EUR/00/5016448 ENGLISH ONLY UNEDITED E70851

Investment for

health

A demonstration project in West Saxony, Germany

Dr Rüdiger Krech Telephone: +45 39 17 12 69 Acting Regional Adviser Healthy Aging

European HEALTH21 target 6, 9, 13, 14 2000

EUROPEAN HEALTH21 TARGET 6

IMPROVING MENTAL HEALTH

By the year 2020, people’s psychosocial wellbeing should be improved and better comprehensive services should be available to and accessible by people with mental health problems (Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

EUROPEAN HEALTH21 TARGET 9

REDUCING INJURY FROM VIOLENCE AND ACCIDENTS

By the year 2020, there should be a significant and sustainable decrease in injuries, disability and death arising from accidents and violence in the Region (Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

EUROPEAN HEALTH21 TARGET 13

SETTINGS FOR HEALTH

By the year 2015, people in the Region should have greater opportunities to live in healthy physical and social environments at home, at school, at the workplace and in the local community (Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

EUROPEAN HEALTH21 TARGET 14

MULTISECTORAL RESPONSIBILITY FOR HEALTH

By the year 2020, all sectors should have recognized and accepted their responsibility for health (Adopted by the WHO Regional Committee for Europe at its forty-eighth session, Copenhagen, September 1998)

ABSTRACT

Keywords

REGIONAL HEALTH PLANNING FINANCING. HEALTH SOCIOECONOMIC FACTORS ENVIRONMENTAL HEALTH INTERSECTORAL COOPERATION CONSUMER PARTICIPATION GERMANY

© World Health Organization – 2000 All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors.

This document was text processed in Health Documentation Services WHO Regional Office for Europe, Copenhagen

CONTENTS

Page

Aim of this report ...... 1

1 Overview of West Saxony investment for health demonstration project...... 1 1.1 Introduction...... 1 1.2 Background on the West Saxony region and eastern Germany...... 2

2 Overview of investment for health concept and principles...... 3 2.1 Background and significance...... 3 2.2 Principles...... 4 2.3 Application of these principles: the real challenge ...... 5

3 How investment for health was put into operation in West Saxony ...... 5 3.1 Developing a health-promoting infrastructure...... 5 3.2 Political and administrative support...... 6 3.3 The individual projects and the umbrella group ...... 7 3.4 Organizational development and action learning...... 8

4 Lessons learned from the project...... 9 4.1 The process and management of the project...... 9 4.2 Local, regional and national commitment, capacity and sustainability ...... 12

5 Future directions for investment for health ...... 21 5.1 Securing investment for health ...... 21 5.2 A multi-level, intersectoral political infrastructure...... 22 5.3 Mobilizing broad, representative participation by the local population ...... 22 5.4 Moving beyond traditional epidemiology-oriented data...... 22 5.5 Local, regional and national capacity to invest for health ...... 22

Annex 1. Short descriptions of the individual projects...... 24

Acknowledgements

We would like to thank those people who made the investment for health project in West Saxony possible: Professor Alfred Rütten for the daily work as the local counterpart, Professor Laurie McMahon from the Office For Public Management in London for his assistance in facilitating the Umbrella Group work, Kai Rudat and Dr Nora Groce for their valuable contribution in the area of community participation, and Professor Lowell Levin for his continuous technical assistance. Finally, we wish to extend our special thanks to Pamela Nelson who, as a graduate from Yale University and intern in WHO, did her field study in Saxony and was instrumental in preparing this report.

Copenhagen, October 2000

Dr Erio Ziglio Dr Rüdiger Krech Regional Adviser Acting Regional Adviser Social and Economic Determinants Healthy Aging

EUR/00/5016448 page 1

Aim of this report

This report gives a brief overview of the background to and the structures and processes involved in the investment for health demonstration project in West Saxony. It describes some observations and concentrates on the lessons learned from the project for the benefit of the West Saxony region, as well as other interested policy-makers, managers, politicians and professionals in WHO European Member States and other governments worldwide. It also suggests a potential future direction for the investment for health approach for West Saxony to consider.

The report is divided into five sections. Section 1 provides some background on West Saxony. Section 2 gives further depth on the concepts and principles upon which the project was based, as well as the significance of the approach to the current and historical political economy of Saxony. Section 3 gives more detail on how the approach was introduced and put into operation in Saxony, including the steps taken to develop the necessary health-promoting infrastructure. Section 4 identifies some of the key lessons learned from the experience, many of them relevant both to the overall project and the individual communities, and also lists possible next steps. Section 5 offers potential future directions and development needs for this project.

1 Overview of West Saxony investment for health demonstration project

1.1 Introduction The investment for health demonstration project in the West Saxony region of Germany brought together nine towns facing similar social, economic, demographic and environmental problems. It began when the Technical University of Chemnitz-Zwickau, representing a growing network of towns and organizations in West Saxony, asked the WHO Regional Office for Europe to help them explore strategies to address some of their most pressing development challenges. Working closely with WHO and other partners, the region’s initial concept evolved to the ultimate overarching goal of developing a “healthy region” by focusing on integrated social, health and economic development. Each town addressed related issues through distinct demonstration projects, and the overall project developed skills and experience that helped all participants to identify and address common issues better in four main areas: • community engagement • building alliances • securing investment • creating and sustaining health.

It also brought the individual communities together as a single, more powerful entity in an attempt to define and secure a healthier future for their region.

The West Saxony investment for health project is particularly important for several reasons: • Economies in transition have experienced dramatic and often devastating changes not only in economic conditions, but also in their social fabric and health status. Although the magnitude of the health consequences in eastern Germany does not compare to other former eastern bloc nations, it is still significant. Through intersectoral work and cooperative planning, this EUR/00/5016448 page 2

project developed practical tools and approaches to begin to address the multiple determinants of health on which there has been an impact in these economies. • Despite the major financial investment that eastern Germany has received from its western counterparts since 1990, the need to rebuild social, economic and environmental resources persists. This project explored potential approaches and began to accumulate an evidence base to show which needs should be targeted, what types of data should be collected to understand and sustain integrated development projects, which actions would be effective and what conditions should be present for success. • While there is great potential to expand participatory democracy, eastern Germany and other areas of eastern Europe face significant challenges in overcoming the legacy of mistrust, perceived powerlessness and apathy of the former socialist state. This project explored possible approaches to public participation and identified alternatives to traditional efforts that may be more effective in this context. • Health is a neutral content area to guide the socioeconomic development process, an approach that may be beneficial to those former east bloc countries that often face an unguided development process, in some cases permeated by corruption. This project is an example of an effort to create a transparent process with decentralized local development projects, which can counteract the trend towards corruption.

Demonstration projects by nature help people to think about issues and consider various tools or approaches. As such, the overall aim of this project, and the role of WHO in it, was to help participants to learn about the process – to think about how to approach particular tasks in order to create change and increase overall local capacity in the implementation and strengthening of the project as a whole. The individual demonstration projects also benefited from the experience of other participants and the overall learning infrastructure.

The project involved a variety of people with different backgrounds and experience including political leaders, property owners, health and non-health professionals, scientists and the public. It also aimed to involve all levels and sectors of government. The project was set up and conducted over a period of approximately two and a half years. Today, the majority of the local partners are continuing to work together.

1.2 Background on the West Saxony region and eastern Germany The unification of Germany brought about many positive developments for the citizens of the former German Democratic Republic: democratization, freedom of movement, and the non- appearance of an expected fundamental economic downturn in the economy.

There is a long history of heavy industry in West Saxony, including textiles, machinery and motor vehicles. After unification many of these factories, by then state-owned, non-profitable and out of date, were closed, many of them leaving a legacy of environmental contamination. These closures and the overall shift from the welfare state to a free market economy led to extremely high unemployment rates and levels of uncertainty that had never before been experienced: in the mid-1990s, the average unemployment rate was approximately 25% (1).

After 1989, births and marriages also dropped significantly, even more than during the First and Second World Wars and the Depression. Between 1989 and 1993, the number of marriages per 1000 fell from 7.9 to 3.1 and total fertility fell from 1517 per 1000 women to 750 (1). A decline in basic demographic variables of this magnitude is considered to indicate a society in shock. EUR/00/5016448 page 3

While it is difficult to extrapolate the effect of social stress on individual behaviour, it seems that there is a complex combination of causes for the drop in births, in particular: • migration to the west, especially among certain professional age groups • the rapid adaptation of the western pattern of later rather than relatively earlier childbirth • a pessimistic outlook and substantial economic difficulty (1,2).

There is also evidence that a mortality crisis occurred in eastern Germany in 1990–1991, which is now considered to be related to the social and economic impact of the transition. Although not comparable in magnitude to that in the Russian Federation, it is still significant. Mortality rates increased considerably, particularly for men aged 15–40 years. Since 1991, mortality rates for females and teenagers have declined rapidly, but those for people aged over 30 years have fallen slowly and no change has been observed for men aged 40–45 years (1).

