City planning for health and

European Sustainable Development and Health Series: 2

European Sustainable European Commission WHO Regional Office Healthy Cities Network Cities & Towns Campaign DG XI for Europe EUR/ICP/POLC 06 03 05B – European Sustainable Development and Health Series: 2 Original English. 1997.

This document results from work led by the WHO Healthy Cities project as part of the European Sustainable Cities & Towns Campaign. This work received financial assistance from the through the European Commission, Directorate-General for Environment, Nuclear Safety and Civil Protection (DG XI).

Target 14: settings for health promotion By the year 2000, all settings of social life and activity, such as the city, school, workplace, neighbourhood and home, should provide greater opportunities for promoting health.

ABSTRACT City planning for health and sustainable development is the second document in the European Sustainable Development and Health Series produced by the WHO Healthy Cities project within the European Sustainable Cities & Towns Campaign. It describes how health and sustainable development are closely related. City health plans form an important model for local plans, using local health profiles and promoting community participation to achieve change at the municipal level. Examples of practice are drawn from Belfast, Bologna, Glasgow and Liverpool. The text includes 47 references and further sources of information.

Keywords URBAN HEALTH HEALTHY CITIES DEVELOPMENT HEALTH FOR ALL EUROPE

© World Health Organization 1997

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 for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark. 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.

ISBN 92 890 1284 6 Foreword 5 Acknowledgements 7 Introduction 8 Life in cities 11 The benefits of living in cities 13 The evolution of cities and the development of suburban life 14 Differences in how city life is experienced 15 Threats to public spaces 16 The effect of economic changes 16 Poverty and inequality and their effects on city life 17 Overcoming the challenges 18 Understanding health 20 Perspectives on health 21 A new coalition for health in society 25 Healthy cities 26 Sustainable development and health 29 Defining sustainable development 30 Developing a framework for action: Agenda 21 31 Implementing Agenda 21 at the local level 35 Environmental factors and health 38 Health outcomes at all levels 41 Health for all and Agenda 21 44 Local Agenda 21 plans 47 Methods and tools in local Agenda 21 planning 49 The role of health in the local Agenda 21 process 52 Contents City health planning 54 What is a city health plan? 55 Foundations of the process of city health planning 57 Involvement of communities in city health planning 63 Steps in producing a city health plan 68 A vision 72 Managing the project 74 Collecting data 77 Setting priorities 80 Developing strategies 81 Drafting the city health plan 85 Implementation, monitoring and evaluation 87 Examples of city health planning 89 Glasgow: starting with a service-based plan 90 Bologna’s health and environmental plan 92 Liverpool: developing a collaborative plan 96 Intersectoral planning for health in Belfast 99 References 103 Further reading 107 ublic health action has always can support the fulfilment of the Foreword focused on the relationships recommendations related to health Pbetween the environment and found in Agenda 21. This document health, and these relationships now draws on the experience of a wide have a global perspective. Frameworks range of work taking place around the for action on socially and world to indicate directions for the environmentally sustainable long journey towards sustainable development are necessary because wellbeing. uncoordinated economic and social The key recommendations on health development is having increasing in Agenda 21 relate to developing adverse effects on people and the municipal health plans, using local planet. The 1992 United Nations health profiles and strengthening city Conference on Environment and networks for health. The work of Development recognized the role of healthy city projects in Europe since urban communities in shaping healthy 1987 provides many specific methods and sustainable development in of tackling these challenges at a Agenda 21, the United Nations municipal level. They include the programme of action on sustainable development of structures that ensure development. the participation of the community as This is the second document in the well as service organizations, the series on European sustainable development of health profiles for development and health produced by cities and towns and the process of the WHO Healthy Cities project within developing and sustaining city health the framework of the European planning. Sustainable Cities & Towns Campaign. Creating healthier and more It sets the background for local Agenda sustainable cities and towns requires 21 and healthy cities, exploring the new approaches to planning. This challenges underpinning these document aims to support people in movements and describing the urban settings who are attempting to similarities between them. In develop collaborative work and particular, this document explores integrated action on the challenges that how the work on health challenges affect health and sustainability. Action developed within healthy city projects needs to be developed at the local,

Foreword 5 national and international levels to cities that have provided material on move towards a healthier and more their experience and especially to the sustainable world. The development and participants of the Multi-city Action sharing of new approaches at the local Plan on Health and Agenda 21 for their level is of key importance in this contributions to and comments on challenge. earlier drafts. I would like to On behalf of WHO, I would like to acknowledge the help and contribution acknowledge and give special thanks for of Pierre Dubè (Urban Development the financial assistance for this work Adviser, WHO Regional Office for from the European Union through the Europe). Special thanks are due to European Commission, Directorate- Charles Price and Mark McCarthy General for Environment, Nuclear Safety (Healthy Cities Project Office, WHO and Civil Protection (DG XI). I would Regional Office for Europe) for like to express my appreciation and coordinating and guiding the warm thanks to David Black and Sue preparation of this document. Many Laughlin (Communicable Health, Glasgow, thanks to David Breuer, who Scotland) for drafting this document. I significantly improved the language would like to extend my gratitude to the and style of this document.

Agis D Tsouros Regional Adviser for Urban Health Policies and Coordinator, Healthy Cities project WHO Regional Office for Europe

6 City planning for health and sustainable development The WHO Healthy Cities Project Office England, Bristol, United Acknowledgements expresses its gratitude to all the cities Kingdom; Dr Igor Krampac that have provided material and and Ms Vesna Smaka-Kinel, especially to the following participants Maribor, Slovenia; Ms Inge Kristiansen, in the Multi-city Action Plan on Health Horsens, Denmark; Dr Jurak Mesik and Agenda 21 and individual experts and Ms Klára Janèurová, Banská for their contributions and comments: Bystrica, Slovakia; Mr Bjarne Eng. Orlando Guerreiro de Almeida Rasmussen, Storstrøm County, and Dr Helena Delgado, Amadora, Denmark; Ms Anni Stroumza, Portugal; Mr Ray Bateson, Mr Kevin Geneva, Switzerland; Ms Tina Svoboda, O’Sullivan and Councillor Olivia Vienna, Austria; Mr Bob Stewart, Mitchell, Dun Laoghaire-Rathdown, Newcastle Healthy City Project, Ireland; Mr Mark Dooris, Mr Kevin Newcastle, United Kingdom; Garritty and Mr Neil Rutherford, Ms Julia Taylor, Liverpool Healthy Preston, United Kingdom; Ms Joan City Project, Liverpool, United Devlin, Dr Susan Christie and Mr Kingdom; Ms Janet Holdsworth, Andrew Hassad, Belfast, Northern Mr John Bibby, Bradford LA21, Ireland, United Kingdom; Bradford, United Kingdom; Dr Ms Stefania Fontanelli, Bologna, Italy; Roderick Lawrence, University of Dr Willy de Haes, Rotterdam, the Geneva, Switzerland; Dr Andrew Lyon, Netherlands; Ms Mari Hakkala, Turku, Forward Scotland, Glasgow, Scotland, Finland; Ms Marianne Halbert, United Kingdom; Ms Pauline Craig and Gothenburg, Sweden; Mr Tony Mr Alan Ferry, Glasgow, Scotland, Harrison, University of West of United Kingdom.

Acknowledgements 7 1 V # ~ @ t T

Introduction

he world is becoming the planet and the ability of many increasingly urbanized. The countries to prosper and support the Tprojected number of people wellbeing of their inhabitants. living in cities is expected to more than The United Nations Conference on double between 1990 and 2025, Environment and Development, held in growing from 2.4 billion to 5.5 billion. Rio de Janeiro in 1992, attempted to This trend is accelerating in developing address a huge range of environmental countries; their share of the total urban and social problems related to economic population will rise from 63% in 1990 and population growth. The Conference to 80% in 2025. The huge increase in stated that the world has reached a urban population linked to the defining moment in its history. A choice economic development of cities and has to be made: either to maintain towns has given rise to concern about development policies that will continue the sustainability of these trends. to destroy ecosystems and further The growth of the deepen the economic divisions within and the development of consumption and between countries or to change patterns that cannot be sustained course. The Conference argued that the ecologically and socially are severely thrust of development within the world stressing the life-supporting capacity of must move towards being sustainable,

8 City planning for health and sustainable development not just for now but for the future. outcomes. To support a move towards Agenda 21 refers to health more than meaningful policies in urban 200 times. One section of Agenda 21 sustainable development, the devoted explicitly to health highlights Conference presented Agenda 21(1), that (1): the United Nations programme of action on sustainable development, as ...the primary health needs of the an agenda for the twenty-first century. world’s population are integral to the Agenda 21 places environmental achievement of the goals of concerns within a social and economic sustainable development. framework, starting from the needs of people (1): Agenda 21 views health as the outcome of environmental, economic and social Human beings are at the centre factors that also affect sustainable of concern for sustainable development. WHO has also developed “The message has development. They are entitled work that sets health outcomes in a come through that – to a healthy and productive life similar framework (2). Since 1978, on a global scale – the in harmony with nature. WHO’s strategy for health for all by the future of mankind will be shaped largely by year 2000 has developed a range of urban conditions. Agenda 21 highlights the role of cities projects within both industrialized Whether or not governments find and towns in developing sustainable countries and developing countries. ways of coping with practices. Local government is Agenda 21 and the health for all accelerating urban growth, whether or not identified as a main partner in programme have many common local authorities find implementing the Conference’s principles and complementary ways of coping with recommendations by developing local processes. They are both international pollution, limiting automobile traffic, Agenda 21 action plans. programmes adopted by countries but securing basic health Agenda 21 sees human health as operating at the national, regional and and social needs – this will determine the fundamental to sustainable local levels. Both have a core concern quality of life for the development. Health is understood as for human health and wellbeing in the generations to come and with it the chance being an outcome of all the factors that present and future. Social, to solve conflict within affect human beings. Sustainable environmental and economic nations and between development requires paying attention challenges are addressed holistically, them. ” to the determinants that shape health and both programmes are based on the Source: Topfer (3)

Introduction 9 principles of equity, sustainability, of local Agenda 21. It brings together community involvement and the main thinking about local intersectoral action. Agenda 21 work and healthy city WHO has established the Healthy projects and explores the challenges Cities project to explore the underpinning the two movements. It opportunities and mechanisms for discusses the links between them and developing collaborative action in cities examines the extent to which to achieve health for all. Many cities practice developed within healthy involved directly in the project and city projects can help to fulfil the others working within this model have recommendations relating to health developed practical experience that can of Agenda 21. be used to fulfil the health Although this book should be requirements set out for local read as part of the series, it also governments in Agenda 21. Especially summarizes some of the important useful models have been developed in concepts of both health for all and collaborative and intersectoral work on Agenda 21 and introduces some of urban health challenges and in the challenges. municipal and city health plans. This document is designed to Trying to make positive changes assist the people responsible for the within cities requires establishing the environment, health and overall rationale and the action required. Both planning in cities in supporting the Agenda 21 and health for all address development of the health core human aspirations. In the form of dimension of planning for local Agenda 21 and healthy city sustainable development. Many projects, both programmes provide people are familiar with one or more important tools for enabling change at of the challenges; this document can Note the local level. Both programmes have promote linkage between different The term “city” in this document means the inspired a range of ideas, information, disciplines and sectors. It can be full range of centres of projects and publications. especially useful for planners and population and settlement, such as This document is a practical guide to developers responsible for or towns and boroughs. taking forward the health component involved in local Agenda 21 work.

10 City planning for health and sustainable development 1 V # ~ @ t T

Life in cities

rban settlements have Cities are complex and dynamic developed over the last places of contradiction that have been Ufour thousand years of the compared to living organisms. They approximately two million years that contain opportunities for developing humans have existed on Earth. Over the potential and enriching the lives of the past century, the balance of the many of their inhabitants. population has tilted away from the Nevertheless, life in cities can reduce countryside, the pace quickening with the wellbeing of some people. In many industrialization, and now nearly half ways cities represent the reality of the world’s population lives in cities. political, economic and social decisions This trend is slowing in industrialized made nationally and globally. On the countries but increasing in developing other hand, past and present struggles countries. War, plague and other for local autonomy have created the diseases, medical advances, trade, identity of each city. They have also technology, religion and perspectives counteracted some of the effects of on urban growth have all played a part national decisions that might otherwise in creating and sustaining cities, have had a more negative impact. The although there is considerable debate state of cities is the outcome of patterns about the relative importance of each. of development that have yielded

Life in cities 11 differing forms and location of to city development, which can provide infrastructure and organization of a focus for solving wider national public buildings and public spaces, problems (4). The objectives in Europe residential areas and recreational and include : cultural facilities. Much of the current worldwide • improving the overall urban debate around cities focuses on the environment driven by heightened problems associated with size and environmental awareness; function. The tenor of this debate is • making cities more sustainable; one of crisis. For example, the most • strengthening the city economy and recent United Nations Conference on entrepreneurship; Human Settlements (Habitat II, the • creating employment by developing City Summit) was held in Istanbul healthy and environmentally sound in1996. The main themes around activities; which progress is needed are: • improving the health and wellbeing of city residents; • governance and opportunities for • improving public transport, citizens to participate in local emphasizing accessibility rather than decision-making; mobility; • housing needs; • creating livable home environments • urban economy, poverty reduction and neighbourhoods, especially in and job creation; the anonymous periphery of cities; • awareness that women and men use • creating viable political, social and and experience cities differently; environmental relationships between • environmental management; and cities and their surrounding counties • disaster mitigation, relief and and regions; and reconstruction. • integrating all urban policies to achieve these objectives. In Europe, the objectives that emerge from the debates about the urban Despite the vast scale of the problems agenda for policy and planning may in cities, too little energy and space are be less oriented towards crisis, devoted to describing and celebrating emphasizing a more holistic approach the benefits of cities. These also need to

12 City planning for health and sustainable development be explored to construct a vision for Living in large settlements provides a the future both for smaller cities as focus for the development of a whole units or smaller parts, such as supportive, humanistic structure for boroughs or districts that significantly human fulfilment. Cities can and control the factors affecting the daily should provide excitement and lives of the population, and for the variation and opportunities for much larger megacities. extending experiences, breaking out Much has been written on cities: of traditional moulds or meeting new their history, their design, their role, people. They are also centres of their culture and their meaning for learning, invention and innovation that residents and visitors in all facets of benefit from cultural diversity. their lives. This brief introduction to Aggregations of people bring life in cities cannot completely distil together a range of skills and new this body of thought, analysis and ideas and ensure that the accumulated theory. The aim is to identify some of wealth, services, education and cultural the aspects of the ongoing debate and opportunities can potentially be to consider reasons for the current provided efficiently and effectively. challenges that any city planning for Similarly, concentrations of people can health and sustainability needs to use the limited land available more consider. productively, allowing agricultural areas to be protected from urban The benefits of living in cities encroachment. The city has been regarded as The size of cities and how they are humanity’s single most impressive and planned are important. Although cities visible achievement. Lewis Mumford, have increased in population and an influential early writer on urban life, population density as they have has described it, at least in its social developed, this growth has not aspect, as (5) necessarily benefited city residents. Large cities are difficult to live in, but ...a special framework directed limits to city size have been rare toward the creation of differentiated because this has been seen as holding opportunities for a common life and a back progress. Research on significant collective drama. urbanization (6) indicates that the size

Life in cities 13 of a city must reflect its ability to fulfil more differentiated into social classes. the social relations that are important A growing middle class and to people and to maximize the strengths improved transport promoted clearer of community living. The question as to zoning of different functions. This led whether cities as a whole or individual to the development of the suburbs and, cities have an optimum size needs to be more recently, the flight to the debated more rigorously. countryside by those who can afford it. Population and some employment has The evolution of cities and the been decentralized from core areas to development of suburban life suburbs since the 1950s. Industrial Cities have evolved and will continue to decline and a growing service sector do so as the factors that affect their size since the 1970s has reinforced this and form change. Urbanization is pattern and has created inner-city specifically connected with economic decay. This spatial reorganization and development and the technological the polarization between different developments that flow from it. In population groups has created a new much of Europe, industrialization and geography of centres and margins, and the capitalist economy have been the many divided or dual cities have motor for rapid change over the past evolved. two centuries by triggering massive The increasing population and migration from rural to urban areas. suburban expansion have had many Before industrialization, people lived effects. The effect on the environment where they worked, but industrial is especially notable and problematic. processes moved the work and forced Large cities demand huge quantities of people to move into larger centres of water, energy and other resources, population. Poor housing and nutrition which affects the environment severely. and limited natural resources such as The effects are exacerbated by the clean water made many people inefficient use of resources and poor unhealthy and made them die young. . The geographical As the health and life expectancy of the separation of the functions of city life population improved, brought about in has created an excessive demand for part by public health initiatives, the transport. population began to grow and became The car has become an addictive

14 City planning for health and sustainable development form of transport for suburban residents and newcomers are The city has been regarded as humanity’s residents. The increasing numbers of important. The ways cities have been single most impressive cars have also led to rapidly flowing planned or developed, both and visible achievement. traffic and/or congestion, resulting in historically and currently, fail to take safety problems, declining amenities in into account the needs of many of city centres, noise and pollution. these diverse groups because the Indeed, transport and consumption groups lack the influence to bring their generate more air pollution than does interests to prominence and therefore manufacturing. The challenge for cities to affect policy and planning decisions. is therefore how to achieve accessibility Gender has an especially profound to city centres and renew the impact. The experience of women and environment while maintaining the men in the city and the way they use it viability of surrounding areas. reflects their roles and responsibilities in the division of labour according Differences in how city to gender. Differences in tasks, life is experienced differential access to and control over To meet the challenges of urban resources and the different value development, cities need to harness the accorded to the activities of women full complement of human energy and and men influence the spatial and skills available. Thus, the attributes and potential contributions of all residents need to be recognized. This also Gender can be defined as the socially requires recognizing that different constructed and culturally determined groups of people experience the city in characteristics associated with women and different ways. men, the assumptions made about the skills All cities have a diverse population; and abilities of women and men based on people differ in gender, age, ethnicity, these characteristics, the conditions in which religion, income, wealth and ability. women and men work, the relations that exist Many cities are becoming more diverse. between women and men and how these are In some cases, this reflects ethnic or represented, communicated, transmitted and religious differences. In others, maintained. immigration is substantial and the Source: Itzin (7) consequent relations between existing

