Yanji Low-Carbon Climate-Resilient Healthy City Project (RRP PRC 50322)

HEALTH IMPACT ASSESSMENT

A. The Project

1. The Jilin Yanji Low-Carbon Climate-Resilient Healthy City project in the People’s Republic of (PRC) will generate a number of benefits for public health. Recent innovations to Asian Development Bank (ADB) project design such as health impact assessment (HIA) and healthy and age-friendly city action and management plan (HACAMP), aim at ingtegrating positive outcomes from urban development and infrastructure projects for human health, building on the traditional relationship of city planning and health considerations and health facility planning. The public health impacts of the project was analyzed during the HIA process and additional structural and non-structural measures were proposed and included in the project to further enhance health benefits of the project.

2. The project is located in Yanji city, which faces challenges of poor urban livability and traffic management, exposure to climate-related flood risk, and risks to water security and safety. The project will provide multiple cross-benefits from an integrated solution to improve the urban livability of a medium-sized city, which is timely and essential to lessen the migration to coastal mega-urban regions and to provide a demonstration project for replication in the PRC. It will contribute to (i) regional public goods of health and improved air and water quality, and (ii) revitalizing the economically challenged northeast area of the PRC.

3. The project will support the first bus rapid transit (BRT) system in the northeast of the PRC and transform Yanji’s urban geography. This will reinforce the east–west linear city arrangement through connecting key areas following principles of transit-oriented development (TOD) with higher density mixed-use and pedestrian-friendly center areas around the BRT stations. It will integrate nonmotorized transport (NMT) lanes and facilities along the corridor, and a series of small roads and river greenways will be provided to ensure safe and pleasant pedestrian and bicycle access to the BRT stations while promoting low-carbon urban mobility and physical activities that enhance public health. The project-supported greenways are designed as sponge city green infrastructure, enhancing climate resilience and urban livability. 1 The project will improve the water supply and wastewater management systems to ensure safe and climate- resilient access to water supply and improved water quality. Capacity development will contribute to the preparation of action plans to demonstrate Yanji as a low-carbon, climate-resilient, and healthy city, contributing to the implementation of the Healthy China 2030 program,2 and lessons and knowledge will be shared with other developing member countries.

4. Outputs. The project will have four outputs that are integrated and expected to generate cobenefits and higher efficiencies. The project focus is on the first BRT line in the PRC’s northeast and in the city; NMT improvements and its integration with sponge city infrastructure and drainage; and water supply system safety and efficiency improvements. The project will support comprehensive, low-carbon, climate-resilient development parallel to and north of the Buer Hatong River, organized along a BRT corridor connecting the industrial park developments and job centers in the east and west of the , and linking many residential districts with the city center, business and retail center, station for high-speed rail, government center, , schools, hospitals, and parks. The overall concept will follow the principles of TOD, focusing on higher density mixed-use and pedestrian-friendly center areas around the BRT

1 Sponge city is a concept of comprehensive urban water resources management, in which greenways, parks, and wetlands maximize ecosystem services, including storm water management, using ecosystem-based adaptation. 2 Government of the PRC, State Council. 2016. The Healthy China 2030. .

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stations promoting low-carbon urban mobility. New green spaces with pedestrian and bicycle lanes will (i) link station areas with project-supported riverfront greenways, creating a network of sponge city infrastructure enhancing climate resilience and urban livability; and (ii) enable more healthy lifestyles for residents and tourists, hence contributing to healthy and age-friendly sustainable city development, applying universal design principles.

5. The four outputs are: (i) low-carbon bus rapid transit line integrated with non-motorized transport infrastructure constructed; (ii) climate-resilient flood risk management and sponge city green infrastructure constructed; (iii) water supply system improved; and (iv) capacity in low- carbon, climate-resilient, healthy city planning, and infrastructure management developed. Output will support among others healthy and age-friendly city master planning and health monitoring, contributing to Healthy China 2030. Details are in the Report and Recommendations by the President to the Board of Directors of the project.