Evidence supports that the major underlying causal factors of the increased morbidity and mortality are psychosocial stress affecting wellbeing. This should not be surprising, given the extreme combination of change that people have faced, including their entire social, economic and political systems. Plausible explanations for increased stress include the loss of established living conditions, seen in increased unemployment and the deterioration of social relations, as well as the massive uncertainty associated with a market economy of which people had had no experience (1).

Although recent investment strategies have had some positive impact on development, in many cases progress has not been consistent or sustainable. In particular, rapid economic development strategies in West Saxony have resulted in divergences in three areas: • between policies within one sector – policies to revitalize inner cities, for example, are counteracted by a major focus on developing commercial areas outside the cities; • between the policies of different sectors – unemployment policies that offer state-funded labour for new businesses may contradict economic development policies designed to encourage new business development; • between local, regional and state level policies – disparities among communities within a region have, in some instances, resulted from investment policies that encourage competition among communities, contradicting overall regional adjustment policies (3).

2 Overview of investment for health concept and principles

2.1 Background and significance The primary focus of the health sector in most industrialized nations over the past 50 years has been on the treatment of sickness. Health care services are of course vitally important, but the origins of most health problems lies much deeper in society. It is increasingly well documented that health or its absence is much more profoundly influenced by social, economic and environmental conditions than by the presence or lack of health services (4–7). The increased morbidity and mortality associated with massive social and economic change in eastern Germany and other former east bloc countries are a dramatic case in point.

As a result, there is growing recognition in eastern Germany and elsewhere that health is produced not only through the provision of health care services, but also through a variety of social, economic and environmental factors. Health production must therefore be tackled through a broad-based health promotion strategy targeting the multiple determinants of health. At the EUR/00/5016448 page 4

same time, health is not simply an end in itself, but a resource for individuals and society. This means that by finding ways to invest resources in factors that determine health, policy-makers and communities can make real improvements in health and in all the external benefits that a healthy population brings to a country or region. A healthier population can make a more productive contribution to overall economic development, requires less social support in the form of health care and welfare benefits, and is more able to support its community life and avoid activities that, over the long term, damage its environment. Integrated social, economic and health development is at the core of the investment for health approach.

The Jakarta Declaration on Leading Health Promotion into the 21st Century (8) placed a new emphasis on the concept of health development, namely that health contributes to economic, social and human development and that such development must proceed in a way that enhances health. It is against this background that investment for health offers a pragmatic approach for linking health improvement to the development of the economic and social infrastructure. This approach is about mutual gain, in recognition that a strategy such as this must reinforce immediate economic priorities while also enhancing people’s health.

2.2 Principles The core principles on which investment for health is founded are as follows. • A focus on health. The objective is to tackle the root causes of ill health and to create opportunities and conditions for better health. While health improvement will not always be the primary policy goal, it is important to assess the impact (both positive and negative) on the health of the population of public policy decisions, including development strategies and investment decisions, particularly those with social and economic implications. • Full public engagement. Genuine involvement of the public, whose health is affected by such policy decisions, requires going beyond traditional electoral and consultative approaches. There must be new and formal opportunities for full democratic involvement at all political levels, which respect gender, age and racial differences consistent with the principles of social justice. • Genuine intersectoral working. In view of the influence on health of decisions taken in and the activities of sectors such as agriculture, education, finance, housing, social services and employment, an effective strategy to improve the health of the population requires the inclusion of all sectors to achieve the necessary synergy. • Equity. The WHO global strategy of achieving health for all is fundamentally directed toward achieving greater equity in health between and within populations and between countries. Equity implies that all people will have an equal opportunity to develop and maintain their health through a fair distribution of the resources and opportunities that support health. • Sustainability. This term, as used here, has a dual significance, indicating first, the aim of creating a durable and resilient investment for health process, and second, that investments are made and resources are managed in ways that do not compromise the health and wellbeing of future generations. • A broad knowledge-base. The development and implementation of policies and plans which will contribute to the achievement of investment for health goals cannot rely solely on technical information, but must be sensitive to community aspirations and goals, so that knowledge in this context will include the judgement and insight of the community as well as research data and knowledge from other scientific sources. EUR/00/5016448 page 5

2.3 Application of these principles: the real challenge The real challenge is to apply this rationale and rhetoric in practice. For these principles to be effectively applied, traditional policy-making approaches are often independent and need change. New policy analysis and assessment skills are needed. Change is difficult and the forces of inertia strong, but the potential benefits of investment for health are enormous. According to WHO’s experience, an agenda for change must include at least the following: • political priority for health • a new focus on health, and not merely health care • real accountability for population health gains and losses • highlighted investment potentials • increased capacity for intersectoral action • new incentives.

Experience and data that document effective methods, tools and strategies must inform these changes. In this connection, WHO’s Health Promotion and Investment Programme gives the possibility for proving initiatives that can stimulate and guide a new dimension in practice. Demonstration projects provide such proving grounds: some projects may resemble one or both of the services shown below, but each is uniquely based on local conditions.

Policy investment service. Working with several Member States, WHO’s policy investment service is preparing to document the specific and synergistic effects of the social determinants of population health; establish methods for identifying aspects of public and private policies that affect health; and design strategies for policy interventions that respect the central intention of policies and are culturally acceptable, feasible, equitable, accountable and sustainable.

The “audit” service. A second initiative, closely linked to the policy investment service, is the design and testing of a system to “audit” health-promoting assets, including all the resources that contribute to health and wellbeing, of a state or region. Audit refers to a process of accounting (identifying and enumerating) those assets that are judged by the population concerned to be relevant. Such surveys can reveal strengths and deficits, thus serving as a map to locate those policy areas that may be most appropriate in nurturing existing health-promoting assets and building new ones.

A WHO European centre is being developed dedicated to facilitating the research necessary to support these services and related demonstration projects and to building public and professional competence to support the development and implementation of these initiatives.

3 How investment for health was put into operation in West Saxony

3.1 Developing a health-promoting infrastructure In 1994–1995, a group of cities, towns and organizations in West Saxony came together to build a regional network for health promotion. Initiated and facilitated by scientists and scholars at the Technical University at Chemnitz-Zwickau, the network grew to include regional decision- makers and grassroots organizations, including a local society for economic development; the public health, culture, youth welfare and town planning departments of two larger cities; and two other rural communities. Simultaneously, the network contacted WHO to explore the possible role that the organization might play in such a project. Since WHO’s Investment for Health Programme and the Chemnitz team shared the same general framework of health promotion, EUR/00/5016448 page 6

they decided to explore a demonstration project of investment for health as an intersectoral strategy for regional development. In the light of the growing regional network, the infrastructure to support a demonstration project seemed to have great potential.

Over the next 18 months, WHO continued to hold discussions with the network and the local health-promoting infrastructure continued to evolve. The network was officially launched through an international Healthy Regions Conference in April 1995, which was held in order to clarify who were the stakeholders in the project and their degree of commitment and input to it. Projects related to town development, new management of industrial wasteland, development of sustainable tourism in rural areas and many other issues, were outlined at the conference. While health may not have been explicitly mentioned in each of the individual projects, it was implicit in their goals for socioeconomic and environmental change.

Following the Conference, three priorities were identified as the necessary support for a demonstration project: 1. the development of a specific substantive platform for the project’s implementation; 2. the identification of a politically competent regional entity to facilitate initiatives related to joint developments in different economic sectors and areas of policy; 3. the establishment of an implementation fund to support the implementation and administration of the project.

By July 1996, massive improvements had been made to the local infrastructure for health promotion in the region. The Regional Centre for Health Promotion was officially formed in order to coordinate the WHO investment for health project at the regional level and to support implementation of the individual projects. It became fully operational as far as equipment, human resources and meeting facilities were concerned and was also able to sustain day-to-day communication, which was critical to ensure consistent communication between WHO and the region. The Centre’s responsibilities also included organizing and training an evaluation team, external liaison with other partners (including external political structures and financial sources), and public relations.

In July 1996, the nine project members in the region also formalized their relationship by joining the existing Association for Health Promotion and Health Sciences in the West Saxony area, which had been founded in January 1996. This legal framework was important because it provided a platform for implementation of the overall project and enabled the region, its local communities, its private enterprises and the university to enter into a formal agreement of cooperation with WHO. As a neutral third party, the main benefit that WHO brought to this arrangement was ensuring collaboration and facilitating learning and exchange across the projects.

3.2 Political and administrative support Clearly, a key issue throughout the initial stages of this project was bringing together the local communities, the university and other local partners to develop the regional infrastructure to support the overall and individual project(s). However, a substantial amount of time and resources were also invested in building regional and state political and administrative support. This included discussing the principles behind the approach and forging relationships with officials at the level of the Regional Commissioner’s office (Regierungspräsidium) and the state of Saxony (Land or province level). The Regional Commissioner’s office is responsible for EUR/00/5016448 page 7

political and administrative mediation of state-supported projects between the municipal and Land levels, so the support and active involvement of officials at each level was very important.

