city planning for health · 72 74 77 80 81 85 87 89 90 92 96 99 103 107 contents. 5 p ublic health...

City planning for healthand sustainable development

European Sustainable Development and Health Series: 2

European SustainableCities & Towns Campaign

Healthy Cities NetworkWHO Regional Officefor Europe

European CommissionDG XI

EUR/ICP/POLC 06 03 05B – European Sustainable Development and Health Series: 2Original English. 1997.

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

Target 14: settings for health promotionBy 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.

ABSTRACTCity planning for health and sustainable development is the second document in the EuropeanSustainable Development and Health Series produced by the WHO Healthy Cities project within theEuropean Sustainable Cities & Towns Campaign. It describes how health and sustainable development areclosely related. City health plans form an important model for local Agenda 21 plans, using local healthprofiles and promoting community participation to achieve change at the municipal level. Examples ofpractice are drawn from Belfast, Bologna, Glasgow and Liverpool. The text includes 47 references andfurther sources of information.

KeywordsURBAN HEALTHHEALTHY CITIESSUSTAINABILITYDEVELOPMENTHEALTH FOR ALLEUROPE

© World Health Organization 1997

All rights in this document are reserved by the WHO Regional Office for Europe. The document maynevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not forsale or for use in conjunction with commercial purposes) provided that full acknowledgement is given tothe source. For the use of the WHO emblem, permission must be sought from the WHO Regional Officefor 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 wouldappreciate receiving three copies of any translation. Any views expressed by named authors are solely theresponsibility of those authors.

ISBN 92 890 1284 6

Foreword

Acknowledgements

Introduction

Life in cities

The benefits of living in cities

The evolution of cities and the development of suburban life

Differences in how city life is experienced

Threats to public spaces

The effect of economic changes

Poverty and inequality and their effects on city life

Overcoming the challenges

Understanding health

Perspectives on health

A new coalition for health in society

Healthy cities

Sustainable development and health

Defining sustainable development

Developing a framework for action: Agenda 21

Implementing Agenda 21 at the local level

Environmental factors and health

Health outcomes at all levels

Health for all and Agenda 21

Local Agenda 21 plans

Methods and tools in local Agenda 21 planning

The role of health in the local Agenda 21 process

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City health planning

What is a city health plan?

Foundations of the process of city health planning

Involvement of communities in city health planning

Steps in producing a city health plan

A vision

Managing the project

Collecting data

Setting priorities

Developing strategies

Drafting the city health plan

Implementation, monitoring and evaluation

Examples of city health planning

Glasgow: starting with a service-based plan

Bologna’s health and environmental plan

Liverpool: developing a collaborative plan

Intersectoral planning for health in Belfast

References

Further reading

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Contents

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ForewordPublic health action has alwaysfocused on the relationshipsbetween the environment and

health, and these relationships nowhave a global perspective. Frameworksfor action on socially andenvironmentally sustainabledevelopment are necessary becauseuncoordinated economic and socialdevelopment is having increasingadverse effects on people and theplanet. The 1992 United NationsConference on Environment andDevelopment recognized the role ofurban communities in shaping healthyand sustainable development inAgenda 21, the United Nationsprogramme of action on sustainabledevelopment.

This is the second document in theseries on European sustainabledevelopment and health produced bythe WHO Healthy Cities project withinthe framework of the EuropeanSustainable Cities & Towns Campaign.It sets the background for local Agenda21 and healthy cities, exploring thechallenges underpinning thesemovements and describing thesimilarities between them. Inparticular, this document exploreshow the work on health challengesdeveloped within healthy city projects

can support the fulfilment of therecommendations related to healthfound in Agenda 21. This documentdraws on the experience of a widerange of work taking place around theworld to indicate directions for thelong journey towards sustainablewellbeing.

The key recommendations on healthin Agenda 21 relate to developingmunicipal health plans, using localhealth profiles and strengthening citynetworks for health. The work ofhealthy city projects in Europe since1987 provides many specific methodsof tackling these challenges at amunicipal level. They include thedevelopment of structures that ensurethe participation of the community aswell as service organizations, thedevelopment of health profiles forcities and towns and the process ofdeveloping and sustaining city healthplanning.

Creating healthier and moresustainable cities and towns requiresnew approaches to planning. Thisdocument aims to support people inurban settings who are attempting todevelop collaborative work andintegrated action on the challenges thataffect health and sustainability. Actionneeds to be developed at the local,

Foreword

6 City planning for health and sustainable development

national and international levels tomove towards a healthier and moresustainable world. The development andsharing of new approaches at the locallevel is of key importance in thischallenge.

On behalf of WHO, I would like toacknowledge and give special thanks forthe financial assistance for this workfrom the European Union through theEuropean Commission, Directorate-General for Environment, Nuclear Safetyand Civil Protection (DG XI). I wouldlike to express my appreciation andwarm thanks to David Black and SueLaughlin (Communicable Health, Glasgow,Scotland) for drafting this document. Iwould like to extend my gratitude to the

cities that have provided material ontheir experience and especially to theparticipants of the Multi-city ActionPlan on Health and Agenda 21 for theircontributions to and comments onearlier drafts. I would like toacknowledge the help and contributionof Pierre Dubè (Urban DevelopmentAdviser, WHO Regional Office forEurope). Special thanks are due toCharles Price and Mark McCarthy(Healthy Cities Project Office, WHORegional Office for Europe) forcoordinating and guiding thepreparation of this document. Manythanks to David Breuer, whosignificantly improved the languageand style of this document.

Agis D TsourosRegional Adviser for Urban Health Policiesand Coordinator, Healthy Cities projectWHO Regional Office for Europe

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The WHO Healthy Cities Project Officeexpresses its gratitude to all the citiesthat have provided material andespecially to the following participantsin the Multi-city Action Plan on Healthand Agenda 21 and individual expertsfor their contributions and comments:

Eng. Orlando Guerreiro de Almeidaand Dr Helena Delgado, Amadora,Portugal; Mr Ray Bateson, Mr KevinO’Sullivan and Councillor OliviaMitchell, Dun Laoghaire-Rathdown,Ireland; Mr Mark Dooris, Mr KevinGarritty and Mr Neil Rutherford,Preston, United Kingdom; Ms JoanDevlin, Dr Susan Christie and MrAndrew Hassad, Belfast, NorthernIreland, United Kingdom;Ms Stefania Fontanelli, Bologna, Italy;Dr Willy de Haes, Rotterdam, theNetherlands; Ms Mari Hakkala, Turku,Finland; Ms Marianne Halbert,Gothenburg, Sweden; Mr TonyHarrison, University of West of

AcknowledgementsEngland, Bristol, UnitedKingdom; Dr Igor Krampacand Ms Vesna Smaka-Kinel,Maribor, Slovenia; Ms Inge Kristiansen,Horsens, Denmark; Dr Jurak Mesikand Ms Klára Janèurová, BanskáBystrica, Slovakia; Mr BjarneRasmussen, Storstrøm County,Denmark; Ms Anni Stroumza,Geneva, Switzerland; Ms Tina Svoboda,Vienna, Austria; Mr Bob Stewart,Newcastle Healthy City Project,Newcastle, United Kingdom;Ms Julia Taylor, Liverpool HealthyCity Project, Liverpool, UnitedKingdom; Ms Janet Holdsworth,Mr John Bibby, Bradford LA21,Bradford, United Kingdom; DrRoderick Lawrence, University ofGeneva, Switzerland; Dr Andrew Lyon,Forward Scotland, Glasgow, Scotland,United Kingdom; Ms Pauline Craig andMr Alan Ferry, Glasgow, Scotland,United Kingdom.

Acknowledgements


The world is becomingincreasingly urbanized. Theprojected number of people

living in cities is expected to more thandouble between 1990 and 2025,growing from 2.4 billion to 5.5 billion.This trend is accelerating in developingcountries; their share of the total urbanpopulation will rise from 63% in 1990to 80% in 2025. The huge increase inurban population linked to theeconomic development of cities andtowns has given rise to concern aboutthe sustainability of these trends.

The growth of the world populationand the development of consumptionpatterns that cannot be sustainedecologically and socially are severelystressing the life-supporting capacity of

the planet and the ability of manycountries to prosper and support thewellbeing of their inhabitants.