Life in cities 15 organizational aspects of the city. The Public spaces are central to many heart of cities usually reflects men’s urban challenges, especially for cities or interests, whereas suburbs are more the districts in which road building has domain of women, thus reinforcing limited these areas, in which shopping gender roles. centres or malls have become the The gradual changes in women’s dominant public space or in which lives, especially the increasing public safety is of concern, especially participation in the labour market and for women, children or elderly people. changes in the form of the family and The desire for security in cities is the household, are making the becoming a major impetus for policy limitations of traditional urban and planning as well as for individual planning and housing policy more behaviour. This desire is leading to apparent. The implications of the fewer public spaces, as some people challenges women face are such that seek to protect themselves from real or gender can no longer be ignored either perceived fears by restricting the use of in planning practice or city governance. public space. This can be further exacerbated by decisions about new Threats to public spaces architecture, public transport and Public spaces include public squares, street lighting, which may be made parks, municipal buildings, cultural without considering collective safety. sites, sporting arenas, leisure facilities, shopping areas and markets, roads and The effect of economic pavements. They have been described changes variously as fortresses of freedom, Economic development has been a spaces for action and islands of major driving force for city humanity. They are viewed as the development. Until recently, connective tissue of cities and have manufacturing was the dominant functional, environmental, cultural source of wealth creation, but its recent and aesthetic roles. They have both decline in industrialized countries in historical and contemporary favour of service industries and new characteristics, and ensuring the technologies has brought about many balance between the two is a constant changes that affect city life. challenge. Unemployment, which is a

16 City planning for health and sustainable development permanent feature of market changing the nature of work, making it The gradual changes in women’s lives, economies, has increased throughout easier to work at home or on the move especially the Europe since the 1980s, leading to using new forms of communication. increasing increased poverty. It has affected The nature of the marketplace is also participation in the labour market and people living in public and private changing as home shopping becomes a changes in the form of housing, thus affecting both the inner possibility. These effects raise questions the family and the household, are making city and the suburbs. The form of the about the nature and use of public the limitations of available work has changed, and this spaces, building developments and traditional urban planning and housing has been accompanied by shifts in the existing buildings and their need for policy more apparent. composition of the workforce. transport and support services. Unemployment generally impoverishes the inner city and Poverty and inequality and reduces the quality of the housing their effects on city life stock, although not as consistently as Poverty is a major challenge for cities many would argue. Inner-city throughout the world. Poor people in neighbourhoods can attract new cities usually have no secure residents because of their cultural and employment, savings or saleable assets symbolic interest, and the location of and are vulnerable to changes in the service industries has also helped to demands of the labour market, the generate a sense of renewal. prices of basic goods, land costs and In some parts of Europe, notably the use and housing policies. The effect on Mediterranean countries, both core city life of increasing urban poverty has areas and the suburbs have continued led in part to the introduction of to grow simultaneously. Other economic reforms, but these very countries have attempted to improve reforms often create new poverty. the lives of people in inner-city slums These measures include shifting by moving them to specially created towards privatization and limiting the areas or townships. Paradoxically, this ability of local government to sustain has also generated problems of poor previous levels of services. In addition, living conditions, unemployment and welfare provision has shifted away from poverty, which have been worsened by redistribution towards targeted the changes in the economy. safety-net programmes. A combination Technological developments are of these factors has made many people

Life in cities 17 homeless or confined them to shanty High levels of poverty in a city are as towns, and both are now widespread in significant for affluent people as they a number of European cities. are for poor people. The existence of Poverty profoundly affects health areas of decline and the emergence of and wellbeing. It contributes derelict spaces affects people’s significantly to the inequalities in perceptions of the city as a whole. The health within many European cities polarization between places with fewer and across Europe. Inequalities in resources and more affluent areas health parallel inequalities in creates disharmony and contributes to environmental quality, which are increasing crime and vandalism. Most similarly associated with poverty, each significantly, large numbers of poor contributing to and exacerbating the people can further weaken a struggling other. economy, as they do not have the Gender is especially key in poverty, resources to consume goods and as women are disproportionately services or to participate fully in all represented among the urban poor. aspects of city life. The reasons for this include women’s situation in the labour market, general Overcoming the challenges inequalities in access to society’s The challenges facing European cities resources and inequities in the and their residents may make it distribution of resources and decision- difficult to imagine how these making power in the household. challenges can be overcome and the Even where women have taken over potential benefits of city life job categories that have traditionally maximized. Whatever the outcome, a been dominated by men and new stage in the history of cities is unemployment among men has probably emerging as the human increased, most women have lower pay community evolves. Some even argue and less job security than most men. In that the form and function of cities will countries where changes in family change profoundly, with suburban patterns have increased the number of areas becoming more dominant and High levels of poverty in households with single mothers, this old city centres or cores becoming a city are as significant for affluent people as has affected women and children by obsolete. they are for poor people. increasing poverty. Many challenged cities desire new

18 City planning for health and sustainable development forms of participation in the decisions choices and options for the future Cities in Europe have begun to reclaim a related to urban policy and planning instead of just seeing ethnic or health agenda away and want these decisions to lead cultural differences as a source of from the confines of medicine and are to action that further enhances problems. Non-sexist or gender- becoming laboratories participation by, for example, conscious urban planning has been of ecological improving safety and access. explored but has not yet been innovation. The significance of these Current approaches alienate the realized despite the increased related developments public from design professionals, involvement of women in urban is that the wellbeing of people and the public administrators, politicians, planning and policy debates and the environment are property owners and investors, as the policy-making process. A non-sexist challenging the dictates of spatial and desires, lifestyles and values of the city would involve action that reflects economic planning. public are often ignored. The an understanding of gender limitations of this undemocratic inequalities in society and ensures approach are slowly being realized as that the built environment and use social wellbeing erodes more despite of space meets the needs of women the apparent wealth and financial as well as men of all ages (8,9). power in many cities. In addition, cities in Europe have Improved forms of representation begun to reclaim a health agenda and an acknowledgement of the away from the confines of medicine importance of community action can and are becoming laboratories of enhance social justice. Nevertheless, ecological innovation. The those who have power are very significance of these related reluctant to share it and often wage a developments is that the wellbeing considerable struggle to maintain it. of people and the environment are Part of the desire for renaissance in challenging the dictates of spatial cities is greater understanding of the and economic planning. benefits of social diversity in the city These themes of health and population instead of viewing it as a wellbeing and the environment are non-issue or as a problem. explored in more detail throughout Recognizing that most cities have a this document together with the multicultural past and present gives implications for practical action.

Life in cities 19 1 V # ~ @ t T Understanding health

here are many different what is complete social wellbeing? accounts of health and what How can it be measured? Tinfluences it. One of the most Nevertheless, the WHO definition of common and useful descriptions is the health does have important strengths definition of health from the WHO that should not be overlooked. Constitution (10): Health is a complex concept. It is not just the absence of disease but a Health is a state of complete physical, state of being that has a number of mental and social wellbeing and not components, such as where people merely the absence of disease or live, whether they are employed or not, infirmity. The enjoyment of the the services and support available and highest attainable standard of health the state of their environment. All is one of the fundamental rights of these factors in an economic and social every human being, without context produce a range of states of distinction of race, religion, health. In addition, WHO maintains political belief or economic that health is a fundamental right of and social conditions. every human being regardless of race, sex, politics or economic This description prompts questions: circumstances.

20 City planning for health and sustainable development Perspectives on health only about 2–3% of the National The medical profession has largely Health Service budget on health dominated policy planning and promotion, and most of this is spent services for health. The early public on health information. health movement succeeded mainly A social model of health is a through work in environmental action contrasting approach. This model and social policy, including clean water considers health as an outcome of the supply, effective drainage and sewerage effects of all the factors affecting the and housing reform. Nevertheless, in lives of individuals, families and the last century the medical profession communities in different ways and has mainly focused on developing through different pathways. specific interventions to counteract Whitehead & Dahlgren (11) (Fig. 1, disease in individuals instead of page 18) describe this in terms of addressing the needs of the population layers of influence. Individuals are at as a whole. the centre with a set of fixed genes. The medical model underpinning Surrounding them are influences on disease-focused interventions views the health that can be modified. body as a machine and considers health The first layer is personal behaviour In 1986 the first the polar opposite of illness. and ways of living that can promote International Increasingly sophisticated medical or damage health. Individuals are Conference on Health Promotion held in procedures and interventions are used affected by friendship patterns and Ottawa, Canada to treat disease. Preventive techniques the norms of their community. declared that: such as immunization and screening The next layer is social and “The fundamental conditions and are deemed to be of prime importance community influences, which resources for health in making and keeping individuals provide mutual support for are peace, shelter, education, food, healthy. members of the community in income, a stable eco- This view makes health care services unfavourable conditions. But they can system, sustainable resources, social responsible for improving and also provide no support or have a justice and equity. maintaining health. Most national negative effect. Improvements in health care resources are allocated to The third layer includes structural health require a secure foundation in these cure and repair, with only a small factors: housing, working conditions, basic prerequisites.” percentage for promoting health. For access to services and provision of Source: Ottawa Charter for example, the United Kingdom spends essential facilities. Health Promotion (12)

Understanding health 21 Fig. 1. The main determinants of health

Source: Whitehead & Dahlgren (11)

Overarching all of these are the role of women or the status accorded factors that can affect whole societies: ethnic minorities can shape their socioeconomic, cultural and ability to live well. Over the past environmental conditions. The decade it has become more and more economic and labour market apparent that the sustainability of the conditions in each country influence all Earth’s ecosystem is a crucial factor the factors that affect health, but so do for maintaining health. The factors the prevalent cultural beliefs in a found in this rainbow are interrelated society. For example, views about the and influence and shape each other.

22 City planning for health and sustainable development Fig. 2. The health gradient

Individually oriented preventive action Health hazards

Lack of education Environmental health hazards

Inadequate foodUnemployment and nutrition Poor housing Poverty

Source: adapted from Making partners: intersectoral action for health (13)

Any systematic attempt to improve agencies responsible for these factors health has to embrace action at all must act in a focused way to improve levels. the health of the groups in society that Another way of representing the have an increased load. “That political, economic effects of the range of health factors in Research from across Europe (14) and social inequalities should manifest society is the health gradient (Fig. 2). has identified a substantial social class themselves in health The health gradient depicts the gradient in influences on health, with differences should effects of a range of factors that can an uneven population distribution of surprise no one. What is surprising is that powerfully affect an individual’s ability health hazards and risk factors. Groups such inequities should to achieve health, especially acting in with lower status have poorer health. be attributed to differences in combination. The steepness of this One response to these inequities has behaviour, when gradient is different for different been to ascribe them to differences in evidence for this view is grossly inadequate sectors of society. The traditional personal behaviour rather than to compared to the wealth model of health promotion that only societal inequities. Fig. 2 shows that of data which links encourages individuals to change their reducing the gradient of health them to social conditions.” behaviour does not ease the load for inequalities requires action on factors poor people struggling against a whole mainly outside the control of Source: Research Unit in Health and Behavioural range of structural factors. The individuals. Change (15)

Understanding health 23 “Health is not an activity. Fig. 3. The health triangle Making meaningful local action plans It is not jogging, or eating well, or not for health requires a clear picture of the smoking, or living in a types of action needed. One framework good environment, or being employed. Rather for conceptualizing this is the health it is the outcome of triangle (Fig. 3). Good health and these and other wellbeing are reached via a number of activities as well. People are more, or Well- hierarchical stages or outcomes. Activity less, healthy according being focused at the top of the triangle does to the resources which they have in their not lead to good health unless activity is everyday lives. Health is also focused at the bottom levels, and the outcome of these factors combined in the Prevention the balance of activity needs to reflect lives of individuals and of illness the characteristics of the local communities.” Healthy behaviour community. Source: Working together for and lifestyles and Poor communities do not always Glasgow’s health: Glasgow preventive medicine city health plan (16) have the prerequisites for physical survival, and health can only be improved by concentrating on Health and social care that level. Nevertheless, even Responsive and appropriate health and social services in areas with widespread poverty, not everyone suffers to the same extent. Health awareness The most effective way Knowledge and understanding of of responding to the factors affecting health health challenges in a community is to attempt to cover Mental survival all the levels of Community and self-esteem the hierarchy at the same time. Physical survival Food, shelter, warmth and safety

Source: adapted from Laughlin & Black (17)

24 City planning for health and sustainable development A new coalition for health in society Ottawa Charter for Health Promotion The complex interrelationships between the factors that affect health Build healthy public policy and the inability of a purely medical • Put health on the agenda of policy-makers in all sectors and at approach to deal with them are being all levels. increasingly understood. The concept • Combine diverse but complementary approaches including of health for all was adopted by the legislation, fiscal measures, taxation and organizational change. thirtieth World Health Assembly at It is coordinated action that leads to health, social and income policies that foster greater equity. Alma-Ata in 1977. • Joint action contributes to ensuring safer and healthier goods This was to be achieved by work and services, healthier public services and cleaner, more incorporating the principles of health enjoyable environments. for all (see page 23), which include statements about equity and also that: Create supportive environments • Societies are complex and interrelated. Health cannot be separated from other goals. The overall guiding principle for the ...health is created in the setting world, nations, regions and communities alike is the need to of everyday life and is influenced encourage reciprocal maintenance: to take care of each other, by actions and decisions of most our communities and our natural environment. sectors. Strengthen community action The partnerships for the promotion and develop personal skills of health that arose from the principles • Support the empowerment of communities. This enhances self-help and social support and allows for the development of health for all are still important of flexible systems for strengthening public participation and now. direction of health matters. The Ottawa Charter for Health • Enable people to learn throughout life. Promotion (12) further developed this thinking, advocating that action to Reorient health services promote health means building healthy • Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should public policy, creating supportive support the needs of individuals and communities for a healthier environments, strengthening life and open channels between the health sector and broader community action, developing social, political, economic and physical environmental personal skills and reorienting components. health services (box).

Understanding health 25 The Healthy Cities The principles of health for all were European cities to develop models of project is one of WHO's main vehicles for giving used to develop a common European good practice in promoting health effect to the strategy of strategy for attaining health for all. and positive health policy. The idea health for all. It has The Member States of the European was one whose time had come. After forged political, professional and Region adopted a health policy for beginning to work with 11 cities in a technical alliances for Europe in 1984 that includes 38 pilot project, WHO found that it had health and uncovered a fertile ground for action regional targets for health for all. This unleashed a movement. In the first at local level. health policy requires fundamental five years 35 project cities were

Source: adapted from changes in approaches to health participating in Europe. National Tsouros (18) development. It focuses on four areas networks developed in 20 countries, of concern: lifestyles and health, risk and 12 groups of cities based on factors affecting health and the specific topics or interests were set up environment, reorienting the health as multi-city action plans. care system and mobilizing political, The pilot project cities were not managerial and technological support project cities because they had to bring about these changes. Health reached some particular level of for all had a good deal of success health. They were part of this work in developing countries, but because they understood the implementation was slow in processes necessary to make cities European countries. healthier. They have demonstrated this by Healthy cities action in specific areas: The idea of the healthy city was raised at the Beyond Health Care conference • making a political commitment to in Toronto in 1984. This was based on work for health in the city; the notion that the city is the level of • giving visibility to health issues in governance closest to the population their city; and therefore can best influence the • making institutional changes to factors affecting health. support intersectoral work and Substantial interest in the idea was involve the community; and generated over the next two years, and • taking innovative steps to improve WHO supported a pilot project health and the environment. (originally limited to 1987 to 1992) for

26 City planning for health and sustainable development The first phase of the project between 1987 and 1992 emphasized developing Health for all principles related to city health planning structures and processes within cities Equity in health means that all people have the right to allow collaborative work between and the opportunity to realize their full potential. organizations, departments and communities. The cities taking part Health promotion: A city health plan should aim to promote have developed initiatives showing health using the principles outlined in the Ottawa Charter for how a range of groups can Health Promotion. successfully participate in developing Intersectoral action: Health is created in the setting of health for all at the city level. Many everyday life and is influenced by the actions and decisions of cities developed a truly integrated most sectors. approach to incorporating health in the local planning process for the first Community participation: Informed, motivated and actively participating communities are key partners in setting time. priorities and making and implementing decisions. In its second phase between 1993 and 1998, the project is focusing on Supportive environments: A city health plan should address formulating and implementing city the creation of supportive physical and social environments. policies targeting health for all and on This includes issues of ecology and sustainability as well as such aspects as social networks, transport, housing and developing comprehensive city health other environmental concerns. plans with explicit targets addressing such issues as equity and sustainable Accountability: Health is created through the interaction of development. About 60 project cities all aspects of the environment and living conditions with the have been designated, and more than individual. Decisions of politicians, senior executives and managers in all sectors affect the conditions that influence 550 cities are part of national health. Responsibility for decisions that affect health creating networks in Europe. conditions should be made explicit in a clear and The Healthy Cities project is useful understandable manner in a form that can be measured and for tackling the complex problems assessed after time. that shape health in cities. The cities The right to peace: Peace is a fundamental prerequisite for have developed new models of health, and the attainment of peace is a justifiable aim for collaborative working within those who are seeking to achieve the maximum state of organizations and between health for their community and citizens. organizations and communities. Source: adapted from City health planning: the framework (19)

Understanding health 27 The Healthy Cities project requires and develop the range of projects and cities to have to a project office, staff collaborative exercises that enable the and budget. These organizational development of truly collaborative foundations allow project staff to build city-wide health promotion.