Although government officials did express support for the approach, the current vertical structure of the political administration limited the depth of actual support. Ultimately, all the resources (financial and non-financial) necessary to implement the overall project were generated entirely from within the individual communities. The importance of a more integrated, intersectoral political infrastructure to this project is explored in section 4 below.

3.3 The individual projects and the umbrella group Each project was different but they all shared the common goal of achieving health gain, as well as some of the content issues shown below (9): • combining living, work, recreation and communication • integrated infrastructure for leisure, culture and physical activity • private enterprises and their community responsibility • integration of economy and ecology • cleaning up industrial wasteland • sustainable tourism.

A more detailed description of each project is in Annex 1.

Each project integrated four perspectives – those of the citizens affected, policy-makers, scientists and professional experts – in a cooperative planning group. These groups brought together stakeholders from multiple levels and aspects of the project, in an effort to bridge the gap between science and public policy, to focus on implementation and to ensure public participation.

Fig. 1. The cooperative planning group, Comprehensive Health Promotion Project, West Saxony

Scientific expertise Affected citizens

Coordination team Evaluation team Cooperative planning (research centre)

Other key stakeholders Decision-makers

The projects in the individual cities could have operated as independent, separate entities. However, the importance of working together and sharing collective experience was emphasized for several reasons. First, separate initiatives face the risk of developing competing objectives and achievements. If, for example, one town is significantly more successful at the expense of another of the same region in securing its own economic security, the overall benefits to the region could be compromised. Working in independent projects also limits the opportunities for learning, whereas working together maximizes the possibility of sharing diverse skills and experience across the region. EUR/00/5016448 page 8

In view of these considerations, an umbrella group was created to serve as the essential mechanism to facilitate cooperation between the different sectors, communities and partners in the region. The primary purpose of this group was to learn about the process of change and strengthen overall capacity. Its specific functions included: • serving as a forum for mutual support • identifying common problems • maximizing skills and resources within and outside the region • identifying the main lessons learned from the individual projects and the overall project • developing strategies to market the development work of West Saxony (10).

The umbrella group consisted of one or two people from each of the nine projects, the programme managers of the Regional Research Centre for Health Promotion and the WHO project team with representatives of the Office for Public Management, Yale University and WHO. The nine projects were to be implemented in coordination with the Research Centre for Regional Health Promotion. They would also serve as technical demonstrations for the umbrella group. The WHO project team’s primary purpose was to support the umbrella group, not to be involved in implementing the individual projects. Its work focused on: • facilitating the dynamics, communication and synergy between projects; • bridging the gap between policy-makers and project managers by providing international experience and knowledge; • supporting the umbrella group by identifying the health implications of the various projects, in order to position health as an investment resource for socioeconomic development (9).

3.4 Organizational development and action learning In the umbrella group, the approach used to facilitate the overall process was that of organizational development, in order to help people to understand the environment in which they work (both internal and external factors) in order to create the necessary changes to meet their goals. The underlying assumption of organizational development is that for sustainable change to occur, the people who are affected by the problems (the “clients”) must understand and recognize the problems and be actively involved in constructing solutions, rather than diagnoses being made and solutions proposed by outside individuals or entities. It was thus important that the role of the participants in the WHO project team and the umbrella group was collaborative. This approach helps to ensure commitment, as well as to identify and build the appropriate skills, both of which are necessary for long-term sustainability.

After considering options, the umbrella group felt that the most effective way to learn and share experience was through practical examples of successes and failures. Thus, a case-based approach was selected through which the group would work on real-life case studies of actual problems in various cities. This would help people to solve the problems and at the same time improve their problem-solving abilities. This is an “action learning approach” (9), which implies several benefits: • the individual learning process can be improved; • participants are able to experience collaborative approaches to problem-solving, as well to think about this type of approach; • the development of an integrated strategy is encouraged.

By including decision-makers in this type of process it was hoped that they would be more likely to develop an appreciation of the investment for health approach and integrate it into their policies. EUR/00/5016448 page 9

4 Lessons learned from the project

4.1 The process and management of the project 4.1.1 Building a collaborative environment Since unification, towns in the eastern part of Germany have been competing individually for limited development funds and are not accustomed to working together in a collaborative manner in a new competitive environment. In additional, although this region has a rich history of self- government and civic involvement, many people are still suspicious that they will not be taken seriously in a cooperative planning effort such as this, particularly the local population. The initial group dynamics were characterized not only by excitement and hope, but also by suspicion and mistrust. Some of the participants’ main concerns at the beginning of the process were: • building trust between decision-makers • ensuring more than token participation • questioning whether the single projects would compete against each other • fear of misuse of confidential information.

Many of the early lessons that emerged from the development and overall experience of the umbrella group related to overcoming suspicions and mistrust in an effort to move toward a collaborative environment of mutual support. Throughout the process, every effort was made to create a genuine dialogue between stakeholders, however it took time to create an environment where participants felt comfortable sharing information and working together. Individual priorities and preferences initially dominated discussions, however as more opportunities for safe compromise arose, tension began to decrease.

One of the first steps for the umbrella group was to identify concerns and expectations common to all of the individual demonstration projects. A complex array of issues were identified, which could not be answered through research and analysis alone as may be done by projects with solely technical problems. Over time, four major areas were identified as common issues to all projects and were addressed through the presentation of case studies: • community engagement • building alliances • securing investments • creating and sustaining health.

Identifying common issues had a synergistic effect because it helped participants to recognize that each brought different skills and experience that could help other participants address similar issues. While the information or content raised in this dialogue was important, it was secondary to the increased trust and understanding that was a result of this process.

Some of the key overall lessons that emerged in building a collaborative environment were the following. • The political history, as well as the current economic and political climate of an area, has a major influence on the nature of the initial interactions and concerns in a process such as this one. The project might have benefited from even further exploration of these variables before its launch. • Part of the process of moving from a competitive to a collaborative environment requires a shift in mentality from a shareholder to stakeholder approach. A shareholder approach is EUR/00/5016448 page 10

common to competitive situations, while a stakeholder approach implies a greater level of mutual support and mutual gain among various interests and groups. • When there is a move to a stakeholder approach, tension is often inevitable given stakeholders’ diverse perspectives and expectations. The way in which these differences are managed and negotiated can have a major influence on the factors underlying this tension. One of the first steps is to uncover and explore the true values and priorities of those involved. However, identifying the different perspectives and expectations of stakeholders is not enough. Competing underlying values also must be mediated in order to increase trust and understanding and come to a productive agreement. • The development of trust and a shared understanding can only come from a process of genuine dialogue. A dialogue is an active, multi-way process that uncovers many stakeholder concerns, in contrast to a passive, one-way mode of communication common to traditional technical consultation. A dialogue offers insight into the true values and priorities of stakeholders, as well as power relationships. Although the information gained during a dialogue is very important, a key by-product can be the development of trust and shared understanding. • An outside, neutral party (such as WHO) can help to facilitate this process. However, the way in which this party operates is critical. It must keep to the role of facilitator, while those affected by the problem drive the process. A sense of ownership will only develop when the impetus for change comes from and is driven by those actually affected by the problem. This is a fundamental premise to the methods of organizational development described earlier. • In any new project, participants may have preconceived notions of another partner’s role and scope of responsibility. Some participants might have expected that WHO, for example, would serve as a more traditional aid-related organization providing easy access to funding. Addressing preconceived notions and expectations can create greater understanding and avoid disappointments in the long term. Being transparent about expectations is important not only initially, but throughout the process.

The next steps to consider in continuing to build and maintain a collaborative environment are shown below. • In the future, it may be beneficial to assess further the potential for collaboration when adding new partners or before starting a new project. Gauging the level of collaboration gives a point from which to build and can enhance the organizational development process. It is clearly important in settings with a limited historical context for collaboration. At the same time, even within the same historical context, the potential for collaboration and between towns, communities and sectors can vary. As a result, it is important to focus on the instincts specific to each partner in order to avoid broad generalizations about a particular region or type of stakeholder. • The expectations of existing and new partners should continue to be revisited through continuing stakeholder analysis and a genuine dialogue.

4.1.2 Building and sustaining momentum There are many aspects to building and sustaining momentum in a project such as this one. In addition to ensuring a strong local health-promoting infrastructure (noted earlier), other important aspects are the overall political infrastructure, alliance-building, community engagement and securing investment. These areas will be explored in later sections. The focus here is on lessons related to the process that has been applied in this project and management- oriented aspects of building and sustaining momentum. EUR/00/5016448 page 11

From the beginning of this project, it was clear that participants were more concerned about the implementation of their individual projects than with technical problems. This should not be surprising, given that most of these projects faced pragmatic challenges as well as significant economic pressures to show visible results early on. It is inevitable, especially in new, high profile approaches, that there will be pressure for visible progress. This project was no different and it must be noted that participants experienced some frustrations at having to stop short of implementation.