B. Baseline Health Profile

6. The project aligns with the Healthy China 2030 Plan (footnote 2) which calls for a Health in All Policies approach to disease prevention and health promotion in the PRC. The plan highlights the importance of an intersectoral approach to improve health in cities, with more than 58% of people residing in cities (mid-2018, according to United Nations), and integrating health considerations in urban planning as a prerequisite of wellbeing in a continuously urbanizing world. HIA has been identified as a mechanism to operationalize and promote cross-sectoral action for health in cities. ADB undertook an initial HIA for the project and this document summarizes the findings and recommendations. A further detailed HIA and a HACAMP will be prepared during the implementation of the project as part of output 4.

7. A health profile of the population of Yanji was provided by city officials during the mission and key health issues are highlighted. Cardiovascular diseases are reported to be the main cause of mortality and morbidity in men and more prevalent than in women. For women the key health issues are hypertension, gynecological diseases, and breast cancer. Hypertension and diabetes are prevalent among the general population. Respiratory infections e.g., flu are common during the cold winters in Yanji. In children, short-sightedness (myopia) and respiratory infections are common. Mental health issues are reported to be common. Access to health care facilities was identified as sub-optimal, especially affecting the elderly. In Yanji, 21.5% of the population is over 60 years of age. Yanbian University with about 30,000 students enrolled is located in the city center next to Renmin Park and the BRT corridor. The university includes a medical school. Yanji is also a pilot Hygienic City in the PRC— a program preceding the Healthy China 2030 plan.

8. Urban environment quality. Air quality in the city has improved considerably in recent years. Current outdoor air quality in the city is good, and complies with PRC standards, with more than 90% of days having “good” air quality, also as a consequence of a previous ADB project,3 and the project is expected to contribute to a further increase in air quality. Key sources of air pollution include vehicle exhaust emissions, especially from older vehicles that are not compliant with current vehicle emissions standards, and industrial chimneys, especially from small- and medium size businesses. Given the local topography the natural ventilation of Yanji is suboptimal being a city in a valley surrounded by hills, and occasionally air pollutants are trapped which negatively affects air quality. Surface water quality is generally good, but during the rainy season, due to misconnection of outdated stormwater and wastewater pipe network, the combined sewer overflows and first flush of rainwater pollute the surface water quality. Also due to unsuitable urban

3 ADB. People's Republic of China: Jilin Urban Environmental Improvement Project.

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drainage planning, the collected stormwater is also drained into wastewater treatment plant (WWTP) in the east end of Yanji city, which leads to overload the capacity of WWTP and wastewater cannot be treated properly and leads to an overflow at WWTP into Buer-Hatong River. This pollutes the downstream of Buer-Hatong River and reduces the environment quality. More detailed information on air, water, and noise quality is in the initial environmental examination of the project.

9. Traffic safety, green space, and healthy lifestyles. There are several traffic incident hotspots around the city causing injuries and even casualties. Access to green open space is limited, especially in the old part of the city in central Yanji where only about 7% of the core city is green open space (net areas), and overall about 36% is open space. Yanji city aims at providing green open spaces in the city at every 500 meters, to which the project will contribute through its greenways and sponge city green infrastructure. The current use of bicycles is estimated to be low, at about 1% of modal share, and generally bicycle infrastructure is poor, with very limited bicycle lanes or bicycle parking facilities provided in the city. Furthermore, current aspects of the built and urban environment discourage physical activity by making it unsafe, uncomfortable, and unappealing for pedestrians and cyclists. Access to public transport in the city could be improved. Bus travel for those aged 65 years and above is free. Universal accessibility features in the city are rare. However, newly constructed public facilities like schools, must comply with accessibility standards.

C. Health Issues Reported by Stakeholders and Community

10. Project-related and health-relevant aspects that were highlighted in consultations with the community included (i) lack of pedestrian safety on the streets and even within sidewalks, caused by poor pavement conditions, and sidewalks that are in many places filled with parked cars, that discourage walking; (ii) lack of public open spaces in the form of green parks and plazas, (iii) lack of seating and public gathering spaces; (iv) lack of physical fitness equipment in public spaces, and poor maintenance of existing physical fitness equipment, and (v) lack of public toilets in the city and especially in green parks i.e., along the existing river greenways on the Buer-Hatong and Yanji Rivers. The project included improvements to these 5 areas identified.