Main requirements for participation in the second phase of the WHO Healthy Cities project • All project cities should establish a widely representative intersectoral policy committee with strong links to the political decision-making system, to act as a focus for and to steer the project. • All cities should appoint a person to be politically responsible for the project. • All project cities should establish a visible project office that is accessible to the public, with a coordinator, full-time staff and an operating budget for administration and management. • All project cities should develop a health for all policy based on the European health for all targets and prepare and implement a city health plan that addresses equity, environmental, social and health issues, within two years after entering the second phase for old project cities and within four years for new cities. Cities should secure the necessary resources to implement the policy. • All project cities should establish mechanisms for ensuring accountability, including presentation to the city council of short annual city health reports The players in healthy that address health for all priorities. city projects are: • All project cities should take active steps to take on the strategic action priorities of the WHO Regional Office for Europe and, in particular, to Local authorities implement the European Tobacco Action Plan and the European Alcohol Health authorities Action Plan. Academic institutions Community groups • All project cities should establish mechanisms for public participation and Tenants’ groups strengthen health advocacy at city level by stimulating the visibility of and Businesses debate on public health issues and by working with the media. Politicians • All project cities should carry out population health surveys and impact Health issue groups analyses and, in particular, assess and address the needs of the most Environmental action vulnerable and disadvantaged social groups. groups Elderly groups Source: adapted from Tsouros (18) Transport groups

28 City planning for health and sustainable development 1 V # ~ @ t T Sustainable development and health

oncern about the effect of The crises of development focus on unrestrained economic the inability of the affluent countries Cdevelopment on the to facilitate meaningful development environment has been growing over in the poor countries. Since the the last decade. In recent years a Second World War, the proportion number of factors have led to of people in the world who are acceptance of the need to devise desperately poor has remained strategies to move towards sustainable constant at about one fifth. Since economic, environmental and social the 1980s, the terms of trade have development. deteriorated for developing countries, It is argued (20) that the move intensifying poverty among these towards the notion of sustainable countries. The impact of financial development arises from a meta-crisis restructuring following growing debts facing the world. This meta-crisis by developing countries has caused comprises a set of three core crises of these governments to cut back social development, environment and programmes, further depriving the security. poor.

Sustainable development and health 29 The root of the environmental crises tackling a web of disparate interests. is the limited capacity of the planet to Regardless of how this is attempted, support humanity. This has two either gradual incremental change or aspects. major structural change, a paradigm The seemingly inexorable rise in shift is required for the global world population of about 100 million economic, political and social systems. per year is increasing consumption of the Earth’s resources, including the Defining sustainable finite stock of mineral resources and development farming land. Resource consumption is Sustainable development as it is now unequal: 20% of the population understood can be traced from Our consume 80% of the resources, mainly common future (21). This report of the in countries located in the Northern World Commission on Environment Hemisphere. and Development (the Bruntland In addition, resources are being report) examined the relationships degraded. Air, water and soil are being between economic development and polluted, including acid rain, ozone environmental sustainability, defining depletion, pollution of water stocks, sustainable development as desertification and poor city air quality, “...development that meets the needs of and is declining. the present without compromising the Since the end of the Second World ability of future generations to meet War, a whole range of wars have their own needs”. continued to destroy people, The Commission was concerned environments, livelihoods and even the about poor people and the huge hope of sustainable development. Huge imbalance in resources between the sums of money have been directed industrialized and developing countries away from investment in positive and therefore believed that economic development towards armies and ever development is required to meet the more powerful weaponry. needs of poor people. However, this These three crises are not separate, development should not be achieved at but interwoven and mutually the expense of the planetary ecosystem. supportive. Moving towards Our common future focused on sustainable development means economics and environment and did

30 City planning for health and sustainable development not explicitly refer to health or to , these definitions move sustainability. Sustainable development from reducing the environmental has since grown to include the idea of effects of economic development as an sustainable societies. Later definitions inherent objective to working towards embrace a broader notion of human development being served by sustainable development. For example, environmentally supportive and Rees (22) defines sustainable equitable economic development. development as: Developing a framework for ...positive socioeconomic change action: Agenda 21 which does not undermine the The United Nations Conference on ecological and social systems upon Environment and Development in which communities and societies 1992 (the in Rio de are dependent. Its successful Janeirio) moved the debate on implementation requires integrated sustainable development further. policy, planning and social learning The major outcomes were the Rio processes; its political viability Declaration on Environment and depends on the full support of the Development, a statement on the people it affects through their principles of forest management and governments, their social institutions Agenda 21. and their private activities. More than 178 governments adopted these declarations at the Conference. The Canadian Public Health Following the Conference, the United Association produced a more concise Nations Commission on Sustainable definition in 1991 (23): Development was formed to oversee progress in implementing Agenda 21. Human development and achieving Agenda 21, the United Nations human potential require economic programme of action for sustainable activity that is socially and development, explicitly addresses the environmentally sustainable in this relationships between social and and future generations. economic development, the need to conserve and manage resources, the By including the concept of social strengthening of the roles of major

Sustainable development and health 31 social groups and how these are to be institutions, law and information for achieved. Agenda 21 has a concern for decision-making. human health and wellbeing at the core Underpinning all this is a set of of all its work. practices and processes that Agenda The Agenda 21 process in cities and 21 (1) states are essential for localities has developed rapidly in its achieving sustainable development: first five years. Agenda 21 has four main areas: social and economic • reducing the use of energy and development, resource management, raw materials and the production strengthening the participation of of pollution and waste; major groups and means of • protecting fragile ecosystems; and implementation. • the sharing of wealth, Social and economic development opportunities and responsibility covers such challenges as international more equitably between North cooperation, poverty, sustainable and South, between countries and consumption, population, health, between social groups within settlements and integrating countries. environment and development. Resource management includes Agenda 21 (1) argues that atmosphere, land resource planning, sustainable development can only be deforestation, fragile ecosystems, rural reached through a process that is development, biodiversity, democratic, cooperative and biotechnologies, oceans, fresh water planned. Sustainable development and waste management. will not be achieved by accident, but Strengthening the participation of must be planned and worked for major groups includes such previously consciously at all levels, from marginalized groups as women, international to local. All people, children, indigenous peoples and including poor and disadvantaged nongovernmental organizations. groups, must have a say in decisions Means of implementation include about the environment and finance, institutions, technology development. All social groups and transfer, sciences, education, interests, including business, capacity-building, international education and voluntary and

32 City planning for health and sustainable development community groups as well as should not obscure the real difficulty governments at all levels need to work facing the process of achieving such in partnership. outcomes. The International Council for Local The transition to sustainable Environmental Initiatives covers development depends on the ability sustainable development planning of governments, intergovernmental comprehensively (24) and gives a organizations, transnational capital succinct picture of the challenging and nongovernmental organizations processes underway at the local level to manage the transition arising from (Fig. 4). The Council points out that the development of new sets of the imperatives of economic, winners and losers in the global community and ecological economy. development often contradict and that local Fig. 4. The sustainable development challenge (and global) sustainable development is the process Economic of bringing the three development development processes into Community balance. Implementing a economic Conservatism strategy for sustainable development development requires negotiation among the Sustainable stakeholders and development developing an agreed plan. This type of multi-agency work is often new to some organizational participants Community Ecological but is central to the work. development development The growing awareness of and willingness to act on the challenges of Deep ecology or Utopianism environmental, social and Source: International Council for Local Environmental Initiatives (24) economic sustainability

Sustainable development and health 33 The transition Pearce (25) attempts to map the to sustainable development needs to to sustainable development needs possibilities for this transition: “Any be planned, managed and to be planned, shift towards sustainability will administered, but it needs a sense of managed and administered, but it inevitably be slow, taking generations, purpose, a vision, a goal towards needs a sense of not years. Full sustainable development which societies can strive. Pearce (25) purpose, a vision, a involves a cultural shift, not just charts various stages of the move goal towards which societies can strive. economic and political tinkering.” towards sustainability and what this The early periods of transition are would mean in terms of policy, the most difficult, when vision is dim economy, society and discourse and resistance is strong. The transition (Table 1).

Table 1. Stages in the move to sustainability

Policy Economy Society Discourse

Stage 1 Lip service to Minor Dim awareness Corporatist Ultra-weak policy tinkering with and little discussion sustainability integration economic media groups; adjustment coverage consultation exercises

Stage 2 Formal policy Substantial Wider public Round tables; integration restructuring education for stakeholder Weak and of micro- future vision groups; sustainability deliverable economic parliamentary targets incentives surveillance

Stage 3 Binding policy Full economic Curriculum Community Strong integration valuation; integration; involvement; sustainability and strong green accounts local initiatives twinning of international at business as part of initiatives in the agreements and national community developing and level; green growth the developed taxes offset world Source: Pearce (25)

34 City planning for health and sustainable development Implementing Agenda 21 at Sustainability (the the local level Charter)(26). Agenda 21 sees local authorities The Aalborg conference provided as being a main partner in the starting point for the European implementation. Their full Sustainable Cities & Towns Campaign, participation is crucial to the success which is supported by the International of Agenda 21. Local authorities are Council for Local Environmental involved in many key components of Initiatives, the WHO Healthy Cities sustainable development in cities and Network, Eurocities (European communities (1). Association of Metropolitan Cities), United Towns Organization and the Action for local Agenda 21 Council of European Municipalities Local authorities are called upon to and Regions. actively participate in the Agenda 21 The signatories to the Aalborg process in their area by collaboratively Charter reaffirmed their commitment developing a local version. It is hoped made at the United Nations Conference that this will build strategies in local on Environment and Development in areas that have the principles of Agenda Rio de Janeiro to have developed a local 21 as their foundation (1): Agenda 21 plan by the end of 1996. The Aalborg Declaration (26) reaffirmed By 1996, most local authorities in each the role of sustainable local country should have undertaken a communities in helping the world to consultative process with their move towards overall sustainability and population and achieved a consensus laid down 14 prerequisites for on a “Local Agenda 21” for the European cities and towns: community. • the role of European cities and towns Local Agenda 21 in Europe in achieving sustainability; The local Agenda 21 process has • the notion and principles of substantial support throughout sustainability; Europe. In 1994 in Aalborg, Denmark, • local strategies towards 80 cities signed the Charter of sustainability; European Cities and Towns towards • sustainability as a creative, local,

Sustainable development and health 35 balance-seeking process; Sustainable Cities & Towns in Lisbon • resolving problems by negotiating in October 1996. This phase focuses outwards; on implementing the principles set • urban economy towards out in the Aalborg Charter, starting sustainability; and undertaking the local Agenda 21 • social equity for urban sustainability; process and implementing the local • sustainable land-use patterns; sustainability plan. By engaging in this • sustainable urban mobility patterns; work, European local authorities will • responsibility for the global climate; contribute to implementing not only • preventing ecosystems from being Agenda 21 but also the Habitat poisoned; Agenda from the Second United • local self-governance as a Nations Conference on Human precondition; Settlements. • citizens as key actors and the The participants in the Lisbon involvement of the community; and Conference endorsed the Lisbon • instruments and tools for urban Action Plan (see box) (27). It was management towards sustainability. based on local experiences as reported and discussed at the 26 workshops at The initial two-year phase of the the Conference and takes into European Sustainable Cities & Towns consideration the principles and Campaign was primarily devoted to recommendations laid down in a disseminating information about local number of documents: the Aalborg sustainability by promoting the Charter (26), a guide from the United Aalborg Charter, urging additional Kingdom Local Authority Association local authorities to sign the Charter and Local Government International and to join the Campaign and Bureau (28), the Sustainable cities providing guidance on the local report from the European Agenda 21 process. Commission’s Expert Group on the Urban Environment (29) and the Local Agenda 21: the second phase Local Agenda 21 planning guide from The next phase was launched at the the International Council for Local Second European Conference on Environmental Initiatives (24).

36 City planning for health and sustainable development Headings from The Lisbon Action Plan: from Charter to action

• We believe that the adoption of the • We shall integrate environmental with Charter of European Cities & Towns social and economic development to towards Sustainability (Aalborg Charter) improve health and quality of life for is one of the best starting points for a our citizens. Local Agenda 21 process. • We shall use advanced tools for • We believe that the local authority sustainability management. should be the main facilitator of the Local • We shall establish programmes to raise Agenda 21 process. awareness among our citizens, interest • We believe that the Local Agenda 21 groups, as well as politicians and local process requires the involvement of the government officers of sustainable entire local authority – whether city, town development issues. or rural community. • We shall gain strength through inter- • We shall enter into consultation and authority alliances: associations, partnerships with the various sectors of networks and campaigns. our community to create synergy through • We shall build North-South and West- cooperation. East alliances for sustainable • We shall seek to get our own house in development. order by implementing the principle of • We shall go ahead in concert with the negotiating outward. European Sustainable Cities & Towns • We shall carry out systematic action Campaign. planning to move from analysis to action.

Source: The Lisbon Action Plan: from Charter to action (27)

Sustainable development and health 37 Environmental factors activities such as cycling and walking) and health and wider effects on air quality, and The links between environmental using and manufacturing automobiles factors and health outcomes have been affects the global environment. recognized and acted on since the early The destruction of the global days of the public health movement. ecosystem has received much national All European cities have examples of and international concern. Table 2 regulation for clean water and control shows some of the possible effects of of housing and industrial hazards these changes on health. dating from the early 1900s. This is Cities in industrialized countries are now commonly described as major consumers of nonrenewable environmental health regulation and resources. The cities of Europe are is enforced by environmental health collectively responsible for a large departments. proportion of the emissions The range of environmental contributing to global climate change: problems has grown both in scale and together with the cities in other in type over the years. Environmental industrialized countries, they provide health problems caused by economic 80% of carbon dioxide emissions, for activity have not only local but national example. and international effects. Examples Many European cities are becoming include water supplies polluted by the site of large-scale environmental, nitrates and pesticides from farming; economic and social challenges. Poverty acid rain caused by industry and power and growing inequality are increasing stations; and foods contaminated with hand in hand with problems of pesticides used in agriculture. pollution, decaying infrastructure, poor There is also a further range of new air and water quality, loss of green problems that early public health space and reduction in housing pioneers could not have imagined, such standards. These factors are as the role of transport policy and its compounded in some countries by the effect on health. Transport has local blind promotion of economic effects on individual health (such as development at the expense of large accidents, the barrier effect and lack of groups of marginalized people. encouragement of health-promoting The relationships in cities between

38 City planning for health and sustainable development Table 2. Possible adverse effects on health due to possible global environmental change

Environmental Manifestation Type (direct, indirect) and timing (early, late) of adverse effects damage

Direct early Direct late Indirect early Indirect late

Enhanced Global warming and Heat wave– Altered distribution of Reduced viability of greenhouse effect climatic change related death vector-borne infectious edible fish in warmed and illness diseases oceans

Natural disasters: Food shortages due to cyclones, floods, altered agricultural landslides, fires productivity

Sea level rise Increased risk of Inundation, social Consequences of damage Destruction of wetlands, flash floods and dislocation, sanitation to foreshore facilities, decline in fish stocks surges breakdown, farm loss roads etc.

Stratospheric Increased ultraviolet Sunburn, photo- Skin cancer, ocular Impaired growth of food ozone depletion B radiation flux at kerat-conjunctivitis, effects; cataracts, crops and marine Earth’s surface suppression of pterygium microorganisms (base of immune system, aquatic food web) increased risk of infection, cancer Acid aerosols Acid rain (and other Possible effects on Killing of aquatic life, Impairment of forest (from combustion precipitation) respiratory system reduced food, impaired growth, reduced ecosystem of sulfurous fossil crop growth productivity fuels)

Land degradation, Erosion, sterility, Decline in Rural depression, Exposure to higher levels Consequences of silting over-intensive nutrient loss, salinity, agricultural migration to shanty of pesticides and fertilizers up of dams and rivers agriculture and chemicalization, productivity towns (see also final may also lead to toxic excessive grazing desertification entry) algal bloom in waterways

Depletion of Lack of well water Decline in agricultural underground for drinking and productivity aquifers hygiene

Depletion of plants Destruction of Deforestation, Shortage of edible Deforestation, and animals, loss of habitat disruption of local species enhancement of biodiversity culture and health greenhouse effect

Loss of genetic Loss of medicinal Greater vulnerability of diversity (species chemicals and other plants and livestock, and strains), health-supporting decline in vitality of weakening of materials ecosystem ecosystems

Other effects of Proliferation of Infectious Effects of breakdown of Various consequences of overpopulation, crowded urban slums diseases, social organization overload of local particularly in poor and shanty towns malnutrition, ecosystem countries (due to migration and antisocial high fertility) behaviour Source: adapted from Tansey & Worsley (30)

Sustainable development and health 39 social wellbeing and health, place in cities. economic development, the quality The report on European sustainable of the community environment and cities (29) tried to conceptualize all the the health of the global ecosystem challenges pictorially (Fig. 5): the have been in focus during the past relationship between cities, sustainable decade. There is movement towards development, global environmental a new model of the interrelationships crises and the outcome of a healthy between all the activities taking society in a healthy environment.

Fig. 5. Concepts of key concern in health and sustainable development

of Europe partly creating Global to Global Healthy environmental ▼ ▼ sustainability ▼ environment

responsible for crises a

will reverse ▼

Cities Urban precondition for life ▼ ▼ safeguards Sustainable promotes Quality of life Healthy ▼ ▼ development ▼ hold the key to and a human society improves

Source: adapted from European Commission Expert Group on the Urban Environment (29)

40 City planning for health and sustainable development Health outcomes Health as an outcome of initiatives at all levels to promote environmental Human health can be identified within sustainability the sustainable development agenda as Most initiatives taken principally for part of the global ecosystem, as a focus environmental reasons improve human for development, as an outcome of health, although this may not always be initiatives to promote environmental explicit. Examples include fewer sustainability and as a sector that accidents and improved physical fitness affects the environment and other caused by transport policies that shift sectors. emphasis from cars to public transport, cycling and walking. Human health as part of the global ecosystem Impact of the health care sector on Human health is sustained by the the environment and other sectors global ecosystem. Unsustainable The health care sector employs many development and consequent damage people and is a substantial user of to the ecosystem directly and negatively natural resources. It therefore has a key affect human health throughout the role in ensuring environmental and world. The cities of the industrialized other benefits by managing its activities world are responsible for a large better. An example is reducing energy proportion of global environmental use in hospitals. The health care sector disruption and damage. also has a role in other aspects of Agenda 21, including attention to Health as a focus for development human rights and the role of women. The first principle of the Rio Declaration on Environment and Specific recommendations in Development is that human health is Agenda 21 the centre of concern for sustainable Agenda 21 has many specific development. Improving health recommendations about health. Some Most initiatives therefore goes hand in hand with refer to well defined health challenges, taken principally for sustainable development. Improving but the most significant environmental reasons health can be necessary to improve recommendations deal with health in improve human health, although this may not other aspects of life. the context of overall development. always be explicit.