The United Nations Conference onEnvironment and Development, held inRio de Janeiro in 1992, attempted toaddress a huge range of environmentaland social problems related to economicand population growth. The Conferencestated that the world has reached adefining moment in its history. A choicehas to be made: either to maintaindevelopment policies that will continueto destroy ecosystems and furtherdeepen the economic divisions withinand between countries or to changecourse. The Conference argued that thethrust of development within the worldmust move towards being sustainable,

Introduction

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9Introduction

not just for now but for the future.To support a move towards

meaningful policies in urbansustainable development, theConference presented Agenda 21(1),the United Nations programme ofaction on sustainable development, asan agenda for the twenty-first century.Agenda 21 places environmentalconcerns within a social and economicframework, starting from the needs ofpeople (1):

Human beings are at the centreof concern for sustainabledevelopment. They are entitledto a healthy and productive lifein harmony with nature.

Agenda 21 highlights the role of citiesand towns in developing sustainablepractices. Local government isidentified as a main partner inimplementing the Conference’srecommendations by developing localAgenda 21 action plans.

Agenda 21 sees human health asfundamental to sustainabledevelopment. Health is understood asbeing an outcome of all the factors thataffect human beings. Sustainabledevelopment requires paying attentionto the determinants that shape health

outcomes.Agenda 21 refers to health more than

200 times. One section of Agenda 21devoted explicitly to health highlightsthat (1):

...the primary health needs of theworld’s population are integral to theachievement of the goals ofsustainable development.

Agenda 21 views health as the outcomeof environmental, economic and socialfactors that also affect sustainabledevelopment. WHO has also developedwork that sets health outcomes in asimilar framework (2). Since 1978,WHO’s strategy for health for all by theyear 2000 has developed a range ofprojects within both industrializedcountries and developing countries.

Agenda 21 and the health for allprogramme have many commonprinciples and complementaryprocesses. They are both internationalprogrammes adopted by countries butoperating at the national, regional andlocal levels. Both have a core concernfor human health and wellbeing in thepresent and future. Social,environmental and economicchallenges are addressed holistically,and both programmes are based on the

“The message hascome through that –on a global scale – thefuture of mankind willbe shaped largely byurban conditions.Whether or notgovernments findways of coping withaccelerating urbangrowth, whether or notlocal authorities findways of coping withpollution, limitingautomobile traffic,securing basic healthand social needs – thiswill determine thequality of life for thegenerations to comeand with it the chanceto solve conflict withinnations and betweenthem. ”

Source: Topfer (3)


principles of equity, sustainability,community involvement andintersectoral action.

WHO has established the HealthyCities project to explore theopportunities and mechanisms fordeveloping collaborative action in citiesto achieve health for all. Many citiesinvolved directly in the project andothers working within this model havedeveloped practical experience that canbe used to fulfil the healthrequirements set out for localgovernments in Agenda 21. Especiallyuseful models have been developed incollaborative and intersectoral work onurban health challenges and inmunicipal and city health plans.

Trying to make positive changeswithin cities requires establishing therationale and the action required. BothAgenda 21 and health for all addresscore human aspirations. In the form oflocal Agenda 21 and healthy cityprojects, both programmes provideimportant tools for enabling change atthe local level. Both programmes haveinspired a range of ideas, information,projects and publications.

This document is a practical guide totaking forward the health component

of local Agenda 21. It brings togetherthe main thinking about localAgenda 21 work and healthy cityprojects and explores the challengesunderpinning the two movements. Itdiscusses the links between them andexamines the extent to whichpractice developed within healthycity projects can help to fulfil therecommendations relating to healthof Agenda 21.

Although this book should beread as part of the series, it alsosummarizes some of the importantconcepts of both health for all andAgenda 21 and introduces some ofthe challenges.

This document is designed toassist the people responsible for theenvironment, health and overallplanning in cities in supporting thedevelopment of the healthdimension of planning forsustainable development. Manypeople are familiar with one or moreof the challenges; this document canpromote linkage between differentdisciplines and sectors. It can beespecially useful for planners anddevelopers responsible for orinvolved in local Agenda 21 work.

NoteThe term “city” in thisdocument means thefull range of centres ofpopulation andsettlement, such astowns and boroughs.

11Life in cities

Urban settlements havedeveloped over the lastfour thousand years of the

approximately two million years thathumans have existed on Earth. Overthe past century, the balance of thepopulation has tilted away from thecountryside, the pace quickening withindustrialization, and now nearly halfthe world’s population lives in cities.This trend is slowing in industrializedcountries but increasing in developingcountries. War, plague and otherdiseases, medical advances, trade,technology, religion and perspectiveson urban growth have all played a partin creating and sustaining cities,although there is considerable debateabout the relative importance of each.

Cities are complex and dynamicplaces of contradiction that have beencompared to living organisms. Theycontain opportunities for developingthe potential and enriching the lives ofmany of their inhabitants.Nevertheless, life in cities can reducethe wellbeing of some people. In manyways cities represent the reality ofpolitical, economic and social decisionsmade nationally and globally. On theother hand, past and present strugglesfor local autonomy have created theidentity of each city. They have alsocounteracted some of the effects ofnational decisions that might otherwisehave had a more negative impact. Thestate of cities is the outcome of patternsof development that have yielded

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Life in cities


differing forms and location ofinfrastructure and organization ofpublic buildings and public spaces,residential areas and recreational andcultural facilities.

Much of the current worldwidedebate around cities focuses on theproblems associated with size andfunction. The tenor of this debate isone of crisis. For example, the mostrecent United Nations Conference onHuman Settlements (Habitat II, theCity Summit) was held in Istanbulin1996. The main themes aroundwhich progress is needed are:

• governance and opportunities forcitizens to participate in localdecision-making;

• housing needs;• urban economy, poverty reduction

and job creation;• awareness that women and men use

and experience cities differently;• environmental management; and• disaster mitigation, relief and

reconstruction.

In Europe, the objectives that emergefrom the debates about the urbanagenda for policy and planning maybe less oriented towards crisis,emphasizing a more holistic approach

to city development, which can providea focus for solving wider nationalproblems (4). The objectives in Europeinclude :

• improving the overall urbanenvironment driven by heightenedenvironmental awareness;

• making cities more sustainable;• strengthening the city economy and

entrepreneurship;• creating employment by developing

healthy and environmentally soundactivities;

• improving the health and wellbeingof city residents;

• improving public transport,emphasizing accessibility rather thanmobility;

• creating livable home environmentsand neighbourhoods, especially inthe anonymous periphery of cities;

• creating viable political, social andenvironmental relationships betweencities and their surrounding countiesand regions; and

• integrating all urban policies toachieve these objectives.

Despite the vast scale of the problemsin cities, too little energy and space aredevoted to describing and celebratingthe benefits of cities. These also need to

13Life in cities

be explored to construct a vision forthe future both for smaller cities aswhole units or smaller parts, such asboroughs or districts that significantlycontrol the factors affecting the dailylives of the population, and for themuch larger megacities.

Much has been written on cities:their history, their design, their role,their culture and their meaning forresidents and visitors in all facets oftheir lives. This brief introduction tolife in cities cannot completely distilthis body of thought, analysis andtheory. The aim is to identify some ofthe aspects of the ongoing debate andto consider reasons for the currentchallenges that any city planning forhealth and sustainability needs toconsider.

The benefits of living in citiesThe city has been regarded ashumanity’s single most impressive andvisible achievement. Lewis Mumford,an influential early writer on urban life,has described it, at least in its socialaspect, as (5)

...a special framework directedtoward the creation of differentiatedopportunities for a common life and asignificant collective drama.

Living in large settlements provides afocus for the development of asupportive, humanistic structure forhuman fulfilment. Cities can andshould provide excitement andvariation and opportunities forextending experiences, breaking outof traditional moulds or meeting newpeople. They are also centres oflearning, invention and innovation thatbenefit from cultural diversity.

Aggregations of people bringtogether a range of skills and newideas and ensure that the accumulatedwealth, services, education and culturalopportunities can potentially beprovided efficiently and effectively.Similarly, concentrations of people canuse the limited land available moreproductively, allowing agriculturalareas to be protected from urbanencroachment.

The size of cities and how they areplanned are important. Although citieshave increased in population andpopulation density as they havedeveloped, this growth has notnecessarily benefited city residents.Large cities are difficult to live in, butlimits to city size have been rarebecause this has been seen as holdingback progress. Research onurbanization (6) indicates that the size


of a city must reflect its ability to fulfilthe social relations that are importantto people and to maximize the strengthsof community living. The question as towhether cities as a whole or individualcities have an optimum size needs to bedebated more rigorously.