While projects can be designed to deliver some tangible results early, a shift in the way success is defined is still very important. A recognition that success is not only defined through implementation of tangible outcomes, but also through process-related outcomes such as the development of tools, skills and strategies that can be used for implementation, can help to create the balance and perspective necessary to maintain momentum.

Collectively and individually, participants faced significant problems and deficiencies that they hoped to address. While it is essential to explore and understand particular problems, it is critical that the overall approach does not focus more on problems than on assets and the capacities for their resolution. A disproportionate focus on problems can stifle momentum and fail to identify valuable community resources. Marginalized communities, for example, are often characterized by their problems and deficiencies, and as a result the wealth of local strengths and capacities that they possess to solve their own problems is often overlooked.

Given the magnitude of some of the problems, as well as the limited history of participatory democracy in most countries (including the former German Democratic Republic), there was also a risk of a more problem-based approach in these communities. Efforts were clearly made to avoid this situation, but a more balanced approach to incorporating both problems and assets within the overall project, as well as some of the individual projects, could have been created. Although one project cannot change the way an entire area is characterized, further exploring and attempting to address these characteristics can help to counter their potentially stifling effects on momentum.

It is important that participants have the authority to make decisions in the group. Otherwise the process can be delayed while approval is sought from those in authority. It is also important that participation in the group is consistent. Delegating responsibility to attend meetings can create gaps in communication and diffuse commitment over time.

The next steps to consider in order to continue to build and sustain momentum are shown below. • Mechanisms to identify and monitor continually the balance between a focus on problems and a focus on community assets should be built into the process and management of this and future projects in an effort to sustain momentum. In future, additional data should be collected for a better understanding of how these projects, and the cities in which they are situated, are characterized to counteract the influence of any predispositions toward a more problem-based approach. • Emphasis should continue to be given to the importance of consistent participation in continuing and future efforts to ensure solid communication and commitment over time. EUR/00/5016448 page 12

4.2 Local, regional and national commitment, capacity and sustainability 4.2.1 An integrated political infrastructure: coordination and balance between different levels and sectors There are many systemic factors that determine a community, region or country’s capacity to build and sustain an investment for health approach. Specific local factors are important to long- term sustainability, but they are also interlinked and interdependent with regional and national commitment and capacity. In this case, all resources, financial and non-financial, necessary to initiate the project were generated from within the local communities. Given their strained financial situation, this signified a major commitment. However, for long-term sustainability, a strong local commitment and capacity is not enough; there must be a balance with regional and national commitment, backed by resources.

As previously noted, considerable time was spent discussing the principles of the approach, especially the importance of intersectoral cooperation, with a variety of players at all levels of government – local, regional and Land – in an effort to build their support and active involvement. The support of all levels was important given that decision-making and resource allocation is primarily driven from the Land level in West Saxony, with the Regional Commissioner’s office serving as an intermediary between the municipal and Land levels. Although intersectoral approaches were still new to the area, many political institutions and decision-makers at various levels did express conceptual support for the development of such approaches. However, early on in the project, it became apparent that it would be difficult to implement such an approach under the existing vertical structure of the political administration.

The current organizational structure of the Land is vertical and sectoral – industry, health and welfare, and education, etc. – rather than allowing for a more horizontal approach to socioeconomic development. Thus, there are limited mechanisms to foster intersectoral approaches and, as a result, most programmes are organized and funded on a sectoral or thematic basis. A unit in the cabinet of the Land President was investigating the possibilities of financing intersectoral projects; no changes were, however, made during the time frame of this project. Thus, there was no real support at Land level.

Explicit separation of sectors and levels of power does not encourage cooperation. Instead, it can foster competition and distrust among stakeholders. Because it is not conducive to intersectoral cooperation, such separation can also discourage the development of sustainable investment strategies. Unfortunately, this also can lead to disparities between regions or communities (3).

Other lessons experienced in moving toward a more integrated intersectoral infrastructure were as follows. • The umbrella group proved to be a highly beneficial temporary mechanism to begin to bring people and resources together for cooperative planning and intersectoral cooperation. It planted the seeds for new ways of thinking and the opportunity to share experience. Cooperative planning and intersectoral working are clearly counter to the traditional way that most managers and civil servants operate in this (and other) areas. Some technical experts, in particular, felt it was difficult to be efficient without a more technical aim- oriented approach, given the multiple perspectives and needs involved. However, over time, participants seemed to gain a clear picture of the benefits and challenges in creating such an approach. Implementing this type of approach in their own work settings or continuing to encourage broader change at regional and Land level will require, in addition EUR/00/5016448 page 13

to familiarity with the concept, an acute appreciation of power relations and the ability to influence and negotiate change. As with other projects, the participants became aware of the importance of these types of skill, recognizing that although they can be identified in a textbook or case study, they are best learnt through application and real-world experience. • The level and depth of structural change required will take time, which underlines the importance of persistence and clarity, including a clear strategic plan. Attempts to create change during the project showed that any minute changes arising from the initial groundwork must be nurtured in order to stimulate further change. A clear strategic plan will help direct these efforts. • All participants came to these projects with varying levels of experience and familiarity with cooperative planning and participatory democracy, as well as free market principles. When gaps or if participants’ experience and level of comfort with various concepts are explored and addressed. • The project also reinforced the fact that working with new sectors requires new approaches and in-depth attempts to find common ground, in order to increase capacity for intersectoral action. In particular, working with private sector investors proved challenging. Early on participants expressed concern over potential conflicts between private sector interests and health concerns. In several projects, a considerable challenge was posed by the need to engage the larger private property owners consistently in the process. Part of the problem is systemic. Before 1992 potential investors could purchase property with no strings attached, which resulted in massive speculation. A new law has now been introduced to address this speculation and encourage development. Under this law, if a city has a potential investor with a concrete development plan, the owner is given the option of implementing the proposed plan. If the owner does not exercise this option within two years, the new investor can implement the plan.

This situation illustrates that new sectors must clearly see the benefits of participating. Intersectoral cooperation is alien to the traditional way of working and sectors will not cooperate just because someone says it is a good idea. Local partners are currently exploring new incentives to attract new private sector partners.

The following are some potential next steps to consider in an effort to move toward a more integrated, intersectoral approach to ensure long-term sustainability. • The creation of permanent mechanisms are essential to continue to foster an intersectoral approach. This will require an explicit, systemic commitment at all levels of government that makes health as much of a priority as social and economic development. Systemic commitment is evidenced in processes and structures that facilitate cooperation, as well as the allocation of resources (financial and non-financial) between and within sectors. It is important that these processes and structures are institutionalized to survive political and leadership changes, since it takes time to implement and realize an investment strategy that is sustainable. WHO has learnt that this type of commitment should have been sought before it agree to cooperate with the project. • To influence this change, project participants should continue to follow up on the groundwork with regional and state government officials, and mobilize other regional partners to strengthen efforts to encourage systemic change that ultimately produces population health gain. Consideration should be given to identifying additional opinion- leaders who can help to move the change process forward, and encouraging them to look to EUR/00/5016448 page 14

the contribution of other sectors in their own work so as to increase awareness of the value of an intersectoral approach. • Consideration should possibly be given to the experience of other countries or regions that have been successful in building intersectoral cooperation and cooperative planning. • The priorities of and incentives for new private sector partners should continue to be explored and consideration given to lobbying for tax breaks or special reward schemes.

4.2.2 Social capital Social capital is the quality and quantity of a society’s social interactions, cohesion and trust. It is seen in the various institutions, networks and norms that convey trust and mutual support, such as the number and type of civic associations, the perception of the extent of community organization and of participatory decision-making, or the extent of trust among community members and households (11). Social capital proved to be important in this project for several reasons. • Thoughtful investment for health approaches can help to build levels of social capital by focusing on people’s ability and willingness to work together for mutual benefit. While improvements in trust and cohesiveness were observed at the regional and local level, this project might have been able to make more improvements in social capital if there had been a greater focus on the nature and degree of social capital in these communities before the project started. Understanding and addressing gaps in social capital can help to build the capacity to support and sustain these projects, and ultimately to influence health. • Levels of social capital can significantly influence how the process and management of projects such as these are carried out and sustained. Communities with strong social capital have a robust capacity to support such projects through pre-existing networks, norms and trust. This was observed at multiple levels of the project, including in joint regional efforts and individual projects. • Although these towns share the legacy of mistrust and perceived powerlessness, each has its own history of civic engagement. Thus, social trust, solidarity and cohesiveness can vary dramatically from village to village and town to town. These differences offer a partial explanation of why some projects are more sustainable than others. As a result, a major overall lesson in the area has been that preliminary data collected to understand, launch and manage such a project must be expanded to include indicators of social capital. It is critical that these data focus not only on the country or region, but also on the town and village.

