanization policies.
For each of these 3 modules illustrative examples from actual situations
were documented as described below.
Module I. Agricultural Development Policy - Health Linkage
(a)
Case on Pesticide use
(b)
Case on the Narmada Valley Project
(c)
Background Note on “Issues in Agricultural Health
Linkages”
Module II. Industrialization Policy - Health Linkage
(a)
Case on Occupational Health Hazards and Safety in Industries
69
(b)
Case on Child Labour
(c)
Background Note on “Industrialization Policy and Health”
Module III. Urbanization Policy - Health Linkage
(a)
Case on Housing in Urban Areas
(b)
Case on Slums
(c)
Background Note on Urbanization, Urban Policies and Health
Implications
A set of study questions was used to help the participants to focus on
concrete issues and, as decision makers, select the course of action to
be taken by weighing the advantages and disadvantages of various
policy options.
70
ANNEXC
BIBLIOGRAPHY
Dr Basu Ghosh, Methodologies for Policy Analysis on Intersectoral
Action in Support of Health and Qualtiy of Life. Unpublished back
ground document. Indian Institute of Management, Bangalore,
October 1989.
Dr P.G.K. Panikar, The Adverse Effects of Development Programmes
on Health - Irrigation Projects on Malaria. Unpublished background
document. Bangalore, October 1989.
DrAungTun Thet, Health Impacts of Development Policies: A Case
Study of Sedawgyi Multipurpose Dam and Irrigation Project in
Myanmar. WHO South East Regional Office, October 1989.
Indian Institute of Management. South East Asia Regional Symposium
on the Implications of public Policy on Health Status and Quality of
Life. Unpublished background document. Bangalore, October 1989.
Marga Institute. Examples of Health Policy Analysis: Sri Lanka An Illustration with Three Examples: Impact of Agriculture Policies
On Health; The Mahaweli Scheme; The Health Impact of Policies on
the Urban Poor (Methodology and Analytical Framework). October
1989.
Marga Institute. Seasonality and Health: A Study of the Socio
economic Environment of Ill Health in 5 Locations. Godfrey
Gunatilleke, et al. 1988.
WHO. Intersectoral Action for Health. Geneva, 1986.
WHO Offset Publication. Intersectoral Linkages and Health
Development: Case Studies in India (Kerala State), Jamaica, Norway,
Sri Lanka, and Thailand, Edited by Godfrey Gunatilleke, 1984.
71
ANNEX D
PROGRAMME OF WORK
WEDNESDAY 18 OCTOBER 1989
72
08.30 - 09.00
REGISTRATION
09.00- 10.00
INAUGURATION
1.
Welcome address presented by
Dr Uton M. Rafei, HSI/SEARO
2.
Remarks by Dr Aleya El Bindari
Hammad, ISC/WHO HQ
3.
Introduction to the Symposium Objectives and Methods
by Prof. Basu Ghosh, IIM
4.
Address by the Chairperson Prof. J. Philip, Director, IIM
5.
Inaugural address by Chief Guest Mr A.B. Datar, Former Chief
Secretary, Karnataka
6.
Vote of Thanks by Dr Sonja
Roesma, WHO/SEARO
10.00- 10.30
Coffee Break
10.30-10.45
Appointment of Chairperson and
Rapporteurs
10.45- 11.00
Introduction to Module I by
Prof. Shyamal Roy, IIM
11.00- 11.30
Individual Case Reading
11.30- 13.00
Small Group Work on Module I
13.00 - 14.00
Lunch Break
14.00 - 15.00
Small group work on Module I
(continued)
15.00- 15.30
Plenary
Case Discussion on Module I
15.30- 15.45
Coffee Break
15.45 - 16.45
Plenary
Exchange of country experiences
17.15 - 17.37
Summary of Module I by Rapporteur
Prof. Jagdish C. Bhatia, IIM
THURSDAY, 19 OCTOBER 1989
09.00 - 09.15
Introduction to Module II by
Prof. Ranajit Dhar, IIM
09.15 - 10.45
Small group work on Module II
10.45 - 11.00
Coffee Break
11.00- 13.00
Small group work on Module II (contd.)