The evolution of cities and thedevelopment of suburban lifeCities have evolved and will continue todo so as the factors that affect their sizeand form change. Urbanization isspecifically connected with economicdevelopment and the technologicaldevelopments that flow from it. Inmuch of Europe, industrialization andthe capitalist economy have been themotor for rapid change over the pasttwo centuries by triggering massivemigration from rural to urban areas.

Before industrialization, people livedwhere they worked, but industrialprocesses moved the work and forcedpeople to move into larger centres ofpopulation. Poor housing and nutritionand limited natural resources such asclean water made many peopleunhealthy and made them die young.As the health and life expectancy of thepopulation improved, brought about inpart by public health initiatives, thepopulation began to grow and became

more differentiated into social classes.A growing middle class and

improved transport promoted clearerzoning of different functions. This ledto the development of the suburbs and,more recently, the flight to thecountryside by those who can afford it.Population and some employment hasbeen decentralized from core areas tosuburbs since the 1950s. Industrialdecline and a growing service sectorsince the 1970s has reinforced thispattern and has created inner-citydecay. This spatial reorganization andthe polarization between differentpopulation groups has created a newgeography of centres and margins, andmany divided or dual cities haveevolved.

The increasing population andsuburban expansion have had manyeffects. The effect on the environmentis especially notable and problematic.Large cities demand huge quantities ofwater, energy and other resources,which affects the environment severely.The effects are exacerbated by theinefficient use of resources and poorwaste management. The geographicalseparation of the functions of city lifehas created an excessive demand fortransport.

The car has become an addictive

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form of transport for suburbanresidents. The increasing numbers ofcars have also led to rapidly flowingtraffic and/or congestion, resulting insafety problems, declining amenities incity centres, noise and pollution.Indeed, transport and consumptiongenerate more air pollution than doesmanufacturing. The challenge for citiesis therefore how to achieve accessibilityto city centres and renew theenvironment while maintaining theviability of surrounding areas.

Differences in how citylife is experiencedTo meet the challenges of urbandevelopment, cities need to harness thefull complement of human energy andskills available. Thus, the attributes andpotential contributions of all residentsneed to be recognized. This alsorequires recognizing that differentgroups of people experience the city indifferent ways.

All cities have a diverse population;people differ in gender, age, ethnicity,religion, income, wealth and ability.Many cities are becoming more diverse.In some cases, this reflects ethnic orreligious differences. In others,immigration is substantial and theconsequent relations between existing

residents and newcomers areimportant. The ways cities have beenplanned or developed, bothhistorically and currently, fail to takeinto account the needs of many ofthese diverse groups because thegroups lack the influence to bring theirinterests to prominence and thereforeto affect policy and planning decisions.

Gender has an especially profoundimpact. The experience of women andmen in the city and the way they use itreflects their roles and responsibilitiesin the division of labour accordingto gender. Differences in tasks,differential access to and control overresources and the different valueaccorded to the activities of womenand men influence the spatial and

The city has beenregarded as humanity’ssingle most impressiveand visible achievement.

Life in cities

Gender can be defined as the socially

constructed and culturally determined

characteristics associated with women and

men, the assumptions made about the skills

and abilities of women and men based on

these characteristics, the conditions in which

women and men work, the relations that exist

between women and men and how these are

represented, communicated, transmitted and

maintained.

Source: Itzin (7)


organizational aspects of the city. Theheart of cities usually reflects men’sinterests, whereas suburbs are more thedomain of women, thus reinforcinggender roles.

The gradual changes in women’slives, especially the increasingparticipation in the labour market andchanges in the form of the family andthe household, are making thelimitations of traditional urbanplanning and housing policy moreapparent. The implications of thechallenges women face are such thatgender can no longer be ignored eitherin planning practice or city governance.

Threats to public spacesPublic spaces include public squares,parks, municipal buildings, culturalsites, sporting arenas, leisure facilities,shopping areas and markets, roads andpavements. They have been describedvariously as fortresses of freedom,spaces for action and islands ofhumanity. They are viewed as theconnective tissue of cities and havefunctional, environmental, culturaland aesthetic roles. They have bothhistorical and contemporarycharacteristics, and ensuring thebalance between the two is a constantchallenge.

Public spaces are central to manyurban challenges, especially for cities ordistricts in which road building haslimited these areas, in which shoppingcentres or malls have become thedominant public space or in whichpublic safety is of concern, especiallyfor women, children or elderly people.

The desire for security in cities isbecoming a major impetus for policyand planning as well as for individualbehaviour. This desire is leading tofewer public spaces, as some peopleseek to protect themselves from real orperceived fears by restricting the use ofpublic space. This can be furtherexacerbated by decisions about newarchitecture, public transport andstreet lighting, which may be madewithout considering collective safety.

The effect of economicchangesEconomic development has been amajor driving force for citydevelopment. Until recently,manufacturing was the dominantsource of wealth creation, but its recentdecline in industrialized countries infavour of service industries and newtechnologies has brought about manychanges that affect city life.

Unemployment, which is a

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permanent feature of marketeconomies, has increased throughoutEurope since the 1980s, leading toincreased poverty. It has affectedpeople living in public and privatehousing, thus affecting both the innercity and the suburbs. The form of theavailable work has changed, and thishas been accompanied by shifts in thecomposition of the workforce.

Unemployment generallyimpoverishes the inner city andreduces the quality of the housingstock, although not as consistently asmany would argue. Inner-cityneighbourhoods can attract newresidents because of their cultural andsymbolic interest, and the location ofservice industries has also helped togenerate a sense of renewal.

In some parts of Europe, notably theMediterranean countries, both coreareas and the suburbs have continuedto grow simultaneously. Othercountries have attempted to improvethe lives of people in inner-city slumsby moving them to specially createdareas or townships. Paradoxically, thishas also generated problems of poorliving conditions, unemployment andpoverty, which have been worsened bythe changes in the economy.

Technological developments are

changing the nature of work, making iteasier to work at home or on the moveusing new forms of communication.The nature of the marketplace is alsochanging as home shopping becomes apossibility. These effects raise questionsabout the nature and use of publicspaces, building developments andexisting buildings and their need fortransport and support services.

Poverty and inequality andtheir effects on city lifePoverty is a major challenge for citiesthroughout the world. Poor people incities usually have no secureemployment, savings or saleable assetsand are vulnerable to changes in thedemands of the labour market, theprices of basic goods, land costs anduse and housing policies. The effect oncity life of increasing urban poverty hasled in part to the introduction ofeconomic reforms, but these veryreforms often create new poverty.These measures include shiftingtowards privatization and limiting theability of local government to sustainprevious levels of services. In addition,welfare provision has shifted away fromredistribution towards targetedsafety-net programmes. A combinationof these factors has made many people

Life in cities

The gradual changesin women’s lives,especially theincreasingparticipation in thelabour market andchanges in the form ofthe family and thehousehold, are makingthe limitations oftraditional urbanplanning and housingpolicy more apparent.


homeless or confined them to shantytowns, and both are now widespread ina number of European cities.

Poverty profoundly affects healthand wellbeing. It contributessignificantly to the inequalities inhealth within many European citiesand across Europe. Inequalities inhealth parallel inequalities inenvironmental quality, which aresimilarly associated with poverty, eachcontributing to and exacerbating theother.

Gender is especially key in poverty,as women are disproportionatelyrepresented among the urban poor.The reasons for this include women’ssituation in the labour market, generalinequalities in access to society’sresources and inequities in thedistribution of resources and decision-making power in the household.

Even where women have taken overjob categories that have traditionallybeen dominated by men andunemployment among men hasincreased, most women have lower payand less job security than most men. Incountries where changes in familypatterns have increased the number ofhouseholds with single mothers, thishas affected women and children byincreasing poverty.

High levels of poverty in a city are assignificant for affluent people as theyare for poor people. The existence ofareas of decline and the emergence ofderelict spaces affects people’sperceptions of the city as a whole. Thepolarization between places with fewerresources and more affluent areascreates disharmony and contributes toincreasing crime and vandalism. Mostsignificantly, large numbers of poorpeople can further weaken a strugglingeconomy, as they do not have theresources to consume goods andservices or to participate fully in allaspects of city life.

Overcoming the challengesThe challenges facing European citiesand their residents may make itdifficult to imagine how thesechallenges can be overcome and thepotential benefits of city lifemaximized. Whatever the outcome, anew stage in the history of cities isprobably emerging as the humancommunity evolves. Some even arguethat the form and function of cities willchange profoundly, with suburbanareas becoming more dominant andold city centres or cores becomingobsolete.

Many challenged cities desire new

High levels of poverty ina city are as significantfor affluent people asthey are for poor people.