The next steps to consider in continuing to build and track social capital are shown below. • Social capital is an essential condition for the success of projects such as these. Communities in Saxony should therefore continue to build their social capital to give better support to and sustain all their local and regional initiatives. The continued fostering of environments that encourage participatory democracy and strong civic engagement is fundamental to the building of strong social capital (see next section). Reaching out to and supporting untapped social resources, such as kinship networks, neighbourhood groups or social associations, can also help to build social capital for this project and future efforts. • Efforts to collect data on indicators of social capital should be expanded. This is important for several reasons. First, an understanding of the level and nature of social capital before a new project is started can influence how it is carried out and identify resources that could help to support and sustain it. Secondly, with the appropriate data, investment for health EUR/00/5016448 page 15

approaches can address gaps in social capital. Finally, gathering data on indicators of social capital is a critical part of monitoring change over time and making potential associations with health gain. Evidence shows that health throughout a community will be better if investments can contribute to building communities where people feel they have a future together and for which they are all responsible.

4.2.3 Community engagement Public participation or community engagement are not merely components of, but at the core of health promotion and its implementation through an investment for health approach. A sustainable investment for health approach results from increasing people’s control over the determinants of health through community action. The term “community action” was explicitly chosen by authors of the Ottawa Charter to represent a certain level of participation that would help to achieve increased control and sustainable action. The term is based on social action theory, which is the approach most closely aligned with organizing the disadvantaged or aggrieved to take action on their own behalf and to challenge the power structures that cause oppression and disempowerment. While there is no single theory of community participation, increased control and active involvement are hallmarks of sustainable change (12).

In practice, community engagement or public participation are still relatively new even to traditional health programmes. They often initially evoke anxieties even among public service managers and policy-makers in areas of the world with long histories of participatory democracy. In this project, participation by the local population primarily came about through involving people who were officially members of the umbrella group and of the individual planning groups. Some of the individual projects also attempted to involve the wider community, making substantial progress in some cases. While there is great potential, it proved to be challenging to bring about representative, community-wide participation beyond the local population in the areas of the individual planning groups. This difficulty is associated with the legacy of apathy, dependency and perceived powerlessness of the former socialist state, although the same can be found in many western European countries too.

The case study on community engagement laid a basic framework for participation by the local population. However, models for broadening participation to include people living in wider areas than those covered by the individual projects varied between communities, based on the projects’ goals, resources, local history and political dynamics. Projects related to urban planning and building are required by law to consult the residents after a plan has been drawn up and before it is implemented. Some cities use this as their model, while others have gone further and created new systems and processes to involve their populations.

Overall, some of the key lessons that emerged in the area of community engagement are as follows. • Representatives of the community are not the community. It should not be assumed that individuals in a planning group speak for all voices in the community. Outreach activities should target those who are not likely to participate or may have difficulty participating, such as those with disabilities or single working parents. This will reduce the likelihood of a situation where only those most likely to participate are represented. • There is no broad-brush approach to participation by the local population. Each community is unique and has its own sense of place resulting from its individual history of civic engagement as well as the current political dynamics. In the light of these differences, it is important that strategies to engage the inhabitants are adapted accordingly. EUR/00/5016448 page 16

• At the same time, all of these communities, to some degree, share the challenge of overcoming the inhabitants’ apathy and perception of powerlessness. Although many people are still suspicious that they will not be taken seriously, surveys also indicate that one of their main priorities is “to have more say in important government decisions” (13). In a society where people want to participate but may be tentative or suspicious about doing so, it is critical that strategies for “community engagement” focus on capacity-building and leadership training to move towards community-driven action. Traditional approaches to participation by the community, such as focus groups or surveys, do not actively involve the community as full partners in the change process. Social action approaches, such as organizing the community, offer a promising alternative. Organizing the community means shifting more power to the community to define problems and construct solutions and engaging them as full partners, which can reverse some of the mistrust, apathy and powerlessness that is limiting current efforts to involve the local people. • If change is to be sustainable, the community itself should drive the impetus for change and should be involved throughout the life of a project. Involving the local population after a plan or project has been developed can have a backlash effect, resulting in tokenism, as well as a potentially avoidable adversarial situation that may be costly in later phases of the project. Bringing in the people affected after a problem has been defined can also reinforce inequitable power relations and further marginalize groups that are not involved. In contrast, early and continual involvement of those affected will help to ensure that the definition and goals of the project are representative of community needs and that hidden assets in the community are identified. This approach builds ownership, which is critical to long-term sustainability.

The next steps to consider in an effort to strengthen a community’s capacity and the overall sustainability of a project are outlined below. • Mobilizing broad, representative community participation among marginalized power groups involves shifting more power to residents in the project areas and the community. Consideration should be given to enhancing the community engagement aspect of the project to become more of a community-action oriented approach that is adapted to local conditions. One way to do this is to implement a social action approach, such as organizing a community. Although historically social action was based on conflict theory and confrontational politics, today strategies are often a mix of both the conflict and consensus type model. • This approach could start with a greater focus on capacity-building and leadership training for residents who are members of the planning groups, to strengthen their capacity to mobilize their communities for broader representation in the project(s). After training, these people would essentially go door-to-door to strengthen neighbourhood relations and to mobilize greater interest and support. Important by-products of this kind of activity are to build relationships and to develop more leaders. Organizing communities has shown that giving priority to leadership development and one-on-one relationships over results can lead to better by-products or output. This also offers a mechanism to tap into the hidden resources and assets of a community, and is especially important in communities characterized predominantly by their problems and deficiencies. Perhaps most importantly, because organizing a community involves the engagement of the community as full partners, it has been shown to reverse the type of mistrust, apathy and perceived powerlessness that is limiting current efforts in West Saxony (12,13–15). It does, however, require an investment in time and enabling resources. EUR/00/5016448 page 17

4.2.4 Building alliances In the light of the multiple dimensions of an investment for health approach, widespread commitments from many interest groups are also an important part of capacity and sustainability. This involves building alliances and new partnerships at all levels – local, regional, state and international. The case study on building alliances highlighted that this approach requires a shift from the classic management model where a leader is at the top of a hierarchical structure, to an issue-based approach to leadership. In an issue-based approach, stakeholders outside the boundaries of specific organizations, as well as those operating within them, are involved in the process. This is counter to the conventional approach to hierarchical organizations and management practice in Saxony and elsewhere. As a result, several key lessons emerged. • The involvement of people from different interest groups, disciplines and professional backgrounds was highly beneficial for the project. Despite the diverse make-up of the group, there is possibly scope for further exploration and identification of the informal influence structure. This often includes people who, although they have no political standing or official position in the hierarchy of a policy-making organization, may have significant influence behind the scenes or may be people to whom decision-makers turn for advice on a specific issue. Tapping into the informal influence structure can ensure that the hidden decision-makers as well as the known ones in a community or region are involved in a project such as this. This can also help to ensure that the project’s values and goals have a broad basis of support and are representative not just of those officially in power, but of the wider population. • Balancing the interests of multiple stakeholders and creating equitable power relations can be challenging. Some participants were concerned, for example, that private investors’ interests might dominate the process. It is therefore important to design explicit mechanisms to balance and negotiate between different interests. The independent project management structure of the Regional Health Promotion Research Centre was highly beneficial in mediating between many of the interests during the process. However, to some degree, it is beyond the scope of the project management structure to ensure that external market forces and private interests do not dominate the process. This will require the concerted effort of all the stakeholders and the creation of a permanent external accountability mechanism charged with ensuring that industry, commerce and other work organizations are held accountable for the impact on health of their products or services. • As the project(s) has progressed, it became clear that it is important to look again at the questions of bargaining power and power relations over time. Although most participants felt that power relations were equitable, local people in some cases expressed concern over their influence in the process. This could have implications for power relations, but could also have multiple meanings and of course could vary dramatically in each individual project. The survey evaluations conducted throughout this project and the feeding back of this information to the umbrella group provided important insights into this and other areas of the project. However, there is substantial potential to gain an even more meaningful understanding of more subjective topics such as power relations, by complementing written surveys with additional qualitative research methods. • Broad-based support emerges from several things, including the capacity of local leadership to sustain the support of the community through planned programming of events, and from visible results or changes. It also requires a continuing awareness of potential new partners whose stake in a project’s work may not be apparent at the outset. Although this project has identified many partners, the main focus and developments have EUR/00/5016448 page 18

been at the local level. As previously noted, there is clearly a need to involve regional and Land stakeholders further. Such efforts are, however, decisive in an investment for health approach. • When many partners, sectors and organizations are involved in a project, consistent communication at the right time can present a challenge. This process involved multiple partners in different areas of the region, so strong communication links were important for its capacity and sustainability. As with other projects, information technology (such as e-mail or fax) can help, but this must be supported by a strategic plan detailing specific duties and responsibilities.

The next steps to consider in an effort to continue to build broad-based community support include the following. • Potential new partners should continue to be identified and assessed to ensure broad-based community support over time. An informal influence structure analysis should be conducted to ensure that not only the known decision-makers, but also those who may have major influence behind the scenes, are involved in the process. • Written survey evaluations should be complemented with additional qualitative evaluations, such as interviews, in future evaluation efforts. This will help to ensure a genuine understanding of topics such as power relations, which are difficult to quantify and explore through written surveys.