11. Focus group discussions with communities raised three key concerns around pedestrian safety, vehicle emissions, bicycle use and general physical activity and walking. Pedestrian safety issues are caused by car driving behavior that make pedestrians feel unsafe while walking on sidewalks alongside roads and crossing roads. People are concerned about vehicle exhaust emissions affecting air quality and their health when walking on streets. Bicycle use is currently not very popular and frequent, and people feel deterred to ride bicycles more often because of poor bicycle infrastructure, obstacles, and safety concerns. There are only limited numbers and areas with dedicated bicycle lanes, and if existing, are often occupied by parked cars. Discussants responded that if improved bicycle infrastructure were provided, many people would consider shifting to bicycles as a transport mode for short distance travel to work, or when going to a market or supermarkets. People would also use bicycles for recreation if bicycle lanes and facilities would be provided in the greenways, wetland parks, or riverside parks. On physical activity and walking, people in the focus group discussions reported that there is a lack of open spaces for exercise and sports facilities, and that more small plazas and parks close to residential communities with good landscaping and sports facilities would be needed. People who are not engaged in physical activity would be more active, do more walking, dancing and using of sports facilities, if such green infrastructure and facilities would be improved. Physical exercise is important to and valued by

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residents, especially among older adults, who think their health would greatly improve by regular physical activity. The project included improvements to the above concerns.

D. Positive Health Impacts by the Project

12. The project will contribute to improved public health through improving (i) air and surface water quality;4 (ii) noise reduction; (iii) urban microclimate; (iv) pedestrian and bicycle safety with reduced risk of injury and fatality; (v) safe pathways to hospitals and schools to and from public transport; (vi) physical activity opportunities improving physical, mental and community health (all from outputs 1 and 2); (vii) reduced flood risk and associated risks of infectious diseases, and reduced disturbance to public life (from output 2); (viii) improved water safety and security (from output 3); (ix) raised awareness about healthy lifestyle choices; and (x) long-term individual and community health improvements from comprehensive healthy lifestyle options from output 4.

13. Impact of improved public transport on health. The project supports the first of three planned BRT lines and will change the urban geography through significantly improving public transport and sustainable urban transport in Yanji along the city’s main development corridor and growth trajectory in east-west direction and it will integrate with enhanced walking and cycling in the city and especially linking to and from the stations and improving pathway networks. Future BRT users will be previous public transport users and a significant number of residents are expected to shift from private cars to BRT and other modes. BRT passengers tend to walk considerably more per trip than people who rely on private cars or taxis for transportation—slightly more than people who use regular buses, because BRT stations tend to be further apart compared with regular bus stops. Beijing BRT Line 1 users walk an additional 8.5 minutes per day on average as a result of the BRT.5 This contributes considerably towards meeting the World Health Organization’s recommendation for physical activity in adults, including older adults, of at least 150 minutes per week of moderate-intensity aerobic physical activity. This results in health benefits for BRT users, as a higher level of physical activity is strongly correlated with better health outcomes.

14. Impact of improved non-motorized transport and parking management on health. The project’s integration with improving pedestrian and cycling networks, facilities, and environment will further increase the likelihood for the physical activity health benefits. These improvements are planned to include improvements to pedestrian sidewalks and crossings along the BRT corridor and near BRT stations, bicycle lanes along the BRT corridor and parking facilities at BRT stations, and to improve vehicle parking management and promote enforcement of parking restrictions in the city by removing cars parked on sidewalks. These interventions will promote pedestrian and bicycle safety and comfort and further encourage walking and bicycling as physical activities. Reducing the number of car trips by using the BRT will result in a decrease in fossil fuel consumption, decrease in air and noise emissions and pollution (low carbon development), reduced traffic congestion, and improved traffic flow which will also make walking and cycling more attractive and improve road safety.