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forms of participation in the decisionsrelated to urban policy and planningand want these decisions to leadto action that further enhancesparticipation by, for example,improving safety and access.

Current approaches alienate thepublic from design professionals,public administrators, politicians,property owners and investors, as thedesires, lifestyles and values of thepublic are often ignored. Thelimitations of this undemocraticapproach are slowly being realized associal wellbeing erodes more despitethe apparent wealth and financialpower in many cities.

Improved forms of representationand an acknowledgement of theimportance of community action canenhance social justice. Nevertheless,those who have power are veryreluctant to share it and often wage aconsiderable struggle to maintain it.

Part of the desire for renaissance incities is greater understanding of thebenefits of social diversity in the citypopulation instead of viewing it as anon-issue or as a problem.Recognizing that most cities have amulticultural past and present gives

choices and options for the futureinstead of just seeing ethnic orcultural differences as a source ofproblems. Non-sexist or gender-conscious urban planning has beenexplored but has not yet beenrealized despite the increasedinvolvement of women in urbanplanning and policy debates and thepolicy-making process. A non-sexistcity would involve action that reflectsan understanding of genderinequalities in society and ensuresthat the built environment and useof space meets the needs of womenas well as men of all ages (8,9).

In addition, cities in Europe havebegun to reclaim a health agendaaway from the confines of medicineand are becoming laboratories ofecological innovation. Thesignificance of these relateddevelopments is that the wellbeingof people and the environment arechallenging the dictates of spatialand economic planning.

These themes of health andwellbeing and the environment areexplored in more detail throughoutthis document together with theimplications for practical action.

Life in cities

Cities in Europe havebegun to reclaim ahealth agenda awayfrom the confines ofmedicine and arebecoming laboratoriesof ecologicalinnovation. Thesignificance of theserelated developmentsis that the wellbeingof people and theenvironment arechallenging thedictates of spatial andeconomic planning.


There are many differentaccounts of health and whatinfluences it. One of the most

common and useful descriptions is thedefinition of health from the WHOConstitution (10):

Health is a state of complete physical,mental and social wellbeing and notmerely the absence of disease orinfirmity. The enjoyment of thehighest attainable standard of healthis one of the fundamental rights ofevery human being, withoutdistinction of race, religion,political belief or economicand social conditions.

This description prompts questions:

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what is complete social wellbeing?How can it be measured?Nevertheless, the WHO definition ofhealth does have important strengthsthat should not be overlooked.

Health is a complex concept. It isnot just the absence of disease but astate of being that has a number ofcomponents, such as where peoplelive, whether they are employed or not,the services and support available andthe state of their environment. Allthese factors in an economic and socialcontext produce a range of states ofhealth. In addition, WHO maintainsthat health is a fundamental right ofevery human being regardless of race,sex, politics or economiccircumstances.

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Perspectives on healthThe medical profession has largelydominated policy planning andservices for health. The early publichealth movement succeeded mainlythrough work in environmental actionand social policy, including clean watersupply, effective drainage and sewerageand housing reform. Nevertheless, inthe last century the medical professionhas mainly focused on developingspecific interventions to counteractdisease in individuals instead ofaddressing the needs of the populationas a whole.

The medical model underpinningdisease-focused interventions views thebody as a machine and considers healththe polar opposite of illness.Increasingly sophisticated medicalprocedures and interventions are usedto treat disease. Preventive techniquessuch as immunization and screeningare deemed to be of prime importancein making and keeping individualshealthy.

This view makes health care servicesresponsible for improving andmaintaining health. Most nationalhealth care resources are allocated tocure and repair, with only a smallpercentage for promoting health. Forexample, the United Kingdom spends

only about 2–3% of the NationalHealth Service budget on healthpromotion, and most of this is spenton health information.

A social model of health is acontrasting approach. This modelconsiders health as an outcome of theeffects of all the factors affecting thelives of individuals, families andcommunities in different ways andthrough different pathways.

Whitehead & Dahlgren (11) (Fig. 1,page 18) describe this in terms oflayers of influence. Individuals are atthe centre with a set of fixed genes.Surrounding them are influences onhealth that can be modified.

The first layer is personal behaviourand ways of living that can promoteor damage health. Individuals areaffected by friendship patterns andthe norms of their community.

The next layer is social andcommunity influences, whichprovide mutual support formembers of the community inunfavourable conditions. But they canalso provide no support or have anegative effect.

The third layer includes structuralfactors: housing, working conditions,access to services and provision ofessential facilities.

In 1986 the firstInternationalConference on HealthPromotion held inOttawa, Canadadeclared that:

“The fundamentalconditions andresources for healthare peace, shelter,education, food,income, a stable eco-system, sustainableresources, socialjustice and equity.Improvements inhealth require a securefoundation in thesebasic prerequisites.”

Source: Ottawa Charter forHealth Promotion (12)



role of women or the status accordedethnic minorities can shape theirability to live well. Over the pastdecade it has become more and moreapparent that the sustainability of theEarth’s ecosystem is a crucial factorfor maintaining health. The factorsfound in this rainbow are interrelatedand influence and shape each other.

Overarching all of these are thefactors that can affect whole societies:socioeconomic, cultural andenvironmental conditions. Theeconomic and labour marketconditions in each country influence allthe factors that affect health, but so dothe prevalent cultural beliefs in asociety. For example, views about the

Fig. 1. The main determinants of health

Source: Whitehead & Dahlgren (11)

23Understanding health

Any systematic attempt to improvehealth has to embrace action at alllevels.

Another way of representing theeffects of the range of health factors insociety is the health gradient (Fig. 2).

The health gradient depicts theeffects of a range of factors that canpowerfully affect an individual’s abilityto achieve health, especially acting incombination. The steepness of thisgradient is different for differentsectors of society. The traditionalmodel of health promotion that onlyencourages individuals to change theirbehaviour does not ease the load forpoor people struggling against a wholerange of structural factors. The

agencies responsible for these factorsmust act in a focused way to improvethe health of the groups in society thathave an increased load.

Research from across Europe (14)has identified a substantial social classgradient in influences on health, withan uneven population distribution ofhealth hazards and risk factors. Groupswith lower status have poorer health.

One response to these inequities hasbeen to ascribe them to differences inpersonal behaviour rather than tosocietal inequities. Fig. 2 shows thatreducing the gradient of healthinequalities requires action on factorsmainly outside the control ofindividuals.

Individuallyorientedpreventiveaction

Environmental health hazards

Unemployment

Poor housing

Poverty

Inadequate food and nutritionLack of education

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

Fig. 2. The health gradient

HealthHealthHealthHealthHealthhazardshazardshazardshazardshazards

“That political, economicand social inequalitiesshould manifestthemselves in healthdifferences shouldsurprise no one. Whatis surprising is thatsuch inequities shouldbe attributed todifferences inbehaviour, whenevidence for this viewis grossly inadequatecompared to the wealthof data which linksthem to socialconditions.”

Source: Research Unit inHealth and BehaviouralChange (15)


Making meaningful local action plansfor health requires a clear picture of thetypes of action needed. One frameworkfor conceptualizing this is the healthtriangle (Fig. 3). Good health andwellbeing are reached via a number ofhierarchical stages or outcomes. Activityfocused at the top of the triangle doesnot lead to good health unless activity isalso focused at the bottom levels, andthe balance of activity needs to reflectthe characteristics of the local

community.Poor communities do not always

have the prerequisites for physicalsurvival, and health can only be

improved by concentrating onthat level. Nevertheless, even

in areas with widespreadpoverty, not everyone

suffers to the same extent.The most effective way

of responding tohealth challenges in a

community is toattempt to cover

all the levels ofthe hierarchy

at the sametime.

Fig. 3. The health triangle“Health is not an activity.It is not jogging, oreating well, or notsmoking, or living in agood environment, orbeing employed. Ratherit is the outcome ofthese and otheractivities as well.People are more, orless, healthy accordingto the resources whichthey have in theireveryday lives. Health isthe outcome of thesefactors combined in thelives of individuals andcommunities.”

Source: Working together forGlasgow’s health: Glasgowcity health plan (16)

Well-being

Preventionof illness

Physical survivalFood, shelter, warmth and safety

Mental survivalCommunity and self-esteem

Health awarenessKnowledge and understanding of

the factors affecting health

Health and social careResponsive and appropriate

health and social services

Healthy behaviourand lifestyles and

preventive medicine

Source: adapted from Laughlin & Black (17)

25

A new coalition for health insocietyThe complex interrelationshipsbetween the factors that affect healthand the inability of a purely medicalapproach to deal with them are beingincreasingly understood. The conceptof health for all was adopted by thethirtieth World Health Assembly atAlma-Ata in 1977.