Sustainable development and health 41 Key recommendations relate to the will only be achieved if the relationships development of municipal health between the areas are equitable, plans, the use of health profiles and the sustainable and livable. Community strengthening of city networks for conviviality, environmental viability health. and economic adequacy need to be balanced. Community conviviality is Principles and methods related to the web of social relations, Agenda 21 recognizes that many of the civic community and social solidarity. challenges it covers, including health, Environmental viability refers to the need to be elaborated further. The quality of the local ecosystem, including health for all strategy and the role of air, water, soil and the food chain. WHO in this are mentioned explicitly. Economic adequacy means having a The main principles of Agenda 21 and level of economic activity that can meet of the WHO strategy for health for all basic needs. are essentially the same, especially In this model a healthy community when they are applied to the main has an integrated approach to strategies for implementing action developing all its components and tries plans at the local level (see Table 3, to be equitable, livable, sustainable and page 41). cohesive, to achieve high environmental standards and to be adequately New ways of thinking about human prosperous. development This model of integrated action has Trevor Hancock (31) describes a new underpinned some of the work within conceptual model of human the Canadian Healthy Community development. This model (Fig. 6) has Projects and in some Canadian three main areas: community, provinces as well as in some of the environment and economy. The European Healthy Cities projects. outcome of the interrelationship of Attempts like this to find conceptual these areas can be conceptualized as models and styles of working that health or, more broadly, as human adequately incorporate social development. sustainability are part of the structure The model suggests that good health of Agenda 21 and WHO’s Healthy Cities and sustainable human development project.

42 City planning for health and sustainable development Fig. 6. Conceptual model and planning tool The model indicates that in order to ensure social cohesion and a civic community, the benefits of economic activity must be distributed in a way that is socially equitable... In addition to being socially equitable, economic activity must be indefinitely Convivial Viable ecologically sustainable; the community must not community Livable environment so deplete natural resources or so pollute the environment... as to Sustainable irreparably harm future generations or distant populations. Finally, the community requires a Equitable livable built environment; this refers to the quality and nature of the built environment, including Adequate housing, roads..., urban infrastructure...and land economy use.

Source: adapted from Hancock Health and (31) sustainable human development

Sustainable development and health 43 Health for all and Agenda 21 collaborative style; The concerns of Agenda 21 and the • both stress the need to support European health for all movement are community capacity; and very similar. Both are concerned about • both suggest intersectoral the health of people within a approaches. framework that tries to make development equitable and sustainable. The programmes also have differences. They also have a similar focus on cities Health for all: and the growth of urban areas. The principles underpinning the • has existed longer; movements are almost identical. • has developed experience in Both Agenda 21 and health for all: collaborative community and organizational work; • are visionary approaches to global • has developed community-based problems; work that is more than just • suggest new paradigms; consultation; and • address ecological, economic and • has accumulated experience of new human health challenges; and ways of developing policy and • are concerned for human wellbeing strategy. now and in the future. Agenda 21: The methods they suggest for change are similar: • is more explicitly inclusive in its philosophy; • both advocate a planned approach; • has a much broader organizational • both advocate change in the way base; and organizations work, moving them • appears to have more support from towards a more open and government.

44 City planning for health and sustainable development “...Health and Table 3. Comparison of principles and processes for planning for health and development are sustainable urban development from health for all and Agenda 21 intimately connected. Lack of development adversely affects the Principles Health for all Agenda 21 health of many people, but development can Equity yes yes damage the Sustainability implicit yes environment in ways Health promotion yes (health) that also reduce health.” Intersectoral action yes yes Community involvement yes yes Source: United Nations [Agenda 21] (1) Supportive environments yes yes International action yes yes

Processes Health for all Agenda 21 Consider existing planning frameworks yes yes Analysis of health, environment and social conditions yes yes Public consultation on priorities yes yes Structures for intersectoral involvement yes implicit Vision yes yes Long-term action plan with targets yes yes Monitoring and evaluation yes yes

Sustainable development and health 45 As yet there are few Both environmental and social What Agenda 21 and health for all examples of local projects and services sustainability issues are receiving offer through local Agenda 21 and the mapping their activities substantial attention at the global level, Healthy Cities movement are new against a framework for sustainable but practical examples of collaborative opportunities for local workers and development (Fig. 7). work at the local level are more difficult communities to draw together with to find. In many areas markedly service providers to explore new ways different organizations fund of working. Some of this innovative environmental projects and health development is already happening and wellbeing projects. This makes within the movements for community the development of joint work health, community transport or between them difficult. sustainable communities.

Fig. 7. Mapping local action towards a sustainable society

Recycling projects

Local legislation and service provision Local welfare benefits campaigns

Environmental Economic integrity vitality Sustainable society

Eco-friendly housing projects Social Community-owned wellbeing services such as child care cooperatives Stress reduction projects

Source: adapted from Working together for Glasgow’s health: Glasgow city health plan (16)

46 City planning for health and sustainable development 1 V # ~ @ t T

Local Agenda 21 plans

local Agenda 21 plan is a • the systematic identification, by Agenda 21 states that: means of extensive public “Each Local Authority comprehensive plan for an area. should enter into a It should be the key overall consultation, of problems and dialogue with its citizens, A local organizations and development plan for that community, their causes; private enterprises and and wide involvement and • the prioritization of tasks to adopt a local Agenda 21.” participation are required to prepare address identified problems; Source: United Nations such a plan. These plans need to • the creation of a vision for a [Agenda 21] (1) through develop environmental, economic and “Local Authorities... social sustainability and therefore have a participatory process involving should be encouraged a range of objectives. all sectors of the community; to... (a) develop and implement municipal and The Aalborg Charter (26) broke • the consideration and assessment local health plans, (b) down the process of developing local of alternative strategic options; survey, where necessary the existing health, social Agenda 21 plans into a number of • the establishment of a long term and environmental areas: local action plan towards conditions in cities, sustainability which includes including documentation of intra-urban • recognition of the existing planning measurable targets; differences.” • the programming of the and financial frameworks as well as Source: United Nations other plans and programmes; implementation of the plan [Agenda 21] (1)

Local Agenda 21 plans 47 Fig. 8. The elements of sustainable development planning

Who are your partners in service delivery? How will Partnerships service users participate in planning? Establish an organizational structure for What services do people planning by service providers and users want? Establish a shared community vision What is the capacity of existing service systems? Can these systems sustainably ▼ meet service demand? How do service systems Community-based issue analysis impact upon other social Identify the issues that must be addressed economic and environmental to achieve the community vision. Do ▼ systems? detailed assessments of priority problems When and how can sustainable service systems and issues be established? ▼ ▼ Targets Action planning ▼ Triggers A measurable Agree on action goals, set targets and A commitment to commitment to triggers and create strategies and take a specified be achieved in action at a future a specific time commitments to achieve these targets. date and/or in

▼ frame Formalize into action plan ▼ response to future conditions

▼ Implementation and monitoring ▼ Create partnership structures for implementation and internal management structures for municipal compliance. When will Monitor activities and changes in services further planning be How will action required? plans be monitored and evaluated? ▼ How will partners and Evaluation and feedback users participate in Do periodic performance evaluations using implementation target-based indicators. Provide results to and evaluation?

▼ service providers and users. Repeat issue analysis and/or action planning processes at specific trigger thresholds. Celebrate and reward achievements

Source: The local Agenda 21 planning guide: an introduction to sustainable development planning (24)

48 City planning for health and sustainable development including the preparation of a Methods and tools in timetable and statement of allocation local Agenda 21 planning of responsibility among the partners; These approaches provide a wide range • the establishment of systems and of planning methods and tools for use procedures for monitoring and in the local Agenda 21 planning reporting on the implementation of process. The common elements are: the plan. partnerships, community-based issue analysis, action planning, This has been further expanded by a implementation and monitoring and number of key agencies.The evaluation and feedback. Fig. 8 shows International Council for Local the relationship of these elements in Environmental Initiatives (24) describes the overall process. sustainable development (local Agenda The description of the local Agenda 21) planning as integrating three 21 process developed by the United planning traditions: Kingdom Local Government Management Board also evokes similar • strategic planning, which has been themes, defining local Agenda 21 as used within the private sector to (32): provide long-term vision and goals; • community-based planning, which ...a continuing process rather than a has been used extensively within single event. There is no standard development to engage local residents “tick list” of things you must do for and service users in participatory Local Agenda 21. The process can development of local projects and involve a range of activities and tools programmes; and from which a local authority and its • environmental planning, which partners can choose according to local was developed in the 1970s to priorities and circumstances. ensure that development projects take environmental issues into The United Kingdom Local consideration and that such projects Government Management Board take measures to mitigate the identifies six key features of the local environmental impact of their Agenda 21 process in the United activities. Kingdom divided into action in the

Local Agenda 21 plans 49 Fig. 9. Steps in the local Agenda 21 process Action in the wider community Managing and ▼ improving the local Awareness-raising Partnerships authorities’ own and education • Meetings, environmental • Support for workshops and environmental conferences performance • • education Working groups/ Corporate • Awareness-raising advisory groups commitments events • Roundtables • Staff1 training and • • Visits3 and talks Environment city awareness-raising • 5 • Support for model Environmental voluntary groups • Partnership management systems • • Publication of local initiatives Environmental information • Developing-world budgeting • • Press releases partnerships and Policy integration • Initiatives to support across sectors encourage behaviour change and practical action Measuring, Integrating monitoring and sustainable reporting on development aims progress towards into the local sustainability authorities policies Consulting and • Environmental involving the monitoring and activities • • Green housekeeping general public Local state of the • • environment reports Land-use2 planning Public consultation • • Transport policies and processes 6Sustainability programmes • Fora indicators • • • Targets Economic development Focus groups • • Tendering and • “Planning4 for real” Environmental • impact assessment purchaser-provider Parish maps • splits • Feedback Strategic • Housing services mechanisms environmental • Tourism and visitor assessment strategies • Health strategies • Welfare, equal opportunities and poverty strategies ▼ • Explicitly environmental Action within the local authority strategies

Source: adapted from Local Agenda 21: principles and process. A step by step guide (32)

50 City planning for health and sustainable development local authority and in the wider and evaluation. community. In Fig. 10, health strategies are The two features related to the local featured in the development of local authority are: policies and are also part of the integration of policy across sectors. • managing and improving the local Health impact assessment and local authorities own environmental health profiles need to be part of the performance; and evaluation planned in considering • integrating sustainable development specific action to promote sustainable aims into the local authorities development. policies and activities. The Lisbon Action Plan (27) states that “We shall carry out systematic The four features of the process in the action planning to move from analysis wider community are: to action.” and that “We shall integrate environmental with social and • awareness-raising and education; economic development to improve the • consulting and involving the general health and quality of life for our public; citizens.”. • partnerships; and The Lisbon Action Plan also clearly • measuring, monitoring and indicates the key values underpinning reporting on progress towards the local Agenda 21 planning process: sustainability. • the local authority should be the key Fig. 9 describes these features more facilitator and show leadership but The players in local thoroughly, teasing out the aspects of not domination; Agenda 21 projects are: planning departments, developing environmental, economic, • the process should involve the entire environmental health health and social strategies that have to local authority, politicians, elected departments, be integrated into the planning process officials and all departments and local authorities, health authorities, for sustainable development. levels of responsibility; academic institutions, Intersectoral and community-based • consultation and partnership with community groups, work through awareness-raising, the various sectors of the community tenants’ groups, environmental action consultation and partnerships is also are needed to make the action plan groups and needed, as is concern for monitoring robust enough that it has a chance of transport groups.

Local Agenda 21 plans 51 being implemented; The role of health in the local • the community should not export its Agenda 21 process problems; The approaches to local Agenda 21 • planning should be systematic and planning require a commitment to participatory in its move from partnerships and intersectoral working. analysis to action; Communities and organizations need • planning should be integrated across to be involved actively in creating environmental, social and economic a local Agenda 21. Health is a sectors to improve health and quality fundamental dimension of Agenda of life for all citizens; and 21 and has a high profile within • planning should use a wide range of communities and organizations. The methods and tools for active inclusion of specific work on environmental, economic, social and health and the consideration of health management. impacts on health and the outcomes of

Shape of a local Agenda 21 document A local Agenda 21 should:

• be a short, clear and accessible published document; • identify the main sustainability issues and aims for the areas; • contain explicit objectives for both the state of the environment and for the quality of life in the area; • say which organizations or sectors will take which actions (and by when) to work towards these objectives – and how performance and achievements will be assessed; and • set out a review process for the whole programme

Source: adapted from Local Agenda 21: principles and process. A step by step guide (32)

52 City planning for health and sustainable development development is both part of Agenda 21 all agenda. Many of these cities have and ensures wide community experience in carrying out local health participation in the development of profiles at the city and community local Agenda 21 plans. levels. They also have experience in Local Agenda 21 plans are general organizing and carrying out city documents: broad frameworks for health plans together with experience change. Detailed action on any one in developing processes for area of the local Agenda 21 plan community participation and requires specific plans for that area. intersectoral action, which are both Agenda 21 advocates that municipal key factors within local Agenda 21 and city health plans and associated work. health profiles be established. These The work developed by Healthy plans need to address the challenges Cities projects shows some of the best affecting health and also support the models for how the health component objectives of Agenda 21. of local Agenda 21 should be pursued. In developing the health aspect of The next section outlines the Agenda 21 work, local authorities can processes, context and steps developed benefit from the experience of cities within Healthy Cities projects to carry and projects working on the health for out city health plans.

Local Agenda 21 plans 53 1 V # ~ @ t T

City health planning

his section describes the • rationalizes scarce resources, development of city health including people’s time and energy; Tplans for cities that wish to • establishes a basis for monitoring the promote a health agenda systematically progress of initiatives and evaluating in conjunction with local Agenda 21. It success; is based on the experience of healthy • develops a basis for budgeting for the city projects. development of appropriate services Formulating a city health plan is an and programmes for health; important process for a city because • demonstrates the commitment of the plan: city organizations to greater community participation in local • places the challenges related to decision-making; and health and the quality of life on the • can improve the experience of living agenda of policy-makers within local in cities, neighbouring areas and government, health authorities and communities over time. other organizations; • links health gains to environmental Effective planning is complex and issues; demanding. Crucially, it involves

54 City planning for health and sustainable development developing a climate with the political The end product is a document that will for planning for health, which city organizations and communities are means that the strategies must involved in producing and for which accommodate the unique political wide consultation has been context of cities and their organizations. implemented. A city health plan: This can be time-consuming and difficult, as there are no quick technical • describes the current health status of fixes. It may also involve new ways of the city population in all its diversity; working for bureaucracies and • outlines the key factors that promote communities. Some challenges may be and limit the health of the common to all countries and others population; specific to each country. • describes the aspects of health that This section highlights: need to be improved and goals that need to be reached; • the nature and value of city health • determines the key priorities; plans; • details an overall framework for A city health plan is a key tool for health • the likely challenges; change; development. It is also an • the processes and structures of • explains the operational plans for an important aspect of the support that provide the foundation agreed time scale; general development of a city... for a city health plan and therefore • provides examples of good practice; [City health plans] make it viable; and and link the health for all strategy with a local • the steps needed to produce a city • presents a process for monitoring analysis of health health plan. and evaluating achievements. priorities and set out the commitments by local authorities and other What is a city health plan? Benefits agencies to improve The WHO Healthy Cities project (19) The cities that have developed city health at the local level. City health plans are also describes a city health plan as: health plans have found that the task a key activity for the has facilitated creating a vision for a implementation of Agenda 21 and need to be ...a key activity for the healthy and sustainable community developed in the context implementation of Agenda 21 and identifying the strategies needed to of overall sustainable [that needs] to be developed in the bring it about. It has helped to move urban development. context of overall sustainable health planning beyond the realm of Source: adapted from City health planning: urban development. health care services or environmental the framework (19)

City health planning 55 City health plans are health departments, where it has who are comfortable working in well not health care plans as such but they are traditionally been located and established ways even if they know that part of a process to influenced. this poses problems. This can lead to “develop a collaborative vision of a healthy and Cities also acknowledge that the resistance to change. Another challenge sustainable community process of preparing a city health plan: results if the social model of health and as well as offering the links between health and local concrete means to reach that vision”. • enables local government to examine Agenda 21 are not universally accepted, its role in relation to the health of and as a result these are neglected. Source: Municipal public health planning: a resource the public; Yet another challenge is political or 33 guide ( ) • aids communication between organizational cultures that expect organizations and promotes immediate results, making it difficult to partnership; accept the time scale involved in • raises awareness of the factors that producing a comprehensive plan, affect health and the implications for implementing it and identifying policy and practice; measurable outcomes. • provides the opportunity to Finally, power is an issue. Power is a counteract inequalities in health; controversial but undisputed part of • improves professional development city and organizational life, and it is and planning skills; necessary to determine who has it, • facilitates closer links with where it comes from and how it can be communities and users of services; harnessed to plans for change. Power is and the potential or capacity of a person or • creates the basis for services that are a group to influence other people or more flexible and responsive to groups, and power can be used needs. positively or negatively. It is therefore necessary to be aware of the positive Challenges and negative uses of power and the Introducing the change required to impact that each can have (box). create and implement an effective city health plan brings with it a series of The relationship of city health plans challenges and threats of which to other city planning planners must be aware. One of these Some cities have no overall arises with people and organizations development plan for the future that

56 City planning for health and sustainable development incorporates all aspects of city life Sources of power in organizations because of the complexity of functions and services, the population needs they Position or authority This is the power that an individual or group holds by virtue of their have to meet and political challenges. In role or position within the organization. Their position gives them the this case, city health plans and other power to do certain things, organize work, allocate resources and instruct others. This type of power is determined by the rules, aspects of local Agenda 21 planning regulations and resources of the organization and limited by your job should acknowledge and react to other title. Control of resources plans and be integrated into them, Control over resources, such as money, personnel, materials or informing the operations of individual technology can be an important source of power, particularly if these resources are scarce. You may have power if you are the only person in agencies and organizations. Each the department who is permitted to access the information databases community, centred around either a or if you have control of people and how they are deployed. geographical area or an issue, also needs Social networks The ability to gather information and mobilize resources and support to develop its own plans, ideally in gives power. This may be acquired through your networks or by building on the influence and power that others have. Social power conjunction with the city health plan. depends on the range of connections you have inside and outside your Cities that have a detailed master plan organization – a case of “it’s not what you know, but who you know”. covering all sectors should give health a Expert power You have expert power if you have a reputation for giving good advice high profile in the policy and social or for managing things well. This type of power is especially valued agenda of this plan. A detailed among professional groups but can also be seen in workers whose experience, expertise or knowledge of the “system” gives them description of other actions aimed at influence. An administration worker who knows the grant-making improving health and the environment procedures of the European Union inside out will have considerable expert power, as does the person who understands the temperamental should form separate but linked photocopier. documents comparable to a city health Control of information Information and its communication flow is critical to organizations. It plan. shapes our knowledge of the world we work in and the issues we are tackling. People who can open or close channels of communication, analyse, filter, summarize or access accurate and reliable information Foundations of the process of will have considerable power to shape knowledge in their organization. city health planning Personal power Two important processes are required Personal power comes from qualities such as charm, intellect, self- confidence, self-esteem etc. People with these qualities are often said to to successfully produce and implement have charisma although it is debatable how much of this is innate and a city health plan: how much of this is developed. For example, self-confidence is also associated with gender, race, disability, class and other factors where social barriers and oppression can affect opportunities to develop self- • intersectoral collaboration; and esteem. Source: adapted from Action for women’s health: making changes • community participation and through organizations (34) development.