15. The project includes planning and investment in new roads focused on walking and cycling to complete the road network and create links to complete the vehicular, bicycle and pedestrian

4 A previous ADB-financed project (footnote 3) has already contributed to improved air and water quality, and water safety and security and this project through its low-carbon, low-impact, climate-resilient green infrastructure approach will contribute to further improvements. 5 World Resources Institute. 2013. Social, Environmental and Economic Impacts of BRT Systems. Washington, DC.https://wrirosscities.org/sites/default/files/Social-Environmental-Economic-Impacts-BRT-Bus-Rapid-Transit- EMBARQ.pdf.

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networks. The project includes new and more scaled roads in industrial parks that will create a more walkable pattern of smaller blocks and link the stations with the river through pleasant greenways. This has the potential to increase street connectivity and neighborhood walkability, promoting active travel and social interactions.

16. Impact of improved traffic management on health. The project also includes an improvement to the city’s traffic management, road safety and intelligent transport system (ITS), to improve traffic flow. Vehicular and people safety, pedestrian crossings, on-street parking management, and exclusive bus lanes, and the installation of signal control facilities, closed- circuit televison, electric-police system at selected locations will be implemented. An integrated ITS control center for daily traffic management and operation will be installed. This subcomponent has the potential to improve traffic flow, reduce congestion, air and noise emissions and improve road and public space safety for all including drivers, bicycle riders, pedestrians, and reduce accidents and risk of injury and fatality.

17. The sponge city green infrastructure and drainage system improvement component of the proposed project will rehabilitate the Chaoyang River and implement sponge city green infrastructure in catchment areas of small tributaries of the Buer-Hatong and Yanji Rivers, and the drainage system contributing to flood risk reduction and improved ecosystem services. This component is planned to include publicly accessible and connected pedestrian and bicycle pathways, green parks and semi-public green spaces and parking lots in residential area to enhance climate resilience, improving the urban microclimate and urban landscape quality, sustainable reduction of flood risk especially following extreme weather events and water pollution, and pedestrian and bicycle pathways along ecologically landscaped river greenways. This will increase people’s access to green space and nature, with associated restorative and mental health and wellbeing benefits, provide opportunities for physical activity and social interactions, and enhance the local small businesses along the greenways. The component’s sponge city green infrastructure “end-of-pipe” solutions with sedimentation tanks and reedbed filters at drainage discharge points at the Buer-Hatong and the Yanji Rivers will contribute to improved water quality.

18. The water supply and wastewater management component will upgrade and replace water supply pipes, install smart water meters in the older residential areas to reduce nonrevenue water. This component will improve the water supply and wastewater management services of the city, enhance water safety and security and reduce risks of poor water quality and wastewater health risks for city residents.

E. Value Addition by Asian Development Bank Health Impact Assessment to Further Enhance Health Benefits

19. During the HIA process a review of Yanji’s health risks and concerns was assessed and project related health issues were identified. Health benefits from the project were analyzed and also further structural and non-structural measures to bring out more additional health benefits as included below.

20. Safe routes to schools, kindergartens, hospitals and elderly care facilities with prioritized and safe pedestrian environment interventions along the routes to and from the planned BRT stations have been included in the project. Further work with schools, health and elderly care facilities should be carried out during the implementation of the project to collect detailed data on how many children walk or cycle to the facilites on which routes throughout the city and develop active travel to school and health and elderly facilities pilot interventions. This is likely to build

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active habits early on in life and impact lifestyles. This data may be collected as travel surveys by the schools themselves, thus calling for interdisciplinary and interdepartmental collaboration.

21. The project includes healthy, age friendly, universal accessibility design features in BRT stations, station areas, NMT interventions and new NMT roads with children and elderly and should further consider dementia-friendly urban design features into station area plans during detailed design. A clearly distinct detailed design for every BRT station should be designed in the early implementation stage of the project so that BRT stations become a well-recognized local and neighborhood landmarks.