This was to be achieved by workincorporating the principles of healthfor all (see page 23), which includestatements about equity and also that:

...health is created in the settingof everyday life and is influencedby actions and decisions of mostsectors.

The partnerships for the promotionof health that arose from the principlesof health for all are still importantnow.

The Ottawa Charter for HealthPromotion (12) further developed thisthinking, advocating that action topromote health means building healthypublic policy, creating supportiveenvironments, strengtheningcommunity action, developingpersonal skills and reorientinghealth services (box).


Ottawa Charter for Health Promotion

Build healthy public policy• Put health on the agenda of policy-makers in all sectors and at

all levels.

• Combine diverse but complementary approaches including

legislation, fiscal measures, taxation and organizational change.

It is coordinated action that leads to health, social and income

policies that foster greater equity.

• Joint action contributes to ensuring safer and healthier goods

and services, healthier public services and cleaner, more

enjoyable environments.

Create supportive environments• Societies are complex and interrelated. Health cannot be

separated from other goals. The overall guiding principle for the

world, nations, regions and communities alike is the need to

encourage reciprocal maintenance: to take care of each other,

our communities and our natural environment.

Strengthen community action

and develop personal skills• Support the empowerment of communities. This enhances

self-help and social support and allows for the development

of flexible systems for strengthening public participation and

direction of health matters.

• Enable people to learn throughout life.

Reorient health services• Health services need to embrace an expanded mandate which is

sensitive and respects cultural needs. This mandate should

support the needs of individuals and communities for a healthier

life and open channels between the health sector and broader

social, political, economic and physical environmental

components.


The principles of health for all wereused to develop a common Europeanstrategy for attaining health for all.The Member States of the EuropeanRegion adopted a health policy forEurope in 1984 that includes 38regional targets for health for all. Thishealth policy requires fundamentalchanges in approaches to healthdevelopment. It focuses on four areasof concern: lifestyles and health, riskfactors affecting health and theenvironment, reorienting the healthcare system and mobilizing political,managerial and technological supportto bring about these changes. Healthfor all had a good deal of successin developing countries, butimplementation was slow inEuropean countries.

Healthy citiesThe idea of the healthy city was raisedat the Beyond Health Care conferencein Toronto in 1984. This was based onthe notion that the city is the level ofgovernance closest to the populationand therefore can best influence thefactors affecting health.

Substantial interest in the idea wasgenerated over the next two years, andWHO supported a pilot project(originally limited to 1987 to 1992) for

European cities to develop models ofgood practice in promoting healthand positive health policy. The ideawas one whose time had come. Afterbeginning to work with 11 cities in apilot project, WHO found that it hadunleashed a movement. In the firstfive years 35 project cities wereparticipating in Europe. Nationalnetworks developed in 20 countries,and 12 groups of cities based onspecific topics or interests were set upas multi-city action plans.

The pilot project cities were notproject cities because they hadreached some particular level ofhealth. They were part of this workbecause they understood theprocesses necessary to make citieshealthier.

They have demonstrated this byaction in specific areas:

• making a political commitment towork for health in the city;

• giving visibility to health issues intheir city;

• making institutional changes tosupport intersectoral work andinvolve the community; and

• taking innovative steps to improvehealth and the environment.

The Healthy Citiesproject is one of WHO'smain vehicles for givingeffect to the strategy ofhealth for all. It hasforged political,professional andtechnical alliances forhealth and uncovered afertile ground for actionat local level.

Source: adapted from Tsouros (18)

27Understanding health

The first phase of the project between1987 and 1992 emphasized developingstructures and processes within citiesto allow collaborative work betweenorganizations, departments andcommunities. The cities taking parthave developed initiatives showinghow a range of groups cansuccessfully participate in developinghealth for all at the city level. Manycities developed a truly integratedapproach to incorporating health inthe local planning process for the firsttime.

In its second phase between 1993and 1998, the project is focusing onformulating and implementing citypolicies targeting health for all and ondeveloping comprehensive city healthplans with explicit targets addressingsuch issues as equity and sustainabledevelopment. About 60 project citieshave been designated, and more than550 cities are part of nationalnetworks in Europe.

The Healthy Cities project is usefulfor tackling the complex problemsthat shape health in cities. The citieshave developed new models ofcollaborative working withinorganizations and betweenorganizations and communities.

Health for all principles related to city health planning

Equity in health means that all people have the right

and the opportunity to realize their full potential.

Health promotion: A city health plan should aim to promote

health using the principles outlined in the Ottawa Charter for

Health Promotion.

Intersectoral action: Health is created in the setting of

everyday life and is influenced by the actions and decisions of

most sectors.

Community participation: Informed, motivated and actively

participating communities are key partners in setting

priorities and making and implementing decisions.

Supportive environments: A city health plan should address

the creation of supportive physical and social environments.

This includes issues of ecology and sustainability as well as

such aspects as social networks, transport, housing and

other environmental concerns.

Accountability: Health is created through the interaction of

all aspects of the environment and living conditions with the

individual. Decisions of politicians, senior executives and

managers in all sectors affect the conditions that influence

health. Responsibility for decisions that affect health creating

conditions should be made explicit in a clear and

understandable manner in a form that can be measured and

assessed after time.

The right to peace: Peace is a fundamental prerequisite for

health, and the attainment of peace is a justifiable aim for

those who are seeking to achieve the maximum state of

health for their community and citizens.

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


The players in healthycity projects are:

Local authoritiesHealth authoritiesAcademic institutionsCommunity groupsTenants’ groupsBusinessesPoliticiansHealth issue groupsEnvironmental action groupsElderly groupsTransport groups

• 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

that address health for all priorities.

• 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

implement the European Tobacco Action Plan and the European Alcohol

Action Plan.

• All project cities should establish mechanisms for public participation and

strengthen health advocacy at city level by stimulating the visibility of and

debate on public health issues and by working with the media.

• All project cities should carry out population health surveys and impact

analyses and, in particular, assess and address the needs of the most

vulnerable and disadvantaged social groups.

Main requirements for participation in the second phase

of the WHO Healthy Cities project

Source: adapted from Tsouros (18)

The Healthy Cities project requirescities to have to a project office, staffand budget. These organizationalfoundations allow project staff to build

and develop the range of projects andcollaborative exercises that enable thedevelopment of truly collaborativecity-wide health promotion.

29Sustainable development and health

1 V # ~ @ t TSustainable

development and health

Concern about the effect ofunrestrained economicdevelopment on the

environment has been growing overthe last decade. In recent years anumber of factors have led toacceptance of the need to devisestrategies to move towards sustainableeconomic, environmental and socialdevelopment.

It is argued (20) that the movetowards the notion of sustainabledevelopment arises from a meta-crisisfacing the world. This meta-crisiscomprises a set of three core crises ofdevelopment, environment andsecurity.

The crises of development focus onthe inability of the affluent countriesto facilitate meaningful developmentin the poor countries. Since theSecond World War, the proportionof people in the world who aredesperately poor has remainedconstant at about one fifth. Sincethe 1980s, the terms of trade havedeteriorated for developing countries,intensifying poverty among thesecountries. The impact of financialrestructuring following growing debtsby developing countries has causedthese governments to cut back socialprogrammes, further depriving thepoor.


tackling a web of disparate interests.Regardless of how this is attempted,either gradual incremental change ormajor structural change, a paradigmshift is required for the globaleconomic, political and social systems.

Defining sustainabledevelopmentSustainable development as it is nowunderstood can be traced from Ourcommon future (21). This report of theWorld Commission on Environmentand Development (the Bruntlandreport) examined the relationshipsbetween economic development andenvironmental sustainability, definingsustainable development as“...development that meets the needs ofthe present without compromising theability of future generations to meettheir own needs”.

The Commission was concernedabout poor people and the hugeimbalance in resources between theindustrialized and developing countriesand therefore believed that economicdevelopment is required to meet theneeds of poor people. However, thisdevelopment should not be achieved atthe expense of the planetary ecosystem.

Our common future focused oneconomics and environment and did

The root of the environmental crisesis the limited capacity of the planet tosupport humanity. This has twoaspects.

The seemingly inexorable rise inworld population of about 100 millionper year is increasing consumption ofthe Earth’s resources, including thefinite stock of mineral resources andfarming land. Resource consumption isunequal: 20% of the populationconsume 80% of the resources, mainlyin countries located in the NorthernHemisphere.