4.2.5 Securing investments A solid investment for health approach takes time to build, implement and mature. Recognition that time is an important part of sustainable development can yield pragmatic benefits over the long-term. Too much focus on short-term economic gain can undermine such a strategy and result in investment that is not sustainable. A focus on social, health and environmental concerns throughout the economic development process can eliminate avoidable costs in these areas and support the overall development process better.

While this rhetoric can be successful in practice, it is challenging to incorporate it into an environment where there is massive economic uncertainty. Concerns over financing were a strong common denominator in all the projects and one that increased anxieties about implementation. There were several key lessons that emerged in attempting to overcome these challenges and secure investment. • In order to avoid the paralysis that can occur when projects lack resources, participants decided early on that identifying and securing potential investment must be handled as a joint corporate effort. The umbrella group spent a considerable time developing a single corporate identity to represent the overall project. Coming together in this way created an overall project infrastructure by uniting the loose organization of the individual projects into one single project, and represented increased bargaining power and shared vision. A clear shared overall mission and strategic plan is a key part of attracting sustainable development. If potential investors sense confusion, they are less likely to be interested. • Once a clear vision is in place, a comprehensive marketing communications plan should be developed to attract resources. The individual towns had communications plans, but the overall project could have benefited from the development of a more comprehensive communications plan at an earlier stage. EUR/00/5016448 page 19

• As noted earlier, the resources necessary to initiate the original project were generated entirely from within the local communities. They included some private support, but this was limited and project participants are well aware that this is an area that can be further exploited in the future. Developing more connections to private sector partners and economic development groups is crucial for the continuation of the regional and individual projects. This is a continuing process and, as discussed earlier, also involves exploring new incentives that may help to attract such partners. • Securing sustainable investment takes time, in large part due to the structural changes necessary to support such an approach. A clear vision of what the region/town will be like in the future is necessary to sustain momentum. As noted earlier, this also requires a shift in how success or progress is defined in the short term from a tangible outcome orientation to more of a process orientation. In other words, in the short term the impact of investment for health can only primarily be judged through the new processes, tools or ways of thinking that have been developed. Substantial progress has been made in adopting new processes or using new tools, such as new systems for public participation, additional outreach to new partners, and the unexpected outcome of a local university adopting a new public health curriculum. Another important outcome has been the acceptance by the state of Saxony that the project as a whole should participate in the world exhibition EXPO 2000. Clearly, this is a major opportunity to develop new partnerships and expand support for the project.

The next steps to consider in an effort to secure sustainable investment are shown below. • The demand for resources far exceeds anything that can be provided through philanthropy or the public sector, so the full resources of the private sector should be explored. New private sector and economic development partners should continue to be pursued, and new incentives to encourage private sector participation and support, such as tax breaks or special reward schemes, explored further. • A formal organization representing the principles identified in the corporate identity process has not yet been created, although it is possible that the Association for Health Promotion and Health Sciences may evolve into this. The creation of a formal entity that represents the overall goals and mission of the project is a crucial part of increasing visibility and bargaining power in an effort to attract the necessary support and resources. Reconsideration should be given to the implementation of recommendation number two in the Phase I report. • WHO and other international partners are currently working on identifying the tools and strategies needed to reorient policy decisions and resources in the process of securing investments for health. Consideration should be given to the outcomes of the Verona II conference, which aims to address these issues.

4.2.6 Producing and sustaining health At the last meeting of the umbrella group, participants described how to produce health. The production of health can add value to economic and social development in an equitable and sustainable manner. While the participants may have used different terms, conceptually they described the criteria below as important indicators to consider when trying to employ an investment for health strategy: • increasing social capital • decreasing social exclusion • improving the physical environment • improving the coping resources of the community • improving economic security. EUR/00/5016448 page 20

Producing and sustaining health clearly requires a multidimensional approach in order to address these broad determinants of health. Some of the key overall lessons related to developing a strategy that aims to produce and sustain health are shown below. • This project began with the types of health and demographic data that are common to epidemiology-oriented interventions, in order to understand the nature and scope of the health problems in the region. However, it gradually became clear that additional data on the conditions that can either promote health or serve as barriers to health promotion were needed in order to understand, formulate and sustain these projects better. As noted earlier, these included further data on the local political and economic environments and cultural assets, mapping of the informal influence structure and, in particular, indicators of social capital. In a broad sense, these data can provide a picture of the local infrastructure to transport the concepts and ideas of investment for health. These types of baseline data are also necessary so that there is a starting point from which to monitor continuously the determinants of a population’s health over time. • Experience in this project reinforced the notion that there are many different dimensions to health, which underlines the importance of involving multiple perspectives in the process. Projects ranged from inner city development through sustainable tourism to management of industrial wasteland, each having a direct or indirect impact on health. These are not traditional disease prevention or health projects, and they therefore require a unique set of skills and expertise. Thus, it is important to evaluate the specific needs of a project initially and throughout the process to ensure that the appropriate mix of participants is involved. This might include professional, non-professional, social and political resources.

The next steps to consider in order to produce and sustain health through this and other projects are shown below. • In order to move toward producing health by addressing some of the indicators above, the data initially collected to support such a project must move beyond the health and demographic data gathered for traditional public health interventions. Future initiatives in Saxony should consider gathering the additional social, economic and political data noted. Ongoing efforts to integrate some of these indicators into an outcome evaluation also should be continued. • A strategic audit of existing skills and expertise should be conducted to ensure that the appropriate mix of participants is involved. Additional resources should be recruited where necessary.

4.2.7 Accountability Accountability includes transparent processes of dialogue and disclosure, as well as involving stakeholders in the planning and decision-making process. True accountability indicates individuals’ or an organization’s acceptance of responsibility for their actions, evidenced in their ability to provide an account or explicit record of activities typically through reporting to a recognized authority. Mechanisms designed to increase accountability can be effective in building commitment, understanding and a common sense of purpose (16).

This project contained three primary accountability mechanisms, including continuing evaluation, community engagement and the umbrella group itself. • The umbrella group was a temporary accountability mechanism that began to build accountability for decisions affecting investments for health in the region. However, as EUR/00/5016448 page 21

already noted, a clearer focus of permanent accountability for intersectoral planning and action at multiple levels of government is also necessary. Given the limited formal mechanisms or structures for accountability, comprehensive awareness and participation among the local population took on an important role in creating accountability. • Continuing evaluation is an important systematic mechanism that can be built into a process to increase accountability. In this case, evaluations provided a tool to assess the internal planning process, as well as the external structures and actors related to the planning process. As regards the internal planning process, both the form (how people participate or communicate within the planning process) and the content (the concrete steps to be implemented) were evaluated. The evaluation of external factors focused on local public policies as well as the lifestyles of the local population. Both types of evaluation were based on a participatory approach, so these data were not an end in themselves. Within the internal planning process, this meant that the evaluation team shared its observations with the organization team and the umbrella group in order to stimulate discussion and change. This participatory approach helped all involved to enhance overall group dynamics, to explore perceptions of the impact of their work and to stimulate decisions, goals and measures for future work. The external evaluation was also designed to inform discussions at the policy-making and population level. A similar process was used in the individual projects (3). • After the participants had evaluated their internal process and perceived external outcomes, they decided to place more emphasis on implementation, in particular securing investment through alliance-building. In order to evaluate the impact of alliance-building on securing sustainable investment, the West Saxony project began to collaborate with the Prince of Wales Business Leader Forum (3), facilitated by WHO. With the Forum, they developed a set of concrete goals and measures, but limited funding has prohibited implementation of a related evaluation.

The next steps to consider in order to increase accountability are shown below. • Relationships with regional and Land government officials should continue to be fostered in an effort to encourage further mechanisms for formal accountability at all levels of government. As noted, the first step is systemic change that embraces an intersectoral approach at all levels of government, in an effort to move towards accountability for decisions within this type of system. • Existing relationships should continue to be solidified and new partners pursued who may be able to support the expansion of evaluation efforts.

5 Future directions for investment for health

This project contributed to a persistent need for actual experience of how the principles of health promotion translate into practice. It was a proving-ground that may stimulate new directions in future investment for health approaches in West Saxony and around the world. While considerable progress was made, there is clearly a potential for further development not only of West Saxony’s capacity to invest for health, but also of the investment for health approach itself.

5.1 Securing investment for health There is still more work to do to determine what it takes to re-orient policy decisions, infrastructures and resources strategically in an effort to secure sustainable investment. This is EUR/00/5016448 page 22

the focus of the forthcoming Verona initiative. Another important part of securing investment relates to expanding private sector support, which, as noted, requires new incentives. Current work in this area can build on lessons learnt in this project.

5.2 A multi-level, intersectoral political infrastructure The current partners in West Saxony are applying for funding from the federal Ministry for Research and Education. The granting of funding would indicate a major step forward in the political infrastructure. However, institutionalized systemic change at all levels and sectors of government would still be necessary for long-term sustainability. To encourage this change, any small developments that emerge from the seeds that have been planted should be nurtured. West Saxony should continue to mobilize other regional partners and opinion-leaders to strengthen efforts to encourage systemic change aimed at producing sustainable population health gain.