22. The project includes urban health public awareness and communication plans campaigns integrated with the infrastructure project components, including: Health promotion signages in parks and bus stops; Physical activity and cardiovascular risk reduction specific campaigns (including related behavioral design features like painted footprints on foot path etc.); Anti- smoking (in public places) and respiratory diseases’ risks reduction campaign (communication campaign on bus stops and in buses).

23. The project will set a target for bicycle modal share for Yanji for 2030. Some European cities have a bicycle modal share upwards of 30%. Given harsh winter weather conditions, bicycle modal share may be established for the summer periods. The project includes improvements to walkability and cyclability and will develop related indicators into the project monitoring and evaluation as partial indicators for urban livability. Examples for indices are the Clean Air Asian Walkability Index, Global Walkability Index, and/or and Asian Cyclability Index.6

24. The project includes a participatory planning and design approach, involving older adults and people with disabilities, as well as children and students into the detailed design of the project features.

25. An HIA and HACAMP capacity development module as part of output 4 of the project has been included. The urban environment has a substantial role in supporting physical activity, health and well-being, the project will further promote and institutionalize a health in all policies approach and more cross-sector collaboration during implementation. This will aim at including public health actors to regularly work with other sectors, such as city planning, transport, education, health care and public park bureaus, in order to continuously assess and report on the state of urban environments that support health, physical activities and well-being.

26. The project will develop a HACAMP for Yanji as part of output 4 including an action plan with prioritized investments in structural and non-structural measures improving public health in Yanji. It will be further detailing recommendations described above and providing comprehensive measures to elevate Yanji as a national healthy city model. Local government will establish a working group coordinated by the land resources and planning and health bureaus and with participation from the ecology and environmental protection bureau, public parks bureau, transport bureau, education, tourism, labor bureaus, and other relevant administrative departments, and with technical support from ADB. As part of this HACAMP, develop a further detailed Yanji City Community Health Profile and undertake a municipal health needs assessment, validate, further specify and identify measures and investment priorities and implementation actions for additional health enhancing opportunities and develop an intersectoral

6 United Nations Human Settlement Program. 2013. Promoting Non-Motorized Transport in Asian Cities: Policymakers’ Toolbox. Manila. http://cleanairasia.org/wp-content/uploads/2015/08/NMT-Toolbox-Report- 2013_v2.pdf.

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monitoring plan, in collaboration with the project design team and the other sectors. As part of the action plan, explore the feasibility of establishing public-private partnerships for the further development and management of public and green spaces and other investments in structural and non-structural measures improving public health in Yanji.

27. Yanji city health profile. For monitoring of health standards, a detailed city health profile will be further developed during project implementation collaboratively with city officials based on a framework provided by ADB. Selected data of the initially prepared health profile are in Table 1.

Table 1: Yanji Municipal Health Profile, Selected Data Health profile of key health indicators The AQI index was 339 days higher than the National (including air pollution) over time Ambient Air Quality Standard II Number of health facilities and hospital beds per 10,000 persons in Yanji: i) Hospitals: 0.75; ii) Basic health Health units per type and hospital beds institutions: 10.2; iii) Specialized public health per 10 000 population institutions:0.15; iv) Other heath institutions: 0.05; v) Hospital beds:88.5 Yanji City Hospital, Yanji City Hospital of Traditional Name, location (on a map) and Chinese Medicine, Yanji Beishan Street Health Service characteristics (type of health facility e.g. Centre, Yanji Jiangong Street Health Service Center, hospital, community health center, Yanji Jinxue Street Health Service Center, Yanji City elderly care facility, etc.) of health Gongyuan Street Community Health Service Center, facilities in the city of Yanji Yanji Henan Street Health Service Center,Yanji Xinxing Street Health Service Centre Current health insurance schemes and Urban medical insurance: 219,200 persons with coverage; cost of medical services coverage of 46%; Rural medical insurance: 54,100 (provided by the state versus to be paid persons with coverage of 70%;, per capita health by people) expenditure at CNY 2,616/person/year 13th Five-year Plan on Health and Wellness in Jinlin National, Provincial and local health Province; Provincial Nutrition Implementation Plan policy implementation and programmes (2017-2030) in Jilin Human resources for health (Number of Health personnesl:7,468 persons; Density per 10 000 health personnel and their density per population:136 10 000 population) Cause-specific mortality rate per 100 Mortality rate: 6.27% 000 population Some urban creeks are polluted by wastewater and some with direct stormwater inflow polluted by first flush. Chaoyang river suffers erosion with high total suspended solids. Yanji river flows through the Yanji Surface water quality core city area, which suffers from direct drainage of storm water and also some wastewater. The Buer- Hatong river water quality gradually worsens as it flows through the city from surface water quality class II to IV. Water Domestic drinking water quality Meets domestic standards High Fluvial flooding risk in Chaoyang river, und high Flood risk and communities exposed to pluvial flooding risk in city area due to insufficient pipe risks network. Per capita green area 40.17m2 Biological, chemical, radioactive Water, high concentration of COD, rest water contaminants (air, water, soil) parameters are unknown. Urban per capita land use for sports 2.8m2 facilities