In addition, resources are beingdegraded. Air, water and soil are beingpolluted, including acid rain, ozonedepletion, pollution of water stocks,desertification and poor city air quality,and biodiversity is declining.

Since the end of the Second WorldWar, a whole range of wars havecontinued to destroy people,environments, livelihoods and even thehope of sustainable development. Hugesums of money have been directedaway from investment in positivedevelopment towards armies and evermore powerful weaponry.

These three crises are not separate,but interwoven and mutuallysupportive. Moving towardssustainable development means

31

not explicitly refer to health or to socialsustainability. Sustainable developmenthas since grown to include the idea ofsustainable societies. Later definitionsembrace a broader notion ofsustainable development. For example,Rees (22) defines sustainabledevelopment as:

...positive socioeconomic changewhich does not undermine theecological and social systems uponwhich communities and societiesare dependent. Its successfulimplementation requires integratedpolicy, planning and social learningprocesses; its political viabilitydepends on the full support of thepeople it affects through theirgovernments, their social institutionsand their private activities.

The Canadian Public HealthAssociation produced a more concisedefinition in 1991 (23):

Human development and achievinghuman potential require economicactivity that is socially andenvironmentally sustainable in thisand future generations.

By including the concept of social

sustainability, these definitions movefrom reducing the environmentaleffects of economic development as aninherent objective to working towardshuman development being served byenvironmentally supportive andequitable economic development.

Developing a framework foraction: Agenda 21The United Nations Conference onEnvironment and Development in1992 (the Earth Summit in Rio deJaneirio) moved the debate onsustainable development further.The major outcomes were the RioDeclaration on Environment andDevelopment, a statement on theprinciples of forest management andAgenda 21.

More than 178 governments adoptedthese declarations at the Conference.Following the Conference, the UnitedNations Commission on SustainableDevelopment was formed to overseeprogress in implementing Agenda 21.

Agenda 21, the United Nationsprogramme of action for sustainabledevelopment, explicitly addresses therelationships between social andeconomic development, the need toconserve and manage resources, thestrengthening of the roles of major



institutions, law and information fordecision-making.

Underpinning all this is a set ofpractices and processes that Agenda21 (1) states are essential forachieving sustainable development:

• reducing the use of energy andraw materials and the productionof pollution and waste;

• protecting fragile ecosystems; and• the sharing of wealth,

opportunities and responsibilitymore equitably between Northand South, between countries andbetween social groups withincountries.

Agenda 21 (1) argues thatsustainable development can only bereached through a process that isdemocratic, cooperative andplanned. Sustainable developmentwill not be achieved by accident, butmust be planned and worked forconsciously at all levels, frominternational to local. All people,including poor and disadvantagedgroups, must have a say in decisionsabout the environment anddevelopment. All social groups andinterests, including business,education and voluntary and

social groups and how these are to beachieved. Agenda 21 has a concern forhuman health and wellbeing at the coreof all its work.

The Agenda 21 process in cities andlocalities has developed rapidly in itsfirst five years. Agenda 21 has fourmain areas: social and economicdevelopment, resource management,strengthening the participation ofmajor groups and means ofimplementation.

Social and economic developmentcovers such challenges as internationalcooperation, poverty, sustainableconsumption, population, health,settlements and integratingenvironment and development.

Resource management includesatmosphere, land resource planning,deforestation, fragile ecosystems, ruraldevelopment, biodiversity,biotechnologies, oceans, fresh waterand waste management.

Strengthening the participation ofmajor groups includes such previouslymarginalized groups as women,children, indigenous peoples andnongovernmental organizations.

Means of implementation includefinance, institutions, technologytransfer, sciences, education,capacity-building, international

33

community groups as well asgovernments at all levels need to workin partnership.

The International Council for LocalEnvironmental Initiatives coverssustainable development planningcomprehensively (24) and gives asuccinct picture of the challengingprocesses underway at the local level(Fig. 4). The Council points out thatthe imperatives of economic,community and ecologicaldevelopment oftencontradict and that local(and global) sustainabledevelopment is the processof bringing the threedevelopment processes intobalance. Implementing astrategy for sustainabledevelopment requiresnegotiation among thestakeholders anddeveloping an agreed plan.This type of multi-agencywork is often new to someorganizational participantsbut is central to the work.

The growing awarenessof and willingness to act onthe challenges ofenvironmental, social andeconomic sustainability

should not obscure the real difficultyfacing the process of achieving suchoutcomes.

The transition to sustainabledevelopment depends on the abilityof governments, intergovernmentalorganizations, transnational capitaland nongovernmental organizationsto manage the transition arising fromthe development of new sets ofwinners and losers in the globaleconomy.

Fig. 4. The sustainable development challenge

Source: International Council for Local Environmental Initiatives (24)


Sustainabledevelopment

Communitydevelopment

ConservatismCommunityeconomicdevelopment

Deep ecologyor Utopianism

Ecologicaldevelopment

Economicdevelopment


Pearce (25) attempts to map thepossibilities for this transition: “Anyshift towards sustainability willinevitably be slow, taking generations,not years. Full sustainable developmentinvolves a cultural shift, not justeconomic and political tinkering.”

The early periods of transition arethe most difficult, when vision is dimand resistance is strong. The transition

to sustainable development needs tobe planned, managed andadministered, but it needs a sense ofpurpose, a vision, a goal towardswhich societies can strive. Pearce (25)charts various stages of the movetowards sustainability and what thiswould mean in terms of policy,economy, society and discourse(Table 1).

Discourse

Corporatistdiscussiongroups;consultationexercises

Round tables;stakeholdergroups;parliamentarysurveillance

Communityinvolvement;twinning ofinitiatives in thedeveloping andthe developedworld

Dim awarenessand littlemediacoverage

Wider publiceducation forfuture vision

Curriculumintegration;local initiativesas part ofcommunitygrowth

Minortinkering witheconomicadjustment

Substantialrestructuringof micro-economicincentives

Full economicvaluation;green accountsat businessand nationallevel; greentaxes offset

Lip service topolicyintegration

Formal policyintegrationanddeliverabletargets

Binding policyintegrationand stronginternationalagreements

Table 1. Stages in the move to sustainability

Source: Pearce (25)

Stage 1Ultra-weaksustainability

Stage 2Weaksustainability

Stage 3Strongsustainability

Policy Society Economy

The transitionto sustainabledevelopment needsto be planned,managed andadministered, but itneeds a sense ofpurpose, a vision, agoal towards whichsocieties can strive.

35

Implementing Agenda 21 atthe local levelAgenda 21 sees local authoritiesas being a main partner inimplementation. Their fullparticipation is crucial to the successof Agenda 21. Local authorities areinvolved in many key components ofsustainable development in cities andcommunities (1).

Action for local Agenda 21Local authorities are called upon toactively participate in the Agenda 21process in their area by collaborativelydeveloping a local version. It is hopedthat this will build strategies in localareas that have the principles of Agenda21 as their foundation (1):

By 1996, most local authorities in eachcountry should have undertaken aconsultative process with theirpopulation and achieved a consensuson a “Local Agenda 21” for thecommunity.

Local Agenda 21 in Europe

The local Agenda 21 process hassubstantial support throughoutEurope. In 1994 in Aalborg, Denmark,80 cities signed the Charter ofEuropean Cities and Towns towards

Sustainability (the AalborgCharter)(26).

The Aalborg conference providedthe starting point for the EuropeanSustainable Cities & Towns Campaign,which is supported by the InternationalCouncil for Local EnvironmentalInitiatives, the WHO Healthy CitiesNetwork, Eurocities (EuropeanAssociation of Metropolitan Cities),United Towns Organization and theCouncil of European Municipalitiesand Regions.

The signatories to the AalborgCharter reaffirmed their commitmentmade at the United Nations Conferenceon Environment and Development inRio de Janeiro to have developed a localAgenda 21 plan by the end of 1996. TheAalborg Declaration (26) reaffirmedthe role of sustainable localcommunities in helping the world tomove towards overall sustainability andlaid down 14 prerequisites forEuropean cities and towns:

• the role of European cities and townsin achieving sustainability;

• the notion and principles ofsustainability;

• local strategies towardssustainability;

• sustainability as a creative, local,



balance-seeking process;• resolving problems by negotiating

outwards;• urban economy towards

sustainability;• social equity for urban sustainability;• sustainable land-use patterns;• sustainable urban mobility patterns;• responsibility for the global climate;• preventing ecosystems from being

poisoned;• local self-governance as a

precondition;• citizens as key actors and the

involvement of the community; and• instruments and tools for urban

management towards sustainability.