City health planning 57 Intersectoral collaboration In exploring public beliefs about There are many stakeholders in city health, the Province of Ontario health plans, such as politicians, (Canada) found that many residents municipal organizations, voluntary pictured the government structures that organizations and communities. All provide them with services thus (35): have their own discrete focus on the factors affecting health and their own ...In many cases governments have set of skills. City health planning become a collection of vertical demands a new vision of health in solitudes with walls, narrow mandates cities that recognizes a social model of and incentives to pass the buck. It has health and involves all stakeholders. created a multiplicity of programmes at There is often little collaboration, and the community level that rarely work even when organizations have started in a collaborative fashion. to develop mechanisms for partnership the local population does not recognize Hancock (31) describes this as this. nineteenth-century governance: the

Fig. 10. Twenty-first-century problems and nineteenth-century structures

Public Parks Traffic Public Planning Environmental works health health

Healthy city

Sustainability ▼ Equity Twenty-first- ▼ century Mobility

▼ problems

Energy ▼ Food ▼▼

Nineteenth-century structures Source: adapted from Hancock (31)

58 City planning for health and sustainable development early municipal departments which the benefits to the workers and originated from the development of communities are clear. Collaboration separate strong disciplines. He points between departments within corporate out that most of the problems faced in structures such as a city council or the twenty-first century cut across between corporate structures, however, these neat boundaries (Fig. 10). can be problematic. Responding to these challenges requires new structures that are democratic and collaborative. In exploring new responses to the Fig. 11. The pillars of health health problems found in cities, the WHO Healthy Cities project represents the relationships between municipal departments, other bodies, the community and the policy framework as pillars of health (16) (Fig. 11). This City health plan highlights the need for cities to extend or develop existing Community collaboration, both horizontally within the city and vertically with other levels of government and the wider community. Intersectoral Business sector Health and Health social sector Economic sector Environment Industry Transport sector Transport collaboration often Education develops naturally Local policies and legislation between grassroots National policies and legislation workers in localities in Health for all/Agenda 21 strategy

Source: adapted from City health planning: the framework (19)

City health planning 59 Some of the influences Mechanisms to support The Healthy and Sustainable Preston that shape the level of collaborative working intersectoral collaboration Steering Group recognized that within local An intersectoral steering committee is a achieving successful external government corporate structures are: key support for the intersectoral work networking and true intersectoral within organizations of healthy city collaboration requires adopting a Management and organizational projects. Such a committee very clearly similar structure (Fig. 12) to minimize structures indicates to the city organizations and the compartmentalizing effect of Blocks to new forms of working are often created by community groups that joint work is organization boundaries, especially at departmentalism and being taken seriously. the strategic management core. protectionism. Success is more likely where Commitment to intersectoral Many of the problems affecting management systems are flexible and corporately led. approaches is also underpinned by collaboration and integration for developing collaborative pilot projects sustainability arise from the rigid Political support Successful integration for specific communities and boundaries that organizations and requires a political lead with organizations. Examples include service departments build around positive member support and organization. funding of local projects in both Belfast themselves, and the Steering Group Finance and resource and Horsens and the development of a suggests two complementary consideration city-wide policy on women’s health in approaches to tackle this. There will almost certainly be a lack of resources for Glasgow. Specific positive actions and coordination or “new” forms of examples of good practice should be work. Competition with service activity can often be a barrier Healthy and Sustainable Preston developed. These are more likely to to funding collaborative work. The Healthy and Sustainable Preston succeed if community participation is Strategy competition Steering Group developed its work on a supported and two or more policy In most local governments there will be in place, or sustainable society plan, examining areas are linked. Such examples could developing, a range of how it could achieve the strategic include: different strategies, e.g., anti- poverty, community integration necessary to achieve its development, economic development, housing, equal goals. This was done by modelling how • fuel and energy efficiency; opportunity. the local council had restructured. The • access to green spaces; External factors council restructuring brought together • affordable warmth; Paradoxically, some of the key policy areas into single • reducing air pollution and preventing special financing initiatives at European and state/city level departments with a strategic respiratory illness; and sometimes force collaboration and partnership onto usually management core, thereby creating • preventing crime and promoting competing departments and synergy within a flexible and community safety. agencies. corporately led system. Source: adapted from a personal communication from the Healthy and Sustainable Preston Steering Group

60 City planning for health and sustainable development The Preston Steering Group suggests • developing structures to ensure local that the most successful actions embrace delivery; one or more of the following: • pilot projects that can be mobilized quickly and become “early winners”; • involving the community to achieve • small-scale, incremental but strategic participation and empowerment; development;

Fig. 12. Model for intersectoral collaboration Strategic apex

Middle line

Operating core

Management layers in stand-alone departments

External networking Strategic departmental integration

Environmental Local health municipal council

National Health Community organizations authority development Planning and fora Strategic Strategic management management core core European Local organizations Anti-poverty Economic authority development and associations initiatives Community organizations Equal opportunities

Source: adapted from a personal communication from the Healthy and Sustainable Preston Steering Group

City health planning 61 Stakeholders in the • targeting different strategies to seen only as an environmental concept planning process differ for each city and address the concerns of different and that more work needs to be done country, but common communities; and to ensure that the understandings from categories could be: • practical examples of integration the United Nations Conference on politicians, policy developers and that politicians support and that Environment and Development inform planners; public sector have wide appeal. developments in all policy areas, service providers; health, education, including environment, economy, environment, transport, The second approach ensures that community and health. The critical housing and welfare etc., voluntary the city or local agencies are all factor for integration is to lead organizations, working towards a common agenda politicians and decision makers within interest groups and and have a common understanding of authorities to develop a clear vision for community groups. Groups may need to be the need to develop integrated policies. the future that embraces the concept of convened to address The Preston Steering Group points out the sustainable society. specific elements of the plan as it develops. that, in many places, sustainability is

Six basic steps in the establishment of partnerships for planning Step 1 Determine the scope of the planning exercise and groups are given responsibility for each of the define goals and objectives. This should be done unique planning tasks. They may also be by the initiating organization (such as the established to focus on distinct issues such as municipality) in consultation with stakeholders. It housing, poverty etc. should include preliminary educational campaigns to generate public interest and support. Step 4 Identify appropriate partners to participate in Step 2 the stakeholder group and its working groups. Create or designate a stakeholder group to coordinate and guide the overall planning effort and to integrate Step 5 the results of discussions, research and planning into Establish terms of reference for the activities an action plan or plans. of each group.

Step 3 Step 6 Establish distinct working group structures under Develop a common community vision to guide the supervision of the stakeholder group. Working the entire planning process.

Source: adapted from The local Agenda 21 planning guide: an introduction to sustainable development planning (24)

62 City planning for health and sustainable development Involvement of communities in Community development city health planning Healthy city and local Agenda 21 The development of wide ranging initiatives need to shift the balance community participation is a key factor away from token involvement to full for the success of collaborative public consultation and participation. approaches to health planning in Achieving meaningful participation the city. Representatives of city means changing organizations and communities should be involved in supporting the communities involved. the process of developing, carrying Community development is an out and evaluating a city health plan. important tool in realizing this, Community participation in the especially for disadvantaged planning process has to be structured communities, which have the poorest clearly. It should be built into the access to decision-making processes in framework for the plan rather than the city. being added as an afterthought. Community development has been defined as a set of processes (36): Community participation Community participation covers ...directed in particular at people who different levels of activity and feel excluded from society. It consists participation: of a set of methods which can broaden vision and capacity for social • communities merely legitimizing change, and approaches, including decisions already taken; consultation advocacy and • offering limited opportunities to relationships with local groups. It is comment on plans that have already a way of working which is informed been established; by certain principles which seek to • enabling people to question and encourage communities – people change proposed ideas; and who live in the same area or who have • in-depth consultation with all something else in common – to tackle options open. for themselves the problems they face and identify to be important, and These different levels of participation which aim to empower them to are considered in Table 4. change things by developing their

City health planning 63 Table 4. Degree of participation, participant’s action and illustrative modes for achieving it

Control Participant’s action Examples High Has control Organization asks community to identify the problem and make all key decisions on goals and means. Willing to help community at each step to accomplish goals.

Has delegated authority Organization identifies and presents a problem to the community. Defines limits and asks community to make a series of decisions which can be embodied in a plan which it will accept.

Plans jointly Organization presents tentative plan subject to change and open to change from those affected. Expects to change plan at least slightly and perhaps more subsequently.

Advises Organization presents a plan and invites questions. Prepared to change plan only if absolutely necessary.

Is consulted Organization tries to promote a plan. Seeks to develop support to facilitate acceptance or give sufficient sanction to plan so that administrative compliance can be expected.

Receives information Organization makes plan and announces it. Community is convened for informational purposes. Compliance is expected.

Low None Community told nothing.

Source: Brager & Sprecht cited in Community development and health: the way forward in Sheffield (37)

64 City planning for health and sustainable development own skills, knowledge and experience Thus, people have different Principles for social action and also by working in partnership approaches to community The principles of the with other groups and with statutory development work that have both Centre for Social Action effectively summarize a agencies. The way in which such strengths and weaknesses. set of values that should change is achieved is crucial and so form the basis for work with communities: both the task and the process [are] Community development and • All people have skills and important. health understanding on which they can draw to tackle There are many ways of responding to the problems they face. Community development can be used the challenge of producing health, and Professionals should not in different ways. One strand focuses much of that work has been based attach labels to service users. on locality and advocates strengthening within communities. Only a few of the • All people have rights, community networks, building self- challenges relating to health can be including the right to be heard, the right to define help activities and developing local totally solved from within these issues facing them and leadership. It brings in such ideas communities. the right to take action on their own behalf. as enablement, support and Community development in the • People acting collectively empowerment. In this view, context of health has received great can be powerful. People organizations such as local government impetus in recent years from the who lack power and influence can gain it and health authorities are essentially commitment of health for all to through working together benign organizations that should community participation and in groups. Practice should reflect this respond sympathetically and effectively empowerment. As community understanding. to make resources available for local development and health have grown, • Individuals in difficulty are often confronted by activity and new local services and can the community and social services complex issues rooted in be challenged to do so. It does, use these methods increasingly, and social policy, the however, leave intact the essential this way of working has gradually environment and the economy. Responses to functioning of the organization. been adopted by mainstream health this should reflect this Community workers often feel more education and promotion and understanding. • Action should strive comfortable with this view than do the community nursing. through its work to communities they serve. Healthy city projects are in a challenge inequality and discrimination in relation Another strand advocates good position to define a strategic to race, gender, age, campaigning and struggling for social perspective for the work to class, disability or any change against the policies and influence the broader factors and other form of social differentiation. organizations that create or support circumstances that influence local Source: adapted from Principles disadvantage. communities. and values (38)

City health planning 65 This often involves: Communities and city health planning • assessing community health needs; Representatives of communities in a • developing a response that takes city must be involved in the process of account of all levels of action developing, producing and evaluating necessary to achieve a healthy city; a city health plan. This is easier to • developing policy; achieve if collaborative community • promoting collaborative work work is already established. between communities and agencies The healthy city projects that have and organizations; carried out city health planning • supporting organizational exercises had spent a number of years development to make community developing collaborative work within involvement easier; communities. This means that • influencing the purchasing decisions requests for community involvement of health and local authorities; in the process of developing a city • influencing the decisions of local health plan are seen as a continuation authorities; and of joint work and not as a tokenist • campaigning for national solutions exercise. to problems affecting health. The Australian National Local Government Environmental Resource Local Agenda 21 initiatives therefore Network (NLGERN) has developed a need to engage with healthy city useful process for forging partnership projects and health for all initiatives in between local government and the their cities so that they can utilize this community called CONSULTT. The expertise. process is described in the box.

66 City planning for health and sustainable development The CONSULTT process

larifying the existing situation by: interviewing key players, Cdistributing a simple survey, reviewing literature and using this information to prepare a discussion paper for circulation. pening up the issues to allcomers: by circulating the discussion Opaper, attending community meetings, holding workshops for special interest groups and presenting all ideas to a public forum. egotiating agreements on direction with the community Nstakeholders before any commitments are made (credibility vanishes if people believe they are only there to rubber stamp other’s decisions). ynthesizing contributions into a common strategy to achieve Sthe negotiated agreement. ndertaking a test of the strategy in practice, either as a feasibility Ustudy or as a trial run of the real thing, before the process is cast in metal and citizens can no longer influence the process. earning from the practical implementation and reporting back to Lthe community and those whose task it will be to implement the strategy. En renching the management solution in community and council Tstructures and then: aking it around again: repeating the whole process at stated Tintervals, so that the system remains responsive and flexible.

Source: Towards local sustainable development: a toolkit of strategies (39)

City health planning 67 Steps in producing a city attitudes, and movement backwards health plan and forwards between them should If the mechanisms for developing the be expected. City health plans have a foundations for collaborative work and developmental, qualitative and community participation have been visionary perspective on the health of established within a city, producing a a city and are not simple routes and city health plan requires progression markers, as demonstrated by the through a series of stages. Passage rationale and definition for a city through these stages may not be linear health plan of the WHO Healthy Cities because of prevailing conditions and project (box).

WHO Healthy Cities project: rationale for and definition of a city health plan

Rationale • A city health plan is a key tool for health development. It is also an important aspect of the general development of a city. The production of a city health plan sets out a city's vision of health and the steps it intends to take to achieve it.

Definition • The city health plan adapts the WHO health for all strategy to the local situation....It integrates all health and health-related activities and links health to all relevant sectors that affect it. • The plan should have explicit and broad support within the city. This includes not only the usual decision-making structures of the city council and administration but also the support of the public. • Where possible the plan should include targets. It should also include mechanisms for evaluation and a process for incorporating the evaluation results into subsequent planning processes. • The city health plan is a point in a process and not an end in itself. It is important to speak of planning as well as the final plan and to recognize that planning is a dynamic process. • The city health plan should be informed by the current health situation in the city as assessed by a city health profile. • The city health plan is not just a collection of policies and activities influencing or relating to health. It is more than the sum of its parts. It provides the basis and a means to create a vision of health and integrated policies and strategies by which to achieve it. Source: adapted from City health planning: the framework (19)

68 City planning for health and sustainable development The steps to a plan several steps are essential (Fig. 13). A city health plan is much more than a fixed description or inventory of A vision problems, resources and solutions. It is A vision involves raising awareness an opportunity to re-discover the fact and gaining commitment to the that many people have a role to play development of the plan and to the in making cities healthier and more vision and the benefits expected to sustainable and that planning should politics, services and communities. be a dynamic process involving many partners. Managing the project The development of a city health The management structure for the plan can be an educational process for project is clarified as well as the organizations and communities. It can composition of the project team and link together organizations and the roles and responsibilities of both. communities, developing larger projects and collaborations from the Collecting data successes of smaller ones, and from Data are collected about health in the these build confidence in the ability of city and the factors affecting it using a collaborative work to provide useful combination of approaches. new policy directions and models. As the relationships in any city are Determining priorities complex, the process of the city health The data collected are then analysed to plan must be decided pragmatically. agree on priorities. Depending on the existing relationships in a city, it may be better Developing strategies to develop a comprehensive city-wide The next step is to formulate goals, consultation on health in the city and objectives, strategies and measurable develop the plan from there. It may be targets to address the priorities more appropriate to develop a plan for identified in the previous step. service provision and a separate community approach and fuse them Drafting the city health plan later (see the examples of Glasgow and When the plan is drafted, it can then be Bologna, pages 86 and 88). Either way, fed back into the process to make sure

City health planning 69 Fig. 13. A seven-step model for city health planning

Implementation, monitoring and evaluation Drafting the city health plan

Developing strategies

Determining priority issues

Collecting data Innovators and developers (internal analysis, community profile build and support the early and community consultation) stages of the process Managing the project

A vision (awareness-raising and gaining commitment)

Foundations for the successful development of the plan

Source: adapted from Municipal public health planning: a resource guide (33)