5.3 Mobilizing broad, representative participation by the local population More experience is also needed in the area of participation by the local population. This work could draw on the success that other areas of the world have had in applying social action- oriented approaches in marginalized power groups. Evidence has shown that action-oriented approaches can reverse the mistrust and perceived powerlessness that is limiting participation here. There is enormous potential to build the capacity necessary for the local people to serve as ambassadors for investment for health principles, which could be a powerful way to increase overall public commitment to the approach.

5.4 Moving beyond traditional epidemiology-oriented data It is clear that the data gathered to understand, formulate and sustain such projects must move beyond the traditional epidemiology-oriented data to include additional social, economic, political and cultural data. It is also clear that these types of data should reflect the level of the partners involved, from national to regional to local. Further investigation is needed to determine the specific indicators that will capture the type of information necessary.

5.5 Local, regional and national capacity to invest for health Although substantial progress has been made, West Saxony’s potential capacity to invest for health could be strengthened further. It is therefore recommended that further analysis be made of the local, regional and national capacity to enhance the sustainability of these projects. One tool that may help with this suggestion is the first Verona benchmark. This is a schedule of the main requirements for the implementation of the investment for health approach, focusing on the characteristics of the system and the identification of what systems would need to be in place. Any country, region or local community can use this tool to assess its own preparedness and capacity to invest for health. It is very comprehensive and addresses many of the issues discussed throughout this report.

Moving to an investment for health approach can be difficult, but each experience of it in action adds to the momentum and evidence base necessary to create this change. This project was one more step towards making a real difference to people’s quality of life and health in West Saxony and around the world.

EUR/00/5016448 page 23

References

1. ZIMMERMAN, K. & RIPHAHN, R. The mortality crisis in East Germany. Paper presented at the United Nations University and the World Institute for Development Economics Research Project Meeting on Economic Shocks, Social Stress and the Demographic Impact, 17–19 April 1997, Helsinki. Helsinki, World Institute for Development Economics, 1997. 2. Economic change, social welfare and health in Europe. Copenhagen, WHO Regional Office for Europe, 1994 (document No. 54). 3. RUETTEN, A. Evaluating healthy public policies. In: Rootman et al. Health promotion evaluation. Copenhagen, WHO Regional Office for Europe, 1999. 4. WHITEHEAD, M. Social inequalities in health: what are the lessons for health promotion? European Committee for Health Promotion Development, 1998. 5. BLANE, D. & MARMOT, M. Social determinants of health: their relevance in the European context. Copenhagen, WHO Regional Office for Europe, 1998 (draft paper for the Verona initiative). 6. KICKBUSH, I. Global experiences in health promotion since the Ottawa Charter. Report of the International Forum on Health Promotion, Tokyo, 1996. 7. HEALTH21: the health for all policy framework for the WHO European Region. Copenhagen, WHO Regional Office for Europe, 1999 (European Health for All Series, No. 6). 8. The Jakarta Declaration: on Leading Health Promotion into the 21st Century. Geneva, World Health Organization, 1997 (document WHO/HPR/HEP/4ICHP/BR/97.4). 9. RUETTEN, A. New partnerships for health promotion: the West Saxony investment in health project. Fourth International Conference on Health promotion, New Players for a New Era: Leading Health Promotion into the 21st Century, 21–25 July 1997, Jakarta. Geneva, World Health Organization, 1997. 10. Investment for health in West Saxony, Phase 1 report. Copenhagen, WHO Regional Office for Europe, 1998. 11. WOOLCOCK, M. Social capital and economic development: theory, evidence, policy. Paper presented at Yale University, 2 February 1999. 12. MINKLER, M. Community organizing and community building for health. Camden, Rutgers University Press, 1997. 13. EL-ASKARI, G. ET AL. The Healthy Neighborhoods Project: a local health department’s role in catalyzing community development. Health education and behavior, 25(2): 146–159 (1998). 14. PECUKONIS, E. & WENOCUR, S. Perceptions of self and collective efficacy in community organization theory and practice. Journal of community practice, 1(2): (1994). 15. WALLERSTEIN, N. & BERNSTEIN, E. Empowerment education: Freire’s ideas adapted to health education. Health education quarterly, 15(4): 379–394 (1998). 16. GONELLA, C. ET AL. Making values count: contemporary experience in social and ethical accounting, auditing and reporting. London, The Institute of Social and Ethical Accountability, The New Economics Foundation and the Association of Certified Chartered Accountants, 1998 (Research report 57).

EUR/00/5016448 page 24

Annex 1

SHORT DESCRIPTIONS OF THE INDIVIDUAL PROJECTS

Business in the City Intersectoral inner-city development in the city of Crimmitschau

The aim The Crimmitschau project deals with the former urban industrial area of Amselstrasse. The area will be developed for new functions and generally revitalized to establish an attractive business area. This will also improve the residents’ quality of life in this district, which is quite close to the city centre.

The issue Business in the city must not interfere with the neighbouring residential areas: it should follow ecological concepts and improve the city structure. The Amselstrasse area will be completely redeveloped and turned into a business area with a high quality of life. Both residents and investors will profit from this. To achieve this objective it will be necessary to develop a versatile structure that is not only centred on industry and trade. Facilities for culture, recreation and sports should complement the residential areas in an ecological fashion. The future traffic system must correspond with the needs of the different target groups, so that the area can be reached not only by car but also on foot or by bicycle.

The initial situation The Amselstrasse area is characterized by industrial wasteland. Crimmitschau was a centre of the textile industry and most of the former factories were spinning or weaving mills, dyeing-houses or plants building textile machines. The contamination typical of this kind of industry and unsettled questions of ownership have been impeding urban development in Crimmitschau and endangering both people and the environment.

The method and the status quo Traditional approaches have not produced satisfying results, so a cooperative planning group has been formed. From the outset decision-makers, scientists, experts, affected residents, property owners and possible investors have had equal rights to introduce their perspectives and interests into the planning process. After four sessions the schedule for the area’s development was divided into three phases. At present a concept is being worked on for the first part of the area which takes into account the guidelines developed in a brainstorming session. This will be implemented over the medium term. EUR/00/5016448 page 25

A Place for People and Business Combining the development of an industrial area and the interests of the residents

The aim An industrial area is being established in the city of Glauchau as the first step towards building a freight traffic centre at this location. However, this is to be not just a business location but also a place with a high quality of life both for the residents and the investors.

The issue The Federal Government, the Free State of Saxony and the authorities of Glauchau have decided that one of the three future freight traffic centres in Saxony will be built in Glauchau. Sophisticated techniques used in these centres will support in an economic and ecological way the redirection of the growing freight traffic towards the railway system. On the other hand, such a development must not be achieved at the expense of the residents and common interests. This area will not therefore only be oriented towards industry and trade. It will also include facilities for culture, leisure and sports. The accessibility of the area will correspond with the different groups using it.

The initial situation It will take approximately 15 years to establish the freight traffic centre. About 3000 jobs will be created in the process. A huge road to rail freight terminal will be built in the immediate neighbourhood which will considerably increase traffic in the area. The planning area also includes the North-western Industrial Area that will be the home of most enterprises belonging to the freight traffic centre. A number of heavily frequented roads border or cross the area. Several residential areas of rural (Lipprandis, Jerisau) and suburban (Gesau) character are situated in the planning area. People living there will be particularly affected by the developments immediately on their doorstep. The residents have formed a citizens’ committee to represent their interests. Because of this complicated situation, several important investors have rejected the area so it has not been possible to achieve the economic goals planned. If the residents continue to refuse acceptance, the future development of the location will be at least impeded.

The method and the status quo A cooperative planning group comprising residents, investors, business people, the city’s decision-makers and experts has been established. All the parties involved have had equal rights to introduce their views into the planning process. A catalogue of specific measures is being revised now, and is being accepted and supported by all those involved. A number of measures aiming at creating mutual understanding have already been implemented.

EUR/00/5016448 page 26

Active City Centre The new city centre of Lichtenstein in a Healthy Region

The aim A new active city centre will be developed as a model project in Lichtenstein. This has been made possible by the complete redevelopment of the area between the railway station, Weststraße, Glauchauer Straße and Zwickauer Straße, which formed the north-western part of the old town centre. The other two central areas of the city centre are included in this process.

The issue The centre of Lichtenstein is to become more attractive and pleasant for both inhabitants and visitors. An active city centre means that living, working, recreation and communication are linked with each other in the best way. It also means that this area must be accessible from both the historical town centre and the residential areas west of the railway.

The initial situation The centre of Lichtenstein consists of three parts – the historical town centre, the baroque town of Callnberg and the north-western part of the old town centre. The historical town centre and Callnberg have seen much building and reconstruction work in recent years, but the north- western part of the old centre with its relatively open structure has been considerably neglected. Among other things, this is probably due to the complicated questions of ownership – most properties are privately owned and surround the small piece of land owned by the city in such a way that no public access road exists.