The initial two-year phase of theEuropean Sustainable Cities & TownsCampaign was primarily devoted todisseminating information about localsustainability by promoting theAalborg Charter, urging additionallocal authorities to sign the Charterand to join the Campaign andproviding guidance on the localAgenda 21 process.

Local Agenda 21: the second phase

The next phase was launched at theSecond European Conference on

Sustainable Cities & Towns in Lisbonin October 1996. This phase focuseson implementing the principles setout in the Aalborg Charter, startingand undertaking the local Agenda 21process and implementing the localsustainability plan. By engaging in thiswork, European local authorities willcontribute to implementing not onlyAgenda 21 but also the HabitatAgenda from the Second UnitedNations Conference on HumanSettlements.

The participants in the LisbonConference endorsed the LisbonAction Plan (see box) (27). It wasbased on local experiences as reportedand discussed at the 26 workshops atthe Conference and takes intoconsideration the principles andrecommendations laid down in anumber of documents: the AalborgCharter (26), a guide from the UnitedKingdom Local Authority Associationand Local Government InternationalBureau (28), the Sustainable citiesreport from the EuropeanCommission’s Expert Group on theUrban Environment (29) and theLocal Agenda 21 planning guide fromthe International Council for LocalEnvironmental Initiatives (24).

37

• We believe that the adoption of the

Charter of European Cities & Towns

towards Sustainability (Aalborg Charter)

is one of the best starting points for a

Local Agenda 21 process.

• We believe that the local authority

should be the main facilitator of the Local

Agenda 21 process.

• We believe that the Local Agenda 21

process requires the involvement of the

entire local authority – whether city, town

or rural community.

• We shall enter into consultation and

partnerships with the various sectors of

our community to create synergy through

cooperation.

• We shall seek to get our own house in

order by implementing the principle of

negotiating outward.

• We shall carry out systematic action

planning to move from analysis to action.

• We shall integrate environmental with

social and economic development to

improve health and quality of life for

our citizens.

• We shall use advanced tools for

sustainability management.

• We shall establish programmes to raise

awareness among our citizens, interest

groups, as well as politicians and local

government officers of sustainable

development issues.

• We shall gain strength through inter-

authority alliances: associations,

networks and campaigns.

• We shall build North-South and West-

East alliances for sustainable

development.

• We shall go ahead in concert with the

European Sustainable Cities & Towns

Campaign.

Headings from The Lisbon Action Plan: from Charter to action

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



Environmental factorsand healthThe links between environmentalfactors and health outcomes have beenrecognized and acted on since the earlydays of the public health movement.All European cities have examples ofregulation for clean water and controlof housing and industrial hazardsdating from the early 1900s. This isnow commonly described asenvironmental health regulation andis enforced by environmental healthdepartments.

The range of environmentalproblems has grown both in scale andin type over the years. Environmentalhealth problems caused by economicactivity have not only local but nationaland international effects. Examplesinclude water supplies polluted bynitrates and pesticides from farming;acid rain caused by industry and powerstations; and foods contaminated withpesticides used in agriculture.

There is also a further range of newproblems that early public healthpioneers could not have imagined, suchas the role of transport policy and itseffect on health. Transport has localeffects on individual health (such asaccidents, the barrier effect and lack ofencouragement of health-promoting

activities such as cycling and walking)and wider effects on air quality, andusing and manufacturing automobilesaffects the global environment.

The destruction of the globalecosystem has received much nationaland international concern. Table 2shows some of the possible effects ofthese changes on health.

Cities in industrialized countries aremajor consumers of nonrenewableresources. The cities of Europe arecollectively responsible for a largeproportion of the emissionscontributing to global climate change:together with the cities in otherindustrialized countries, they provide80% of carbon dioxide emissions, forexample.

Many European cities are becomingthe site of large-scale environmental,economic and social challenges. Povertyand growing inequality are increasinghand in hand with problems ofpollution, decaying infrastructure, poorair and water quality, loss of greenspace and reduction in housingstandards. These factors arecompounded in some countries by theblind promotion of economicdevelopment at the expense of largegroups of marginalized people.The relationships in cities between

39

Table 2. Possible adverse effects on health due to possible global environmental change

Enhancedgreenhouse effect

Stratosphericozone depletion

Acid aerosols(from combustionof sulfurous fossilfuels)

Land degradation,over-intensiveagriculture andexcessive grazing

Depletion of plantsand animals, loss ofbiodiversity

Other effects ofoverpopulation,particularly in poorcountries

Heat wave–related deathand illness

Natural disasters:cyclones, floods,landslides, fires

Increased risk offlash floods andsurges

Sunburn, photo-kerat-conjunctivitis,suppression ofimmune system,increased risk ofinfection, cancer

Possible effects onrespiratory system

Decline inagriculturalproductivity

Lack of well waterfor drinking andhygiene

Deforestation,disruption of localculture and health

Infectiousdiseases,malnutrition,antisocialbehaviour

Global warming andclimatic change

Sea level rise

Increased ultravioletB radiation flux atEarth’s surface

Acid rain (and otherprecipitation)

Erosion, sterility,nutrient loss, salinity,chemicalization,desertification

Depletion ofundergroundaquifers

Destruction ofhabitat

Loss of geneticdiversity (speciesand strains),weakening ofecosystems

Proliferation ofcrowded urban slumsand shanty towns(due to migration andhigh fertility)

Inundation, socialdislocation, sanitationbreakdown, farm loss

Skin cancer, oculareffects; cataracts,pterygium

Rural depression,migration to shantytowns (see also finalentry)

Decline in agriculturalproductivity

Shortage of ediblespecies

Effects of breakdown ofsocial organization

Altered distribution ofvector-borne infectiousdiseases

Food shortages due toaltered agriculturalproductivity

Consequences of damageto foreshore facilities,roads etc.

Killing of aquatic life,reduced food, impairedcrop growth

Exposure to higher levelsof pesticides and fertilizersmay also lead to toxicalgal bloom in waterways

Loss of medicinalchemicals and otherhealth-supportingmaterials

Reduced viability ofedible fish in warmedoceans

Destruction of wetlands,decline in fish stocks

Impaired growth of foodcrops and marinemicroorganisms (base ofaquatic food web)

Impairment of forestgrowth, reduced ecosystemproductivity

Consequences of siltingup of dams and rivers

Deforestation,enhancement ofgreenhouse effect

Greater vulnerability ofplants and livestock,decline in vitality ofecosystem

Various consequences ofoverload of localecosystem

Environmental Manifestat ion Type (direct, indirect) and t iming (ear ly, late) of adverse effects damage

Source: adapted from Tansey & Worsley (30)


Indirect lateIndirect earlyDirect early Direct late


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

▼

▼

▼▼

▼

▼

▼

Cities Urbanlife

Globalenvironmental

crises

Globalsustainability

Healthyenvironment

Quality of lifeSustainable

development

of Europe partly

responsible for

hold the key to

safeguards

andimproves

promotes

a

Healthyhuman society▼

precondition for

will reverse

to creating

a

▼

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

social wellbeing and health,economic development, the qualityof the community environment andthe health of the global ecosystemhave been in focus during the pastdecade. There is movement towardsa new model of the interrelationshipsbetween all the activities taking

place in cities.The report on European sustainable

cities (29) tried to conceptualize all thechallenges pictorially (Fig. 5): therelationship between cities, sustainabledevelopment, global environmentalcrises and the outcome of a healthysociety in a healthy environment.

41

Health outcomesat all levelsHuman health can be identified withinthe sustainable development agenda aspart of the global ecosystem, as a focusfor development, as an outcome ofinitiatives to promote environmentalsustainability and as a sector thataffects the environment and othersectors.

Human health as part of the global

ecosystem

Human health is sustained by theglobal ecosystem. Unsustainabledevelopment and consequent damageto the ecosystem directly and negativelyaffect human health throughout theworld. The cities of the industrializedworld are responsible for a largeproportion of global environmentaldisruption and damage.

Health as a focus for development

The first principle of the RioDeclaration on Environment andDevelopment is that human health isthe centre of concern for sustainabledevelopment. Improving healththerefore goes hand in hand withsustainable development. Improvinghealth can be necessary to improveother aspects of life.

Health as an outcome of initiatives

to promote environmental

sustainability

Most initiatives taken principally forenvironmental reasons improve humanhealth, although this may not always beexplicit. Examples include feweraccidents and improved physical fitnesscaused by transport policies that shiftemphasis from cars to public transport,cycling and walking.