70 City planning for health and sustainable development that it meets people’s needs and across agencies and communities in expectations. health for all and healthy city projects. Implementation, monitoring They then brainstorm for ideas and and evaluation examples of work that seem to address Progress is monitored, achievements problems similar to those in their city. are reviewed and feedback is given in This group of innovators and enablers an ongoing process to ensure that the supports much of the early strategies are implemented. developmental work. These groups need to include senior actors in city One of the problems of describing services, as they have access to developmental work by steps is the fact politicians and management and key that work needs to be seen to have a figures from community beginning. The beginning can be organizations. difficult to pin-point precisely. The The foundation and early steps of foundation work described earlier city health planning work need (pages 54–63) includes how to support support (Fig. 14). This is especially organizations in working together, the important in the early days of projects development of structures to allow and plans, when they are vulnerable to communities to participate actively in pressure from service departments that making decisions and the development perceive threats to their territory or of a vision and support for new work. from communities that are trying to This foundation work has to be shape the project policy. Healthy Cities project developed and supported by a group. Guiding the development of this WHO Regional Office New and innovative approaches to area of work is difficult, as the for Europe, Scherfigsvej 8, problems in the city are usually participants in the process vary. DK-2100 developed locally in the interfaces Communication with members of Copenhagen, between organizations and healthy city projects (contact the WHO Denmark. 45 39 17 17 17 professions. Healthy Cities project for details of Tel. + Fax +45 39 17 18 60 Concern about health in a city often projects in your area) can indicate the E-mail brings together like-minded people problems and successes of this work. [email protected]

City health planning 71 Implementation A vision If healthy city projects also support and monitoring

Drafting the plan Developing political commitment and/or fund community-level work, City health plans attempt to develop a this is beneficial. Local politicians can Developing strategies type of major organizational change see the work in progress and involve Setting priorities that is generally difficult to achieve. themselves with a successful project, Collecting data Organizations and departments are thereby gaining respect in their local Managing the project competitive entities that like to area. A vision dominate their territory, to delineate One of the problems with this type ▼ Foundations their boundaries and to allow people in of work is the long lead time for only on their terms. The support of outcome. A strategy for informing local local politicians can circumvent some of politicians of the time scale for these problems, as the politicians can outcome is essential to prevent loss of often mediate in internal rivalries. commitment over time. Local political support and involvement have been crucial in setting Partnerships for city health up healthy city projects, as they provide planning an entry gate into decision-making in The work of the healthy city projects in the city. Strong political commitment to all their different settings has been the development of intersectoral work successful because broad partnerships on health is essential. This is also true have been formed at city level to for work on sustainable development. support and develop their work. The management or steering groups The vision of working together for a of healthy city projects operate at the healthy city and holding a common highest levels within the city aim seems to provide a neutral playing administrative and political structures, field for the work of organizations and and senior politicians usually participate communities. This also appears to be in these groups. Membership of such a true for the challenges related to group gives them access to senior people sustainability. Nevertheless, developing in other organizations such as such intersectoral groups is never easy, universities, health authorities and regardless of their level of regional authorities and also reinforces organizational support. When a project the fact that the issues being dealt with brings together core organizations at are serious and substantial. the city level, very clear aims and

72 City planning for health and sustainable development objectives for the partnership are The following approaches can be used “The vision is for a future in which required. in developing a vision for the city economic prosperity, The fact that the WHO Healthy health plan: social justice and protection of the Cities project requires participatory natural environment and collaborative project structures • consultation documents to be are pursued eases the problem of supporting the circulated to service organizations simultaneously to secure good health development of the vision for a city and community groups; and enhance well- health plan within the services and • briefing seminars for management; being for all people, now and for community. A healthy city project team • public seminars to explore new generations to come.” usually carries out or coordinates this visions for the city’s health; Source: Liverpool city health work. • community-based vision workshops plan (40) for both community members and Developing the vision service providers; Explaining the vision, aims and • discussion of city health in local benefits of a city health plan within mass media; organizations requires a development • developmental workshops across group with access to senior service agencies to explore the management. Members need to have a benefits of collaborative work; sound background in the concepts, • seminars synthezising the ongoing models and processes of health for all work in the city that already and a keen understanding of local supports this approach. organizational dynamics. The development of the city health No city is a desert in this sense, and plan must have professional support there is an opportunity for creative from the start. The team needs to have licence in putting together community expertise in strategy and policy action and new service development to development across city service show what can be achieved. The aims provision (health, environment, of this work are to raise awareness of economics, education, etc.) and the the opportunities that could arise from ability to organize awareness-raising the plan, to gain support from the city events in both service and community services and the community for the settings. The composition and support idea of a plan and to raise awareness of of this team can be crucial to success. the potential benefits to the city.

City health planning 73 Implementation and monitoring Managing the project The box on page 71 shows the

Drafting the plan Management structure membership of a typical project.

Developing strategies As everyone living and working in the Time and effort has to be spent in

Setting priorities city is responsible for creating supporting, educating and developing sustainable and healthy cities, the this group. It is imperative that they Collecting data management of the city health understand well the aims, processes Managing the project ▼ planning process needs to reflect this. and benefits of the plan. The A vision The management structure differs by development of clear committee rules Foundations country and city, but the management is also important in such a diverse must reflect the values of participation group as this. Steering committee and cooperation. members from agencies have to have Preparing a city health plan requires the mandate to commit their agency to a steering group and a project team. tackling the challenges that arise as part of the planning process. One model is Steering group shown in Fig. 14. The steering group needs to have clear terms of reference for the relationship Project team with its funding partners and the other A skilled organization is needed to stakeholders. The steering group develop collaborative projects; this is oversees the work of the project and not a part-time task for an overworked provides its links into and between the civil servant. A team is required whose participating agencies and the members understand the intricacies of community. The organizations and the relationships between the partners, groups whose work affect public health not just the organizational stakeholders should be represented. Members need but also community, academic and to be in senior positions in their voluntary stakeholders. organizations to enable the project to This is not a convenient place to put obtain funding and support. excess staff waiting for retirement. The members should represent the Project coordinators and development community, services, politics and workers need to be intelligent and academe and include experts in think clearly, educated at least to degree planning, public health, strategy level and have a practical development and health promotion. understanding of the social and

74 City planning for health and sustainable development political model of health and • educating participants about the experience with collaborative work aims and goals of the plan. within an organization. They need to be allowed to develop work both Space and financing within and outside the funding A separate office space is required of a organizations. standard that reflects the importance If the health plan team is based and the values of this work. The office within an organization, the team needs should be easily accessible for members to be positioned within the strategy of the public as well as staff from the development section or the chief partner organizations. executive’s department. If the team is based in the local authority, the team Membership of the steering group needs to form strong links with the of a typical collaborative health project public health function within the city. • Chair of the health authority It should not be thought of as an • Chair of the regional authority extension of a health promotion or • Senior politicians from the regional environmental health department. The and local authorities city health plan team will have a set of • Director of public health specific tasks to develop and support • Academic professor of public health the plan. These could include: • Director of environmental health • Director of health promotion • serving the steering group; • Director of planning • taking responsibility for developing • Representatives of the local voluntary associations the planning process and the plan; • Representatives of the local tenants’ associations • organizing the development of the • Representative of the community health councils range of consultations and vision • Representatives of the local health-based workshops; nongovernmental organizations • coordinating the consultation • Representatives of the healthy city working groups process within the organizations (such as women, environment and poverty) and community; • Representative of local community health projects • organizing a communication and • Representative of the strategic planning department public relations strategy for the plan of the local authority and carrying it out; and

City health planning 75 Fig. 14. A management structure for a city health planning project

Making and keeping partners Health If the process of Voluntary sector developing interest authority and community and support has been groups positive, the city will have a city health plan project with an Local intersectoral steering group. Several government Academic developmental stages departments Steering sector in the formation are group required to get this far.

1. The group has an agreed aim or vision. This is based on research into the Planning health indicators and group the factors that affect health in the city.

2. The group has agreed objectives and Administrative key issues to be taken support Project forward and has team started to draft plans to achieve them.

3. Membership criteria for the steering group Project are agreed. Community working support groups unit 4. The group has agreed on the roles, responsibilities and reporting mechanisms of the partners in the steering group.

76 City planning for health and sustainable development The project has to have a reasonable this. Helping to facilitate change in The state of health of a city cannot be changed level of funding that is protected for organizations takes years and not overnight; there is no the life of the project. It should have months; making a healthy city takes quick fix in this type of work, and a sensible access to short-term development decades and not years. time scale and targets money from statutory agencies and This type of project must have time have to reflect this. other sources, but the partners need to and support to develop. Credibility jointly fund the project and view it as needs to be built for collaborative work part of their core services. This is both within the partner organizations important in working with the and at the grassroots level. A range of agencies. The plan must be seen as a successful collaborative activities around central part of the process of health is required to gain credibility in developing strategy in the city. This developing a city health plan. cannot be achieved if the project is perceived to be short term with Collecting data Implementation transient staff. Developing a plan for the health of a and monitoring The project team also has to be sure city requires being aware of the current Drafting the plan that they work collaboratively to state of health in the city. This Developing strategies optimize development. One way of necessitates a city health profile, which Setting priorities doing this is to make sure that the should provide a broad picture of Collecting data project has enough money for salaries health by examining all the factors that ▼ Managing the project and seed projects (especially affect health outcomes in the city. A vision community ones) but not for large In most cities the health authorities Foundations joint projects. To fund these, the produce a range of figures related to project has to build intersectoral health. These are usually illness and alliances, thereby reinforcing the death statistics that indicate the state of philosophy, values and utility of the health in the city. Producing a city project’s work. health profile requires this information but also the range of other routinely Time scale collected data in the city to provide a The state of health of a city cannot be broad overview of the state of health. changed overnight; there is no quick fix Data should be included on poverty; in this type of work, and a sensible housing conditions; access to transport time scale and targets have to reflect and food; provision of health and

City health planning 77 Sample data from social services; employment figures and needs and health-profiling exercises. a city health economic statistics; and statistics These give a rich picture of health and profile traditionally related to health. The data health needs in communities. Demographic data should be presented according to class, A wide range of methods are used, Population density gender and geographical area. including local implementation of Population change Examples of broad descriptions of validated health assessment forms (44) Age groups the factors that affect health in cities and the use by communities of focus Gender Ethnicity can be found in healthy city projects as groups and rapid assessment methods. city health profiles for specific areas Examples of these types of work can be Socioeconomic data Education levels (41,42). The WHO Healthy Cities found throughout the Healthy Cities Income distribution Project Office has also produced a and health for all networks. Occupations guidance document on health profiling Developing and supporting this type Benefit recipients (43). of work demands skills that may need Employment Such collaborative productions to be brought in to the project team. Health data highlight the social, environmental and Attention needs to be paid to the scale Mortality by cause economic basis of health in cities. They of this work. Morbidity by cause Notifiable diseases are very useful overviews, but other Mental health pictures of health in the city are needed • Is an assessment needed in all Immunization rates to develop the city health plan. communities in your city? Accident figures Community health profiles and needs • If not, who chooses the Health behaviour assessment exercises provide representative communities? Environmental data information about people’s perception • Time scales have to reflect the need Environmental quality indicators of the health issues in their local areas. to develop support in the Environmental community. monitoring Community-based assessment of • Volunteers may need to be trained. Risk assessment data health needs • The community should have a voice Pollution data In addition to the quantitative material in the choice of methods, and this Service provision provided by the large-scale data that may mean a period of education and Transport services Health and social are collected routinely, a picture of how discussion. services communities perceive their health and Education and leisure the factors that affect it is required. Community assessment is important Community support This can be accessed by carrying out because it can encourage support for and networks community-based assessment of health joint work at a local level. The

78 City planning for health and sustainable development assessment usually involves local launching of the results of the research workers and communities with the as a publication, video, play or a comic support of academics or external book should be used to generate consultants. Most community profiling further interest in the topic. uses residents as interviewers or Once the data about the city and enablers. This strengthens the communities have been collected, the commitment of communities to the results should be fed back to the process and the outcome. The materials agencies and communities that have produced are good examples of the been involved as part of the ongoing strength of community development openness in developing the plan. approaches (45). The data collection provides the health plan steering group with a wide Producing reports range of information about the city’s Just as how the research is carried out is health and the factors that shape it. important, the way such reports are Levels of disease and illness, poverty, produced, disseminated and acted the broader environment and service upon is also important. The knowledge provision and their interrelationship and experience of local communities should be explored in the city health on the factors that promote or restrict profile. Differences in health status and their ability to achieve good health its relationship to socioeconomic status should be respected. Communities and geographical and environmental should understand how the results of factors should also be teased out; all the research will be used. of this should be grounded by Reports should be designed and information on citizens’ views about printed to a reasonable standard. The the factors affecting their health.

City health planning 79 Implementation and monitoring Setting priorities The health issues and data should then

Drafting the plan The city and community health be placed in these categories.

Developing strategies profiling and needs assessment Setting priorities is very difficult as

Setting priorities produce a wide range of information. many forces are always competing for ▼ This material needs to be collated and increased budgets and time. A Collecting data categorized and then the priority combination of techniques should be Managing the project challenges for the plan need to be used to reach a list of priorities that can A vision determined. be taken forward by the city and its Foundations agencies. Simplifying the data Organizing the data into general Use of experts themes can aid in setting priorities. Many data collected regularly by the This is best carried out by a group city agencies will be compared with comprising the project team and some national and regional figures. Localities members of the steering group and in the city may also be compared. This community researchers. This process means that differences between the city can take a while, so a day should be set and other areas can be highlighted and aside for this. used to help in setting priorities. The project team should produce an Service departments may already have overview of the data and draw up some statutory responsibilities and fixed provisional categories to be discussed national priorities such as reducing with the group. Possible categories deaths from heart disease or improving could be: water quality. Specialist help from agencies and universities may be used • the physical environment to discern trends in local data and to • the social and cultural environment conduct comparative assessments of • community safety data, but this should not be the only • women’s health approach. • children’s health After the city health profile is • accidents published and the data are simplified, a • specific diseases (such as cancer) series of public consultations should be • health education. organized for a number of reasons:

80 City planning for health and sustainable development Implementation • to allow public dialogue on the Developing strategies and monitoring

findings of the profile and to validate When the priority themes and issues Drafting the plan

the findings from the community have been determined, they should be Developing strategies ▼ surveys; converted into strategic targets the health Setting priorities • to allow the public to identify their plan can address systematically. Collecting data priority issues; and The health plan has to address Managing the project • to keep the public aware of the problems organizationally and A vision process of producing the city health systemically with a long-term plan. perspective. It has to work across Foundations organizations and groups, acting The consultations should take a variety synergistically and integrating efforts of forms, such as large public meetings, by different stakeholders to achieve small local focus groups, meetings with common aims. This means that it has community leaders, meetings with to be linked to local formal planning department heads and discussion processes and be consistent with them. groups with staff teams and inter- The broad intersectoral group agency groups. developed for setting priorities should be When this process is completed, all involved in the continuing development the stakeholders in the city health of the plan. Representatives from the planning process should be consulted service departments should not be the to formalize the priorities for the plan. only ones shaping the strategies. This process has three stages. Small The wider the group developing the group meetings are held with service strategies, the better the chance that new providers and communities separately and innovative collaborative work will to explore their priority issues. Then develop. In addition, this enhances the these findings are compiled for the commitment from the community and steering group so that the priorities for all the stakeholders. the plan can be categorized and ranked. This document describes the stages of Finally, a public forum should feed the the development of strategic plans using priorities back and reach a consensus aims, objectives, strategies, targets and on them. programmes.

City health planning 81 Aims To ensure through services and Aims are general statements about a programmes that people have both theme that outline an outcome. Aims physical and economic access to the should be broad and compatible with food they need for a healthy life. the vision and philosophy of the planning process. The priority issues for this theme For example, one of the key themes to could be: develop from the priority-setting may have been . The aim for the • food and poverty health plan for this theme could be: • food safety

Guidelines for developing strategies The following issues should be considered in order to develop effective strategies:

• The issue should be thoroughly understood. It may be that some extra time is needed to explore the context surrounding the issue such as current policies, attitudes of key players and social factors. • There should be a clear understanding of the characteristics of the target groups for the strategic interventions, including issues of age, gender, culture and their attitudes and beliefs about the issue. • Research should be conducted into current strategies (to avoid duplication) and those that have been previously successful. • The strategies should be achievable but not at the expense of discarding challenging strategies for the sake of easily achievable ones. • Strategies should provide “early wins” (short-term achievements) so that both the local government and the community can see the efficacy of the time spent in planning. • Strategies may include formalizing an already existing process and giving it direction. Source: adapted from The local Agenda 21 planning guide: an introduction to sustainable development planning (24)

82 City planning for health and sustainable development • nutritional awareness Strategies • access to shops Strategies are the plans for achieving • food quality the objectives. The strategies are an • heart disease opportunity to build on the strengths • obesity of the intersectoral group managing • community gardens the plan. The proposals should not • partnerships. just be rooted within the departmental services but should give options for These priority issues would provide the development of new working the platform from which to develop relationships across local government, the objectives for the plan. the voluntary sector and community stakeholders. Objectives Objectives are commitments to A strategy framework produce a specific outcome by a The five action areas of the Ottawa specific time. All the actions necessary Charter provide a useful framework to produce the outcome are shown in a for conceptualizing overall strategy: strategy in clear, manageable steps. Objectives need to be achievable for the • building healthy public policy stakeholders involved. • creating supportive environments For example, one of the priority • strengthening community action areas under the theme of food security • developing personal skills was local food partnerships. An • reorienting health services. objective for that area could be: Table 5 provides examples of possible To nurture local food partnerships strategies for realizing the objective of that influence where, when and at nurturing local food partnerships that what price people can buy their food. could be mapped onto this framework.