The method and the status quo To find a solution, a cooperative planning group was formed that included decision-makers, scientists, experts, and the residents and land-owners of this area. After a brainstorming session the group – following basic ideas formulated by themselves – analysed the situation and defined the future functions of the north-western part of the city centre. The resulting concept, which was agreed by the planning group, states short-, medium- and long-term measures together with responsibilities and deadlines. These are being implemented step by step, starting with a first footpath through the area. Currently, work is going on to create a new concept for a future playground and park area. Whether this area will fulfil all its intended functions largely hinges on future cooperation between private land-owners, the authorities and the planning group.

EUR/00/5016448 page 27

Space for Action Integrated development of leisure and sports facilities in Limbach-Oberfrohna

The aim The planning of sports facilities is to become an integrated part of town planning in Limbach- Oberfrohna. Areas for sport, leisure and recreation will be developed as a whole to create activity areas. This will improve the quality of both the life in the town and of the location.

The issue Integrated planning of facilities for sport, leisure and recreation means developing and implementing a concept that will significantly increase the wellbeing of the inhabitants of and visitors to Limbach-Oberfrohna, so it is an important aspect of health promotion. At the beginning the real demand must be ascertained. Existing approaches will be integrated. The structure of the facilities will be coordinated in such a way that a wide variety of possibilities for sport and leisure time is offered – ranging from activity areas close to residential areas to sports facilities of regional importance. Adjusting planning to the needs of the population guarantees a high degree of acceptance and identification of the inhabitants with the project.

The initial situation There is a diversity of interests such as leisure-time sports, physical education at school and club sports. Besides, different authorities are responsible for sports, leisure and recreational areas. This resulted in many divergences in Limbach-Oberfrohna and the neighbouring communes. These tendencies will be addressed through an integrated concept that includes the existing development plans of the towns and villages involved.

The method and the status quo Cooperative planning is being used as an integrated approach. The opinions of the people affected, decision-makers, scientists and experts are being included in an innovative development plan. The interests of private investors are also being considered. Drawing on an extensive collection of ideas, the objectives of the project have already been defined in the planning process, the existing sports and leisure facilities analysed and existing plans incorporated. Following the example of the “Golden Plan East”, a concept will be worked out that documents the future development of the activity areas.

EUR/00/5016448 page 28

Intelligent Tourism Health-promoting development of the infrastructure in the region of Mittweida

The aim Tourism strategies based on environmental awareness will be implemented in such a way that they promote the cultural, social, natural and economic resources of the region.

The issue The project is based on the concept of intelligent tourism that represents a new approach or philosophy for the development of tourism. Features of intelligent tourism are: • it attracts the visitor in a comprehensive way – relaxation of the body goes hand in hand with emotional stimulation of the mind by new and instructive experiences; • based on a comprehensive approach, it takes into account the numerous interrelationships between the environment, economy and society; • it has a lasting effect and uses natural resources sparingly, and its proceeds are being re- invested in the region; • it is open to a wide variety of tourist activities – from nature-oriented to technical ones; • it uses regionally existing strengths and capabilities to develop a special strategy.

The initial situation The main problem is the isolated local development of recreational areas, industrial sites, shopping facilities and communications. In the long run, this isolated approach can neither guarantee the region’s economic survival nor make it sufficiently attractive for the population. A network correlating the individual activities is therefore absolutely necessary.

The method and the status quo A cooperative planning group has been set up which includes the decision-makers of the urban and the rural district of Mittweida, business people, scientists, tourist agencies, associations and clubs. In a brainstorming session a catalogue of measures was developed which are being implemented step by step by all parties involved and other partners. The infrastructure for tourism will be improved, for example by setting up an interactive tourist information terminal, building an intelligent traffic-control system, and creating regional marketing chains.

EUR/00/5016448 page 29

The Rosenhof – a residential area in the centre of Chemnitz New alliances for the revitalization of an inner-city residential area

The aim The reconstruction of the inner-city residential area of Rosenhof has to take account of different interests. On the one hand, construction and city-planning factors and demands must be considered. On the other hand, the interests of present and future residents and business-owners must be taken into consideration to find economically and socially acceptable solutions. At the same time there is the chance to make the centre of Chemnitz – and thus the whole city – more attractive for visitors and investors, and to turn it into more of a home for the residents.

The issue The local public utility Stadtwerke Chemnitz AG and the property owner Grundstücks- und Gebäudewirtschafts-gesellschaft mbH (GGG) want to do more than just upgrade this urban residential area, which is typical of Chemnitz. Through cooperation among themselves and with other partners, they want to preserve this traditional housing area, improve the quality of the housing, and make it more attractive for residents and visitors. The changes brought about by upgrading the buildings will be used to facilitate a better understanding between the various interest groups in the area.

The initial situation The Rosenhof is considered difficult in terms of city planning. At present the GGG is upgrading the panel construction apartment houses built in the 1960s, after which the derelict grounds around them will be redesigned. The Rosenhof will get a modern design corresponding with its functions as housing area and centre of communication and business. However, at the moment this objective, which is generally supported by everybody, is causing grave inconvenience for the tenants and business people as well as for visitors.

The method and the status quo A brainstorming session of the cooperative planning group that includes the Stadtwerke AG, the GGG, tenants, business people, investors, scientists, the Chemnitz authorities, and non-profit associations has produced a first set of ideas about the future use and design of the Rosenhof. On this basis they will work out with other partners a catalogue of practical measures acceptable to all concerned.

EUR/00/5016448 page 30

Looking Beyond the Workplace Health promotion at Volkswagen Sachsen

The aim The Volkswagen health insurance company (BKK) wants to use the health promotion approach to improve the wellbeing of the personnel and their families. Furthermore, the BKK wants to support improved relationships between companies and the region. The BKK intends to achieve these objectives in close cooperation with the VW management in Saxony, the works council at VW, the neighbouring communes, and institutions in the region.

The issue The “Volkswagen Sachsen health promotion at the workplace and beyond” initiative is an intersectoral project to improve the health of the personnel and their families. An essential part of the project is continuing feedback from the workers, meaning that they are actively involved. Central points of the project are programmes to develop behaviour that supports health, the health-oriented design of working and living conditions at the plant, and the joint development of health-promoting structures outside the company with neighbouring communes and institutions (e.g. in the area of sports).

The initial situation Industrial safety and safety engineering have always been important principles at VW in Saxony. Nevertheless, it was difficult to explain health promotion to the workers. There was hardly any cooperation with the communes in the neighbourhood of the plant.

The method and the status quo The VW management, members of the work council, experts, scientists, and – most important of all – those concerned have developed a catalogue of specific measures that are being implemented step by step. The first steps will deal with the analysis of data concerning the clinical picture and working conditions/motivation. On the basis of this information a health atlas will be developed for the company’s plants, which will be useful in planning specific activities to raise health awareness among the personnel.

EUR/00/5016448 page 31

Health Region Central Erzgebirge Establishing a regional network linking the development of the spas at Warmbad and Thermalbad Wiesenbad with the development of tourism in the Central Erzgebirge region

The aim A number of communes, enterprises and rural districts want to develop a “Health Region”. This initiative is based on an agreed framework of coordination for the development of Warmbad and Thermalbad Wiesenbad as health resorts. An integrated concept linking the development of the spas with the development of tourism (nature, cure, culture, history, recreational facilities, etc.) will be created and implemented. This concept will also include marketing guidelines.

The issue The tradition of cures at Warmbad and Thermalbad Wiesenbad, which is more than 500 years old, will be revitalized and continued. This will be done based on integrated, spa-specific, scientific development concepts and a joint marketing strategy. The two spas do not see themselves as competitors but as the two nuclei for the development of the whole region. Public and private investment for the necessary improvement of the health resorts’ infrastructure will be coordinated. Successfully implemented, this investment for health would help to build a solid economic and ecological foundation for this region of Saxony, which has been particularly badly affected by the structural weakness of the economy and unemployment.

The initial situation Warmbad, which is in the rural commune of Gehringswalde, and the nearby Thermalbad Wiesenbad have the only thermal healing springs in Saxony. The revival of the traditional spas, which would also stimulate the economy of the whole region, is impeded by highly restrictive changes in the public health sector and in the distribution of subsidies. However, the participants in this project see these unfavourable conditions mainly as a challenge to find new solutions to create health in the widest sense of the word.

The method and the status quo A permanent working group including representatives of both spas, the tourism industry, the communes and the rural district has been established and has worked out a joint marketing concept. The most important parts of this have already been implemented (brochures, spa magazine, joint public relations for the region). A cooperative planning group is working on the preconditions for ambulatory cures and health tourism that will be new areas for the development of the spas. The planning group includes representatives of the two spas and the spa companies, the health and social insurance institutions, the Mittlerer Erzgebirgskreis and Aue/Schwarzenberg rural districts, members of associations and business people.