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Employment and unemployment Unemployment:1.8% (2018)Urban per capita disposable income: CNY Average income, low-income groups 33,865/year; Rural per capita disposable income: CNY and poverty 14,252/year; Urban low-income population: 14,494 persons; Rural low-income population: 3,862 persons. 2 Universities with 4,477graduates, 20,896 undergraduates; 5 secondary technical Schools with 1,585 students; 7 high middle schools with 9,257 students; 16 junior middle schools with 14,398 students; Education system and accessibility 2 vocational middle schools with 2,336 students; 27 primary schools with 30,773 students; 1 special education school with 131 students; and 16,174 students in kindergartens. Social security coverage: 87.95% in urban; 91.3% in Social security system and coverage rural areas. Source: Asian Development Bank with information by Yanji City Government

28. Universal design. To keep all citizens of Yanji included in all aspects of societal life, in particular children and elderly and mobility or sensory impaired people, universally accessible urban spaces, sidewalks, plazas, parks, road crossings, public buildings, and an accessible public transport system design should be a priority for the city.7 To promote and ensure universal access to public transport systems and the BRT the project includes the design features in Table 2, among others.

Table 2: Implementing Universally Accessible Public Urban Transport Elements at station platform 1. Ramp or surface at platform level for station access 2. Tactile floor guideways (routes) 3. Tactile signs in raised letters (pictograms, text and/or Braille) 4. Courtesy doors 5. Support staff 6. Call button 7. Visual information 8. Audible announcements 9. Interior station lighting Complementary elements for public access: 1. Marked pedestrian crossings 2. Ramp and/or sidewalk/curb surface at street level 3. Audible pedestrian traffic light 4. Pedestrian bridges or tunnel for station access (only in the absence of street-level accessibility) 5. Elevator 6. Lack of Physical barriers (obstacles to the accessible route) 7. Public lighting Operational service features 1. Level of service at stations in peak hours 2. Level of service by BRT vehicles in peak hours 3. Distance between BRT vehicles and the platform Interior design and adaptation of BRT vehicles 1. Horizontal or vertical support bars for passengers travelling while standing 2. Visual and audible information

7 Categories of passengers that should be considered for universal accessibility planning include wheelchair users, hearing impaired, sight impaired, mobility impaired (users with walking aid, frail old users, etc.), encumbered (users with small children, heavy luggage or shopping, push chair and any other hindrance), persons with cognitive difficulties and unencumbered (all other passengers).

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3. Adequate width of doors and aisles 4. Preferential seating for persons with disabilities or limited mobility such as seniors, pregnant women, people with visual disabilities who use guide dogs, and persons using wheelchairs or strollers Accessibility conditions for intermodal transport 1. Existence of infrastructure for direct connections with other forms of public transportation and/or BRT lines (accessible routes) 2. Horizontal or vertical signage and illumination during night hours BRT = bus rapid transit. Source: Asian Development Bank with information by Yanji city government