Objectives also need to be developed Targets for the other priority issues as well as Strategies need to identify measurable strategies by which the objectives will targets as part of their development. be reached. Setting targets is a difficult and complex

City health planning 83 process; they need to: specified to address health in a city using a social model. For example, • be achievable targets can be: • be specific and measurable • have a timetable • technical: for example, air quality, • have the support of the stakeholders. reducing sulfur dioxide concentrations in the air by A wide range of types of targets can be 10% over the next 12 years;

Table 5. The Ottawa Charter for Health Promotion (12) as a framework for strategy development using the example of food partnerships Healthy Supportive Community Personal Reorienting public policy environments action skills health services

Develop a retail Municipal and Development of “Get Cooking” Health centres to planning policy health authorities local bulk-buy training have gardens that supports make available and food schemes and vegetable local-scale land for cooperative plots shopping community market schemes Good eats on a gardens low-budget Health Provide planning Using waste courses promotion support for Local food audits land as departments to community carried out by allotments and Market fund fruit and market gardens municipality and market gardens gardening, vegetable community management initiatives aimed Local purchasing Skill-sharing and marketing at children and policy for fresh Agencies to schemes, youth courses through disadvantaged fruit and support local food and elderly community communities vegetables forum people working education together Hospitals to Lobby retail Food growing and support local sector to consider cooking as part of Development of market gardens the needs of the school curriculum local economy by purchasing poor trading schemes locally Community transport schemes

84 City planning for health and sustainable development Implementation • behavioural: reducing the percentage Drafting the city health plan and monitoring

of 18-year-old girls who smoke by The next stage is drafting the plan. Drafting the plan ▼ 10% within 10 years; and The plan is a document that is the Developing strategies

• process: increasing the level of visible result of the long and complex Setting priorities collaborative work between the local work of the project team and Collecting data authority and the health authority intersectoral steering group. The draft Managing the project by 15% over the next 8 years. plan is the first result of this work A vision many people see, and high-quality Targets are important in ensuring that writing and production are important. Foundations the aims and objectives of the plan are The plan should be written and achieved and should be set for all edited for a general nontechnical strategies. Hand in hand with the audience and should be presented strategies and targets go the clearly with distinct sections. A city development of programmes to health plan should be written in the allocate the tasks. active voice: “we will do it” rather than “it will be done by this department”. Programmes Illustrations and diagrams improve the Programmes are the work plans for the impact of the plan. It should be targets. They are not usually included designed by a graphic designer and not in the actual health plan but are just typed and should be tested on its separate publications from the agency potential readership. or team responsible for achieving the strategic targets. The programmes need Content of a city health plan to outline: The WHO Healthy Cities Project Office (19) suggests that a city health plan • the parameters of the task; contain the following information: • the actions to be taken; • who will be implementing • the political status of the plan; the actions; • the process of developing the plan; • the resources that are necessary; • the principles on which the plan is • an appropriate time frame; and based; • criteria for monitoring and • the findings of the health assessment evaluation. based on the health profile;

City health planning 85 • the background of and committees on policy and resources relationships with previous policy and on joint planning; and legislation; • boards of other organizations, the • priorities chosen, and the reasons, health authority, local business methods and criteria used; forums and large local employers; • the strategic aims, including targets; • community health workers and • the plans and action to be carried public health departments; out by each sector and level of • community groups and agencies; government; and • local mass media, to generate public • follow-up and the process for interest and debate; and monitoring, evaluation and review. • the general public, including making the plan easily accessible at public The links between the health plan and libraries and community centres. other city plans should be shown. Summary documents should be Consultation and feedback produced in different forms and on the draft plan languages. The project team should Comments and amendments to a also develop and support a range of draft plan are an important part of organizational and community-based the intersectoral and developmental fora and seminars from which to approach to this work. A strategy collect feedback. The plan needs to go for distributing, reviewing and through a number of versions before it commenting on the draft plan should can be presented to the statutory target a number of sectors, including: agencies for adoption as policy. Adoption by the agencies, partners • members of the service and stakeholders is not the end of the departments in all the city agencies planning process but the beginning of (management and all levels of staff the next phase of planning for a should have the opportunity to healthier city. The lessons learned from discuss and comment on the plan); the process and from the monitoring • local politicians as individuals and and evaluation of the policy should be local political structures, such as the fed into the next version of the plan.

86 City planning for health and sustainable development Implementation Implementation, monitoring Monitoring and monitoring ▼ and evaluation Structures to record and report the Drafting the plan

Implementation action taken to implement the health Developing strategies

A health plan is only as good as its plan are needed, and mechanisms to Setting priorities implementation. The first step in allow reporting within and between Collecting data getting the plan implemented in stakeholders should be developed. Managing the project municipal organizations is to get it A regular accounting system should A vision accepted as policy. This means that be set up for reporting performance an identified person or section in and progress. This could be built Foundations the administration has to take around the regular meetings of the responsibility for overall coordinating group and should also be coordination and monitoring. collected and published as part of an The project team should develop annual review. a framework that ensures the This review should be carried out by coordination among the group of a subgroup of the coordinating body officers and workers who are and should: responsible for implementing and monitoring all the programmes • assess progress towards the vision included in the city health plan. and aims of the plan; The steering committee for the plan • describe the state of local health in should then become the coordinating relation to national figures; body for the health plan. This helps to • determine whether targets have been ensure that the stakeholders continue met and strategies implemented; to own the plan and that the plan is • discuss successes and failures; and not hijacked by one agency or group. • examine whether plan targets should The coordinating body should be reassessed. receive regular reports from the person or section that has overall The monitoring strategy should responsibility for the plan and from include the development of structures the group of programme coordinators. for regular feedback to and from the The coordinating body can then community. This can take the form of ensure progress for programmes. community conferences, local focus

City health planning 87 An excellent action groups and input into community chosen should be measurable, valid and plan provides no guarantee that groups of many types. A similar easy to collect and should show whether problems will be structure should be developed for the action has had the expected result. solved, that needs will service departments and key figures in They should also be useful in be met, or that the life of a community will the organizations, such as politicians exploring how well the planning and become more and managers. strategic development process worked, sustainable. Indeed, one of the major Regular information-sharing the impact of the strategy within the hurdles that local reinforces interest and commitment to community and the agency in both the government may encounter in the plan and its processes. As part of short and longer term and the outcome: establishing a local that, a public relations strategy needs to the change in the wellbeing of the Agenda 21 planning be developed to support and not community. process is the scepticism its residents supplant the more time-consuming but Evaluation is necessary for a number and service users may rewarding feedback and consultation of reasons. The value of this approach feel towards more planning and more structures. to health development can be assessed. plans. Evaluation can point to successes and

Source: adapted from The Evaluation failures, allowing successes to be local Agenda 21 planning The progress towards achieving the replicated and failures to be modified. guide: an introduction to sustainable development strategic targets should be evaluated at Evaluation also provides sources of 24 planning ( ) the end of the designated time frame to funding and other resources with assess the effectiveness of the plan. This information that supports their is more comprehensive than regular continuing involvement and creates monitoring and comes at the end of the basis for further development the planning cycle. The indicators and change.

88 City planning for health and sustainable development 1 V # ~ @ t T Examples of city health planning

his section provides examples vision and managing the project) of city health planning are usually assured by the city’s Tprocesses. The steps and commitment to the principles processes described have been used of health for all. Structures to in developing city health planning promote collaboration and around Europe. They are intended as a appropriate management are guide to be adapted to suit the needs therefore already in place. This of each city. The examples have similar section explores the experiences of sets of steps but in slightly differing four European healthy city orders, reflecting the needs of their projects that have carried out city cities. health planning exercises. The City health planning within healthy detailed descriptions of the city projects has a flying start on the processes can make it easier to model presented in this document, as understand the work involved and the foundations and early steps (a the potential outcomes.

Examples of city health planning 89 The process of developing Glasgow: starting with a themselves provided overviews of the plan within the agencies took about three service-based plan their work and how it relates to a years from start to launch, The city of Glasgow, Scotland broad picture of health. A draft city but it was only possible (population 750 000) started the document was produced over a year because of the strong collaborative structure and development of its city health plan based on these and personal high-level commitment the with a model to be used as a plan for interviews. project has worked to achieve and develop over the agencies in the city. This was to be After extensive consultation the its lifetime. used to gain more support for Healthy City Project steering group, collaborative work and to establish a the local authority and health firm foundation from which to develop authority approved the draft. a community perspective on planning The draft was again circulated for for health in the city. updating and comment by all the The process of developing the plan service agencies. (Fig. 15) can be viewed as circular, This process of developing the plan beginning within and feeding back into within the agencies took about three the most powerful decision-making years from start to launch, but it was committees of the city. only possible because of the strong The process started by obtaining collaborative structure and high-level commitment from the most important commitment the project has worked to decision-making fora in the city. High- achieve and develop over its lifetime. level commitment to the idea was The launch of the document was not necessary to provide access to senior the end of the process but the management in the service agencies. beginning of the task of building wider The planning team conducted a community participation and series of meetings to develop an development for the plan. overview of the work of the agencies. After the plan was adopted and The City of Glasgow already launched, a strategy for monitoring, collected an extensive range of health review and development was put in and social statistics, and these were fed place to monitor strategic targets and into the process. The agencies take forward the collaborative work.

90 City planning for health and sustainable development Supporting and ➚ Monitoring, evaluation and development developing work The next planning cycle of community consultation on this plan ➚ towards the next and development of structure for version of the plan. integrated service and community plan. ➚ Fig. 15. Glasgow’s process of Public launch of city health plan. developing a service-based city ➚ health plan Plan presented to policy and resource committees of local authority, health authority and city council for acceptance as policy for the organizations. The process begins ➚ Final plan produced and presented to steering group Consultation between the for approval. project team and the steering group on the process for developing a city health plan. ➚ ➘ Final draft re-circulated for consultation. Heads of departments of all agencies in city, local authority, ➚ health authority and city council identify departmental Final draft plan produced, representatives. incorporating comments and discussion with representatives. ➘ Introductory meeting with departmental ➚ representatives (half day). Outline philosophy Second set of interviews with departmental behind the plan, discuss sociopolitical models representatives to clarify departmental of health, the state of health of the city and plans on health and targets about health the process of developing the plan. outcomes that will be part of the final plan. ➘

➚ All meetings are managed From this meeting representatives take Comments and amendments. and reported by the project on the task of drafting a report (A) about team: all interviews are how health is perceived, supported and ➚ carried out by the project developed by their service agency. ➘ Draft plan circulated to all team. Attention is paid to participating agencies for the need for the project consultation. team to develop a good Second development overview of city services meeting (half day) explores and their work. how all city services affect ➚ people’s health. Draft report presented to steering group for discussion and approval. This also reminds ➘ steering group members of their responsibility to support and promote the draft plan in their From this meeting, representatives political and service areas. provide a report (B) describing the references to health outcome in

➚ the planning documents of their City health plan team drafts a city organization.

health plan from the reports, working ➘ documents, interviews and data about the city. From the two meetings and reports

➚ (A and B), the city health plan team produces a draft document describing Individual interview with each overall city service provision and their departmental representative on relationships to health outcomes.

strengths, weaknesses, opportunities ➘ and threats for further health

work in their department. This allows

the health plan team the opportunity to ➘ Third development meeting get a real picture of how health work is (half day). This meeting looks ➘ This document is presented to viewed in the department. at the draft document and the project steering group and explores opportunities for then circulated to all service intersectoral work to improve departments for information Examples of city health planning health outcomes in the city. and comment. 91 Bologna’s health and The objectives for the healthy city environmental plan process include building strategic links Bologna joined the WHO Healthy with other sectors and organizations Cities project in 1994, building on that substantially influence health and work taking place in the city since strengthening national alliances and 1991. This work had developed the support systems. The goal is to achieve community capacity for health action, a comprehensive city health profile and which led to the development of a self- to plan to tackle such challenges as protection health project and the equity and sustainable development. opening of a health shop. This work Because the principles and practice involved the local community actively of health for all and local Agenda 21 in gathering and producing overlap substantially, the Municipality information on health. intends to integrate environmental This collaboration at the local level issues and health in developing a is reflected in the activities and comprehensive municipal health and developments at the municipal level. environmental plan. The local Agenda The Municipality of Bologna has 21 team and the Healthy City Project signed the Aalborg Charter, joined the Office are analysing the environmental European Sustainable Cities & Towns factors in the city and preparing a city Campaign and the WHO Healthy health profile. Cities project and initiated a local Agenda 21 process in 1996. Environmental indicators The Environmental Department is The Agenda 21 team has already responsible for local Agenda 21, developed a set of 80 environmental coordinating collaboration both within indicators divided into three categories: the municipal board and at the local status, pressure and response (Fig. 16). level. The commitment towards local The challenges identified are air and Agenda 21 and the Bologna Healthy noise pollution, water resources, use of City Project are clearly shown in the energy, waste disposal, transport, political plan for the city for the years industrial activities, urban water 1995 to 1999, in which the main goal is planning and misuse of resources. This the development of long-term action set of indicators will constitute a plans towards sustainability. permanent database that will be

92 City planning for health and sustainable development updated regularly. From this, a consultations and seminars were held sustainability index based on 12 in Bologna to develop a citizens’ forum indicators will be developed. for local Agenda 21. This forum, which As the indicators were being has representatives from environmental developed, a series of public groups, trade unions, the Artisans’

Fig. 16. Bologna’s environmental indicators Environmental indicators

Pressure Status Response Energy consumption Concentration of SO2, Green spaces NO2 and O3

Water consumption Concentration of heavy Wastewater-treatment metals in waters capacity

Soil consumption Contaminated areas Waste disposal

Waste disposal ...... Transport services

......

Sustainability index

Source: adapted from a personal communication from S. Fontanelli

Examples of city health planning 93 Confederation, the Industrialists’ significant stages of the preparation of Confederation, the professional the local Agenda 21 plan. The citizens’ associations, the Consumers’ forum will be involved with the local Association and other voluntary Agenda 21 team in developing and groups, will be involved in all determining the 12 environmental

Fig. 17. Chronology of the health and environmental plan for Bologna

Healthy City Project Local Agenda 21

1991 Start of the self-protection health project

1993 Opening of the health shop

1994 Joined second phase of the Signed the Aalborg Charter WHO Healthy Cities project

1995 Bologna becomes coordinating city of the Italian Healthy Cities Network

First edition of the city health profile

1996 Start of close collaboration with the Start of the local Agenda 21 process local Agenda 21 team Analysis of the environmental situation Bologna is appointed as the coordinating city for the Italian members of the European Sustainable Cities & Towns Campaign

1997 City health plan Local Agenda 21

Health and environmental plan for Bologna

Source: adapted from a personal communication from S. Fontanelli

94 City planning for health and sustainable development indicators for the sustainability index. social challenges than it has been Aims of the health shop The tasks and priorities for the actual for environmental challenges. local Agenda 21 plan will be discussed The Healthy City Project team is Identify and integrate with the citizens’ forum, and their developing methods and initiating the environmental and social aspects suggestions and priorities will be taken discussions with the community that could affect into account. The final document will about what challenges they perceive health. represent a collaborative effort to be the most important. Reach out to the between the community and the It is hoped that the health shop can population in the various areas of the agencies and will provide a good base be used as an important tool in town in a new and for working together in implementing finding and integrating the social and more direct way, the plans. environmental factors affecting health encouraging healthier lifestyles and in communities. A health network is behaviour. A city health profile and social being developed that will be Create health equity indicators decentralized in the nine districts of networks as well as Bologna’s Healthy City Project the city, enabling these communities a database by means of information completed the first city health profile to be reached in a new and more technology. in 1995 and is now working on direct way. This network will have the selecting a set of indicators of social health shop as a focal point. equity. This is seen as an important step in developing coordination of The health and environmental plan intersectoral action for health. The The health and environmental plan development of a set of indicators will (Fig. 17) will be based on the findings help in the future definition of an from the city health profile and the index of social sustainablility and environmental reports and will serve capacity. This objective is still much as a guide for the priorities for action more difficult to achieve for health and to be developed.

Examples of city health planning 95 Liverpool: developing a Healthy Cities project in 1988. collaborative plan During the first phase of funding, the The City of Liverpool felt strongly that Liverpool Healthy City Project was developing health plans should not be devoted to getting organized and to seen as a one-off exercise that will set in establishing commitment among all motion all the work needed to solve a agencies to the philosophy, strategy and city’s health and environmental principles of health for all. During the problems at once. Instead a health plan second phase of funding, the Project should be viewed as a process of became involved in developing its own consultation, data-gathering and city health plan. analysis, mobilizing the resources In 1993, new arrangements and required to make key improvements structures were put in place for public and open new channels of health in the city, thereby bringing communication between different public health within the mainstream sectors and communities in the city planning processes of the key that can learn to work together on a authorities (Fig. 18). The Healthy City continuing basis. Project was revised with a brief to set In Liverpool, the consultation with up task groups on priority health the service organizations and the challenges in the city. These task groups community has been tightly were made accountable to a newly coordinated with the planning process. formed Joint Public Health Team and The health plan is a five-year strategy to the Joint Consultative Committee. to improve the quality of life and The role of the task groups was to health in the city. The plan has long- develop strategic and operational plans The vision is for a future in which term and short-term targets and aims towards the development of an overall economic prosperity, to get everyone moving in the same city health plan. Task group topic areas social justice and included the national health promotion protection of the direction to take action on the natural environment underlying causes of ill health in policy key topic areas of cancer, heart are pursued Liverpool and to achieve the levels of health, sexual health and accidents. A simultaneously to secure good health health described in the document on fifth task group was set up on housing and enhance well- health strategy for England (46). for health to address the underpinning being for all people, now and for Liverpool became one of the first factors of ill health such as poverty. generations to come. cities to participate in the WHO Housing was considered to be an

96 City planning for health and sustainable development extremely good indicator of poverty. to air pollution and the desire for a The plan was made available in full draft Members of the task groups included clean, green city. This was followed by format, as a summary representatives from the health poverty and unemployment, mental guide, as translated versions of the authority, the Liverpool City Council, health, housing, access to health summary guide in the voluntary sector, the Trades services, education and training, young seven different Council, the City Health Promotion people having more influence in the languages, on audio- tape in different Department, community health city, diet and nutrition, accidents and languages, in Braille, in councils, universities, the Chamber of transport. large print, in articles in newspapers, in Commerce and the communities of the Comments from the consultation discussions on radio city themselves. About 150 people were were then included in the revised city and in free newsheets to every home in the involved in developing the city health health plan, and the final version of the city. plan. plan (40) was launched on 7 April 1996 The draft city health plan was to coincide with World Health Day, launched for consultation in January which focused on healthy cities in 1996. 1995. The plan was produced in a The city health plan reflects the need number of versions and used in a to address the wider socioeconomic, number of settings with facilitators to environmental, political and ensure accessibility for all groups. A discriminatory determinants of ill video was also made to aid group health. Action is being taken, for discussion. Responses were elicited by example, to tackle the problem of questionnaires and letters. widespread poverty in the city. This The analysis of the consultation action includes using new money such revealed that people widely supported as European Union Objective 1 the plan. City residents understood the funding to target areas of the city with links between the underlying causes of the intention of creating new work. ill health and the main causes of Existing resources are being redirected premature death and illness and agreed towards city regeneration and that tackling these would have the investment in the economy, and the greatest impact on health. The city is working towards balanced environment was ranked as the first of targets for environmental the top ten concerns expressed by local sustainability. people. This included the environment The plan is already influencing – in general and specifically in relation mainstream activity in the Liverpool