13.00 - 14.00
Lunch Break
73
J
14.00- 15.30
Plenary
Case discussion on Module II
Coffee Break
15.45 - 16.15
Plenary
Exchange of Country Experiences
16.15 - 16.30
Summary of Module II by Rapporteur
Prof. Basu Ghosh, I1M
FRIDAY, 20 OCTOBER 1989
74
09.00 - 09.15
Introduction to Module III by
Prof. Vinod K. Tewari, IIM
09.15 - 10.45
Small group work on Module IB
10.45 - 11.00
Coffee Break
09.15 - 10.45
Small group work on Module III (contd.)
13.00- 14.00
Lunch Break
14.00- 15.30
Plenary
Case discussion on Module III
15.30- 15.45
Coffee Break
15.45 - 16.15
Plenary
Exchange of country experiences
16.15 - 16.30
Summary of Module III by Rapporteur
Prof Basu Ghosh, IIM
SATURDAY, 21 OCTOBER 1989
09.00 - 09.30
Session Objectives
Methodologies for policy analysis
Introduction by Dr A. El Bindari
Hammad WHO/HQ
09.30- 11.00
Discussions
11.00- 11.15
Coffee Break
11.15 - 13.00
Discussions
13.00- 14.00
Lunch Break
14.00 - 15.30
Small group work on methodology
for policy analysis
15.30- 15.45
Coffee Break
15.45 - 16.30
Presentation of methodologies for policy
analysis in individual countries
SUNDAY, 22 OCTOBER 1989
FIELD TRIP
MONDAY, 23 OCTOBER 1989
09.00 - 10.45
Plenary
Presentation of country group reports
and discussion
75
10.45 - 11.00
Coffee Break
11.00- 13.00
Plenary
Presentation of country/group reports
and discussion
13.00 - 14.00
Lunch Break
14.00 - 15.30
Plenary
15.45 - 17.00
Plenary
TUESDAY, 24 OCTOBER 1989
11.30 - 12.00
12.30- 14.00
76
Opening Session
1.
Introductory'Address by
Prof. J. Philip, Director I1M
2.
Welcome Address by
Dr D.B. Bisht
Director, Programme Management
WHO/SEARO
3.
Remarks by Dr A. El Bindari
Hammad, ISC/WHO HQ
4.
Inaugural address by
H.E. Shri P. Ventakasubbiah,
Governor of the State of Karnataka
5.
Vote of Thanks by Prof. Basu
Ghosh, IIM
Lunch Break
14.00 - 15.45
Plenary
Presentation of policy options on
Agriculture vis a vis health.
Discussions
15.45 - 16.00
Coffee Break
16.00- 17.15
Discussion continued
WEDNESDAY, 25 OCTOBER 1989
09.00 - 10.45
Plenary
Presentation of Policy options on
industrialization vis a vis health.
Discussions
10.45 - 11.00
Coffee Break
11.00- 13.00
Discussion continued
13.00- 14.00
Lunch Break
14.00 - 16.00
Plenary
Presentation of policy options on
Urbanization vis-a-vis Health.
Discussion
16.00 - 17.00
Visit to the Institute for Tea
77
THURSDAY, 26 OCTOBER 1989
78
09.30 - 10.45
Discussion on Final report
10.45 - 11.00
Coffee Break
Adoption of the final report. Discussion
1100
Closure of the Symposium
'bf® 8®
tii® I®©? diS^Xsfc]’ jWSfflQ Offig' ©f? !W W; iMMiug @g
-
.
W0®W
•
•
'
.
.
. & g^ggg^a® te ©sjlt^w
■•■:>.
@? )Waedt
■ (?®
i?TSi!5tJ(.=g’ ®ftl&
■
{jl.jMi';>
piiisji
®ei^h
sasite^Ws SOW,
'‘SsISIKj f® iii®@2lo-Si5-?!
adtidOBIfiv!®:,sosfi
’ .idi 'rjlil hit iWaM'
■ (ilfti®® jaSi&db/ ©BfeisJi ©rft'i! 'i&ifsS) dtSf^dfei»>
/A® Jfeftfe di gaj)X=- .
a
ifer
- Media
3115.pdf
Position: 1781 (5 views)