Examples of city health planning 97 Fig. 18. The health City Council and Liverpool Health planning process Authority. Some action has already Task been incorporated, and consequently groups the city is working and thinking differently. Gone are the old ways of ▼ thinking only about the present, short- Identify problems term crisis management, exclusive ways

▼ and establish of working and centralization of priorities planning. ▼ The new ways of thinking and acting revolve around long-term Develop strategic and ▼ operational plans neighbourhood planning, partnerships between agencies and local people, ▼ local action and cooperation, output that can be measured, concern for Draft city

▼ future generations and an increased health plan understanding of health challenges and ▲ ▼ the impact on health of various policies and actions. Consultation shapes The impact of the plan on health will ▼ targets and final plan be measured. Indicators will be developed for measuring progress over the next five years of the plan, and a ▼ City health plan review of progress will be published ▼ annually. ▼ New programmes and

▼ collaboration to tackle problems ▼ Monitoring, evaluation

▼ and feedback

98 City planning for health and sustainable development Intersectoral planning for Aim health in Belfast The aim of the city health plan is to Belfast started its process of developing create a vision for the health of the a health plan (Fig. 19) with a very clear people of the city across all sectors and to rationale and structure (47): develop integrated policies and strategies by which to achieve it. Since many different factors contribute to health, responsibility for Objectives its production rests with a wide range The objectives of the plan are: of individuals and agencies, each having a role to play individually and • to develop a city health profile, collectively in the production of good including qualitative and quantitative health in our city. Government has a data that will describe the health of the strong role to play through its people of the city and the conditions economic and social policies. in which they live; Employers, large and small, have a • to make visible the challenges relating role to play through their impact on to health: for example, the current the environment, the products they planned health activities and policies supply, the jobs they provide and the of statutory sectors and the facilitation conditions under which their of new integrated approaches to and employees work. coordination of all health and health- Planning for health in the city related activities within the city; therefore becomes the responsibility • to enable communities in the city to of all relevant sectors within the city, participate and influence decision- which impact upon it, environmental, making processes about health and the social, education, housing and health provision of health-related public care sectors. services; • to provide a rational basis for An aim and objectives for the city decision-making, geared towards health plan were developed from this investing in health and reducing philosophy. inequalities in health; and

Examples of city health planning 99 • to develop a monitoring and planning process. Overall and specific evaluation framework that will outcomes for the plan are also outlined. indicate the progress of strategies for The overall outcomes desired by action and measure the outcomes. the city health plan are:

Process measures, outcome and time • a common direction towards health scales are provided for each stage of the in the city for all agencies; and

Fig. 19. Process for developing the Belfast city health plan

Development of monitoring and evaluation frameworks to be carried out

▲ ▲

Development of a draft city health plan ▲ Statutory organizations: Voluntary organizations: explore their contribution produce a report on their to health in the city and existing services and summarize current policies their effects on health and plans that affect health

▲

Development of a city health profile describing health status, socioeconomic statistics, environmental statistics and causes of poor health

Time scale in months start 1 2 3 4 5 6

100 City planning for health and sustainable development • improved coordination and synergy • integrated policies evident in the resulting from the process will future planning cycles of statutory enhance individual programmes. organizations; • increased coordination between The specific outcomes desired by sectors on appropriate service the city health plan are: delivery to meet community needs; ▲ over the lifetime of the plan and its strategies ▲

▲ ▲ ▲ ▲

Community involvement Production of city health plan and A series of seminars on action strategy the issues around health in the city From a series of inter-agency and ▲ ▲ leading to the community meetings, a city health production of a plan with action strategies and consensus timetables is produced. document that informs discussion This is then put into operation with statutory agencies over the next five years. ▲

8 9 10 11 12 13 14 15

Examples of city health planning 101 • evidence of change in the policy of • the development of locality health statutory organizations that invest plans; in good health; • community needs being evident, • action strategies with time scales both in policy changes and strategies and indicators that will lead to for action; improvement in people’s quality of • the development of support life in such areas as environment structures for negotiation; and health, poverty and health, • increased satisfaction from social networks for health and communities on delivery of services; appropriate services; • evidence of collaboration between • community involvement in future government departments that planning and development of policy supports the long-term viability of and service in local areas; communities; • strengthened community • evidence that socially excluded participation in statutory groups are being involved in organizations; planning policy and programmes; • ethnic minority communities being • evidence that organizations are involved in assessing needs and developing and building sustainable developing action plans; policies and programmes in • an increased understanding of the partnership with communities; and wider dimensions of community • evidence of capacity-building within needs and of the range of skills and communities. resources within communities; • new partnerships formed with the Similar to all the city health plans statutory, voluntary, community developed within healthy city projects, and private sectors at the the fundamental work of gaining community, city, country and commitment and having support and European levels to sustain long- staff to carry out this work is part of term action; the project.

102 City planning for health and sustainable development 1. United Nations, Earth Summit – 7. Newman, P. & Itzin, C., ed. Gender, Agenda 21. New York, United culture and organisational change: References Nations Department of Public putting theory into practice. London, Information, 1993. Routledge, 1995, pp. 1–7. 2. Health for all targets – the health 8. Women in the city: housing, services policy for Europe. Copenhagen, and the urban environment. Paris, WHO Regional Office for Europe, Organisation for Economic Co- 1991 (European Health for All operation and Development, 1995. Series, No. 4). 9. Sandercock, L. & Forsyth, A. A 3. Topfer, K. Our cities, our future. In: gender agenda: new directions in Price, C. & Tsouros, A., ed. Our planning theory. In: Le Gates, R.T. cities, our future: policies and action & Stout, F., ed. The city reader. plans for health and sustainable London, Routledge, 1997, pp. 407– development. Copenhagen, WHO 420. Healthy Cities Project Office, 1996, 10. Constitution of the World Health pp. 1–4 (document no. EUR/ICP/ Organization. In: WHO basic HCIT9401/MT04(A)). documents. 40th ed. Geneva, World 4. Mega, V. The wellbeing of cities and Health Organization, 1994. citizens in Europe. In: Price, C. & 11. Whitehead, M. & Dahlgren, G. Tsouros, A., ed. Our cities, our What can be done about future: policies and action plans for inequalities in health? The lancet, health and sustainable development. 338: 1059–1063 (1991). Copenhagen, WHO Healthy Cities 12. Ottawa Charter for Health Project Office, 1996, pp. 15–37 Promotion. Health promotion, 1(4): (document no. EUR/ICP/ iii-v (1986). HCIT9401/MT04(A)). 13. Making partners: intersectoral action 5. Mumford, L. What is a city? for health. Copenhagen, WHO Architectural record, 82: 1937. Regional Office for Europe, 1990. 6. Davis, K. The urbanisation of the 14. Benzeval, M. et al., ed. Tackling human population. In: Le Gates, inequalities in health: an agenda for R.T. & Stout, F., ed. The city reader. action. London, Kings Fund, 1995. London, Routledge, 1997, pp. 1–11. 15. Research Unit in Health and

References 103 Behaviour Change. Changing the future: policies and action plans for public health. Edinburgh, John health and sustainable development. Wiley and Sons, 1989, p. 108. Copenhagen, WHO Healthy Cities 16. Working together for Glasgow’s Project Office, 1996, pp. 1–4 health: Glasgow city health plan. (document no. EUR/ICP/ Glasgow, Glasgow Healthy City HCIT9401/MT04(A)). Project, 1995. 23. Health implications of the ecological 17. Laughlin, S. & Black, D., ed. Poverty crises. Ottawa, Canadian Public and health: tools for change. Health Association, 1991. Birmingham, Public Health Trust, 24. The local Agenda 21 planning guide: 1995. an introduction to sustainable 18. Tsouros, A. WHO healthy city development planning. Toronto, projects: state of the art and future International Council for Local plans. Health promotion Environmental Initiatives Local international, 10(2): 133– Agenda 21 Initiative, 1996. 141(1995). 25. Pearce, D. Sustainable development: 19. City health planning: the framework. the political and institutional Copenhagen, WHO Healthy Cities challenge. In: Kirkby, J. et al., ed. Project Office, 1995. Sustainable development: the 20. Kirkby, J. et al., ed. Sustainable Earthscan reader. London, development: the Earthscan reader. Earthscan Publications, 1995, pp. London, Earthscan Publications, 287–90. 1995, pp. 1–14. 26. Charter of European Cities and 21. World Commission on Towns towards Sustainability Environment and Development. (the Aalborg Charter). Brussels, Our common future. Oxford, European Sustainable Cities & Oxford University Press, 1987. Towns Campaign, 1994. 22. Rees, W., & Lawrence, R. Urban 27. The Lisbon Action Plan: from environment, health and the Charter to action. Brussels, economy: cues for conceptual European Sustainable Cities & clarification and more effective Towns Campaign, 1996. policy implementation. In: Price, C. 28. United Kingdom Local Authority & Tsouros, A., ed. Our cities, our Associations and Local Government

104 City planning for health and sustainable development International Bureau. Agenda 21: a changes through organizations. guide for local authorities in the Glasgow, Women’s Health Working United Kingdom. London, Local Group, Glasgow Healthy City Government Management Board, Project, 1996. 1994 (Supplement No. 2). 35. Premier’s Council on Health, Well- 29. European Commission Expert being and Social Justice. Health for Group on the Urban Environment. all Ontarians. A provincial dialogue European sustainable cities. Brussels, on the determinants of health. European Commission, 1994, pp. Toronto, Queen’s Printer for 27–31, 74–84. Ontario, 1994, p. 1. 30. Tansey, G., & Worsley, T. The food 36. Monitoring and evaluation of system. London, Earthscan community development in Northern Publications, 1995, pp. 14–15. Ireland. Belfast, Voluntary Activity 31. Hancock, T. Planning and creating Development Branch, Department healthy and sustainable cities: the of Health and Social Services, 1996, challenge for the 21st century. In: p. 29. Price, C. & Tsouros, A., ed. Our 37. Community development and cities, our future: policies and action health: the way forward in Sheffield. plans for health and sustainable Sheffield, Healthy Sheffield, 1993. development. Copenhagen, WHO 38. Principles and values. Leicester, Healthy Cities Project Office, 1996, Centre for Social Action, De pp. 65-88 (document no. EUR/ICP/ Montford University, 1993. HCIT9401/MT04(A)). 39. Towards local sustainable 32. Local Agenda 21: principles and development: a toolkit of strategies. process. A step by step guide. London, Canberra, National Local Local Government Management Government Environmental Board, 1994. Resource Network, Australian 33. Municipal public health planning: a National University, 1994, p. 21. resource guide. Queensland, Healthy 40. Liverpool city health plan. Liverpool Cities and Shires Project, healthy city 2000. Liverpool, City of Queensland Health and Queensland Liverpool, 1996. University of Technology, 1995. 41. Black, D. & Womersly, J., ed. 34. Action for women’s health: making Glasgow’s health: old problems new

References 105 opportunities. Glasgow, Greater 45. Black, D. & Craig, P. Assessing Glasgow Health Board, 1994. health outside the health service. 42. Hair, S. Glasgow’s health: women In: Harris, A, ed. Needs to know: count. Glasgow, Glasgow Healthy a guide to needs assessment for City Project, 1995. primary care. London, Churchill 43. City health profiles: how to report on Livingston, 1997, pp. 117-126. health in your city. Copenhagen, 46. Department of Health. WHO Healthy Cities Project Office, Health of the nation: strategy for 1995 (document no. ICP/HCIT94/ health in England. London, 01 PB2). HMSO, 1992. 44. Ginnerty, P. et al. Moyard: a health 47. Belfast city health plan strategy profile. Belfast, Eastern Health and document. Belfast, Belfast Healthy Social Services Board, 1985. City Project, 1996.

106 City planning for health and sustainable development Sustainability International Council for Local Further Commission of the European Environmental Initiatives, Canadian Communities. Green paper on the International Development Research reading urban environment. Communication Centre and United Nations from the Commission to the Council Environment Programme. The local and the Parliament. Brussels, Office for Agenda 21 planning guide. Toronto, Official Publications of the European ICLEI/IDRC, 1996. Communities, 1990 (CB-CO-90-276- EN-C). United Nations Development Programme, United Nations Centre for Crombie, H. Sustainable development Human Settlements and World Bank. and health. Birmingham, United Towards environmental strategies for Kingdom Public Health Alliance, 1995. cities. Washington, DC, World Bank, 1994 (Urban Management Programme Manual for local Agenda 21 incentral Policy Paper, No. 18). and eastern Europe. Copenhagen, Ministry of Environment and Energy, United Nations Centre for Human Denmark, 1995. Settlements. Implementing Agenda 21: sustainable human settlements Sustainable development: the Earthscan development. Nairobi, United Nations reader. London, Earthscan Publications, Commission on Sustainable 1995. Development.

Planning for the planet: sustainable United Nations, Earth Summit – development policies for local and Agenda 21. New York, United Nations strategic plans. London, Friends of the Department of Public Information, Earth, 1994. 1993.

International Council for Local United Nations Centre for Human Environmental Initiatives. European Settlements. The Habitat agenda: draft local Agenda 21 planning guide. statement of principles and Brussels, European Sustainable Cities & commitments and global plan of action. Towns Campaign, 1995. Istanbul, UNCHS (Habitat II), 1996.

Further reading 107 Environmental health in urban Health for all starter pack. Liverpool, development: report of a WHO Expert UK Health for All Network, 1993. Committee. Geneva, World Health Organization, 1991 (WHO Technical Poverty Report Series, No. 807). Robbins, D. Observatory on national policies to combat social exclusion. Health challenges Brussels, European Commission The urban health crisis: strategies for (DG V), 1994. health for all in the face of rapid urbanization. Geneva, World Health Thake, S. & Staubach, R. Investing in Organization, 1994. people: rescuing communities from the margin. York, Joseph Rowntree Research Unit in Health and Foundation, 1993. Behavioural Change, Changing the public health. London, Wiley, 1989. Sinfield, A., ed. Poverty, inequality and justice. Edinburgh, University of City health plans and city health Edinburgh, Department of Social planning. Copenhagen, WHO Healthy Policy and Social Work, 1993 (Social Cities Project, 1994. Policy Series, No. 6).

Jacobson, B. et al. The nation’s health. Communities against poverty: resource London, King Edward’s Hospital Fund pack. Glasgow, Strathclyde Poverty for London, 1991. Alliance, Strathclyde Regional Council, 1994. Allen, P. Off the rocking horse: how local councils can promote your health and Poverty and health environment. London, Green Print/ Wilkinson, R. G. Unhealthy societies. Merlin, 1992. London, Routledge, 1996.

Draper, P. Health through public policy: Benzeval, M. et al., ed. Tackling the greening of public health. London, inequalities in health: an agenda for Green Print/Merlin, 1991. action. London, Kings Fund, 1995.

108 City planning for health and sustainable development Laughlin, S. & Black, D. Poverty and Leather, S. Less money – less choice. health: tools for change. Birmingham, Poverty and diet in the UK today. In: Public Health Trust, 1995. National Consumer Council, ed. Your food – whose choice? London, HMSO, Women’s health 1992. Her share of misfortune – women, smoking and low income. Edinburgh, Race Action on Smoking and Health, 1993. Smage, C. Health and ethnicity: a critical review. London, Kings Fund Graham, H. Hardship and health in Institute/SHARE, 1995. women’s lives. London, Harvester/ Wheatsheaf, 1993. Housing Burridge, R. & Ormond, D., ed. Doyal, L. What makes women Unhealthy housing: research, remedies sick: gender and the political economy and reform. London, E and FN Spon, of health. London, Macmillan, 1993. 1996. Lawrence, R. Strategies for housing and Women’s health towards a better world. social integration in cities. Paris, Report of the first meeting of the Organisation for Economic Co- global commission on women’s health, operation and Development, 1996. 13–15 April 1994. Geneva, World Health Organization, 1994 (WHO/ Bhatti, M. et al. Housing and the DGH/94.4). environment: a new agenda. London, Chartered Institute of Housing, 1994. Food Food and low income: a practical guide Collaboration for advisers and supporters working with Winer, M. & Ray, K., ed. Collaboration families and young people on low handbook: creating, sustaining and incomes. London, National Food enjoying the journey. Amherst, H Alliance, 1994. Wilder Foundation, 1992.

Further reading 109 Wilcox, D. Guide to effective International Institute for Sustainable participation. Brighton, Partnership Development Books, Delta Press. http://iisd1.iisd.ca/contents.htm

Fieldgrass, J. Partnerships in health Sustainable Cities Programme promotion: collaboration between the http://unep.unep.no/unon/unchs/ statutory and voluntary sectors. London, scp/scphome.htm HEA/NCVO, 1992. European Partners for the Speller, V. & Funnell, R. Towards Environment Sourcebook evaluating healthy alliances. London, http://www.epe.be/EPE/ HEA/Wessex Institute of Public Health sourcebook/SB_Contents.html Medicine, 1994. WHO Healthy Cities Geneva Information on the Internet http://www.who.ch/programmes/ Local Sustainability: the European WHOProgrammes.html good practice information service http://cities21.com/europractice WHO Healthy Cities Copenhagen http://www.who.dk/tech/hcp/ index.htm

110 City planning for health and sustainable development “The prerequisites and prospects for health cannot be ensured by the health sector alone. ” Source: Ottawa Charter for Health Promotion (12)

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