Impact of the health care sector on

the environment and other sectors

The health care sector employs manypeople and is a substantial user ofnatural resources. It therefore has a keyrole in ensuring environmental andother benefits by managing its activitiesbetter. An example is reducing energyuse in hospitals. The health care sectoralso has a role in other aspects ofAgenda 21, including attention tohuman rights and the role of women.

Specific recommendations in

Agenda 21

Agenda 21 has many specificrecommendations about health. Somerefer to well defined health challenges,but the most significantrecommendations deal with health inthe context of overall development.

Most initiativestaken principally forenvironmental reasonsimprove human health,although this may notalways be explicit.



Key recommendations relate to thedevelopment of municipal healthplans, the use of health profiles and thestrengthening of city networks forhealth.

Principles and methods

Agenda 21 recognizes that many of thechallenges it covers, including health,need to be elaborated further. Thehealth for all strategy and the role ofWHO in this are mentioned explicitly.The main principles of Agenda 21 andof the WHO strategy for health for allare essentially the same, especiallywhen they are applied to the mainstrategies for implementing actionplans at the local level (see Table 3,page 41).

New ways of thinking about human

development

Trevor Hancock (31) describes a newconceptual model of humandevelopment. This model (Fig. 6) hasthree main areas: community,environment and economy. Theoutcome of the interrelationship ofthese areas can be conceptualized ashealth or, more broadly, as humandevelopment.

The model suggests that good healthand sustainable human development

will only be achieved if the relationshipsbetween the areas are equitable,sustainable and livable. Communityconviviality, environmental viabilityand economic adequacy need to bebalanced. Community conviviality isrelated to the web of social relations,civic community and social solidarity.Environmental viability refers to thequality of the local ecosystem, includingair, water, soil and the food chain.Economic adequacy means having alevel of economic activity that can meetbasic needs.

In this model a healthy communityhas an integrated approach todeveloping all its components and triesto be equitable, livable, sustainable andcohesive, to achieve high environmentalstandards and to be adequatelyprosperous.

This model of integrated action hasunderpinned some of the work withinthe Canadian Healthy CommunityProjects and in some Canadianprovinces as well as in some of theEuropean Healthy Cities projects.

Attempts like this to find conceptualmodels and styles of working thatadequately incorporate socialsustainability are part of the structureof Agenda 21 and WHO’s Healthy Citiesproject.

43

Adequateeconomy

Convivialcommunity

Viableenvironment

SustainableEquita

ble

Liva

ble

Health andsustainable

humandevelopment

Fig. 6. Conceptual model and planning tool The model indicates thatin order to ensure socialcohesion and a civiccommunity, the benefitsof economic activity mustbe distributed in a waythat is sociallyequitable... In addition tobeing socially equitable,economic activity mustbe indefinitelyecologically sustainable;the community must notso deplete naturalresources or so pollutethe environment... as toirreparably harm futuregenerations or distantpopulations. Finally, thecommunity requires alivable built environment;this refers to the qualityand nature of the builtenvironment, includinghousing, roads..., urbaninfrastructure...and landuse.

Source: adapted from Hancock(31)



Health for all and Agenda 21The concerns of Agenda 21 and theEuropean health for all movement arevery similar. Both are concerned aboutthe health of people within aframework that tries to makedevelopment equitable and sustainable.They also have a similar focus on citiesand the growth of urban areas. Theprinciples underpinning themovements are almost identical.

Both Agenda 21 and health for all:

• are visionary approaches to globalproblems;

• suggest new paradigms;• address ecological, economic and

human health challenges; and• are concerned for human wellbeing

now and in the future.

The methods they suggest for changeare similar:

• both advocate a planned approach;• both advocate change in the way

organizations work, moving themtowards a more open and

collaborative style;• both stress the need to support

community capacity; and• both suggest intersectoral

approaches.

The programmes also have differences.Health for all:

• has existed longer;• has developed experience in

collaborative community andorganizational work;

• has developed community-basedwork that is more than justconsultation; and

• has accumulated experience of newways of developing policy andstrategy.

Agenda 21:

• is more explicitly inclusive in itsphilosophy;

• has a much broader organizationalbase; and

• appears to have more support fromgovernment.

45

Table 3. Comparison of principles and processes for planning for health and

sustainable urban development from health for all and Agenda 21

Principles Health for all Agenda 21Equity yes yesSustainability implicit yesHealth promotion yes (health)Intersectoral action yes yesCommunity involvement yes yesSupportive environments yes yesInternational action yes yes

Processes Health for all Agenda 21Consider existing planning frameworks yes yesAnalysis of health, environment and social conditions yes yesPublic consultation on priorities yes yesStructures for intersectoral involvement yes implicitVision yes yesLong-term action plan with targets yes yesMonitoring and evaluation yes yes


“...Health anddevelopment areintimately connected.Lack of developmentadversely affects thehealth of many people,but development candamage theenvironment in waysthat also reducehealth.”

Source: United Nations[Agenda 21] (1)


Both environmental and socialsustainability issues are receivingsubstantial attention at the global level,but practical examples of collaborativework at the local level are more difficultto find. In many areas markedlydifferent organizations fundenvironmental projects and healthand wellbeing projects. This makesthe development of joint workbetween them difficult.

Fig. 7. Mapping local action towards a sustainable society

Sustainablesociety

Socialwellbeing

Environmentalintegrity

Economicvitality

Recycling projects

Community-ownedservices such aschild care cooperatives

Stress reduction projects

Eco-friendlyhousing projects

Local welfarebenefits campaigns

Local legislationand serviceprovision

As yet there are fewexamples of localprojects and servicesmapping their activitiesagainst a frameworkfor sustainabledevelopment (Fig. 7).

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

What Agenda 21 and health for alloffer through local Agenda 21 and theHealthy Cities movement are newopportunities for local workers andcommunities to draw together withservice providers to explore new waysof working. Some of this innovativedevelopment is already happeningwithin the movements for communityhealth, community transport orsustainable communities.

47

1 V # ~ @ t T

A local Agenda 21 plan is acomprehensive plan for an area.It should be the key overall

development plan for that community,and wide involvement andparticipation are required to preparesuch a plan. These plans need todevelop environmental, economic andsocial sustainability and therefore havea range of objectives.

The Aalborg Charter (26) brokedown the process of developing localAgenda 21 plans into a number ofareas:

• recognition of the existing planningand financial frameworks as well asother plans and programmes;

• the systematic identification, bymeans of extensive publicconsultation, of problems andtheir causes;

• the prioritization of tasks toaddress identified problems;

• the creation of a vision for asustainable community througha participatory process involvingall sectors of the community;

• the consideration and assessmentof alternative strategic options;

• the establishment of a long termlocal action plan towardssustainability which includesmeasurable targets;

• the programming of theimplementation of the plan


Agenda 21 states that:“Each Local Authority

should enter into adialogue with its citizens,local organizations andprivate enterprises andadopt a local Agenda 21.”

Source: United Nations [Agenda 21] (1)

“Local Authorities...should be encouragedto... (a) develop andimplement municipal andlocal health plans, (b)survey, where necessarythe existing health, socialand environmentalconditions in cities,including documentationof intra-urbandifferences.”

Source: United Nations [Agenda 21] (1)



PartnershipsEstablish an organizational structure forplanning by service providers and users

Establish a shared community vision

Community-based issue analysisIdentify the issues that must be addressed

to achieve the community vision. Dodetailed assessments of priority problems

and issues

Action planningAgree on action goals, set targets and

triggers and create strategies andcommitments to achieve these targets.

Formalize into action plan

Implementation and monitoringCreate partnership structures for

implementation and internal managementstructures for municipal compliance.

Monitor activities and changes in services

Evaluation and feedbackDo periodic performance evaluations usingtarget-based indicators. Provide results toservice providers and users. Repeat issueanalysis and/or action planning processes

at specific trigger thresholds.Celebrate and reward achievements

TargetsA measurablecommitment tobe achieved ina specific timeframe

TriggersA commitment totake a specifiedaction at a futuredate and/or inresponse tofuture conditions

▼

▼

▼

▼

▼

▼▼

▼

▼

▼

▼Fig. 8. The elements of sustainable development planning

Who are your partners inservice delivery? How willservice users participate inplanning?

What services do peoplewant?

What is the capacity ofexisting service systems? Canthese systems sustainablymeet service demand?

How do service systemsimpact upon other socialeconomic and environmentalsystems?

When and how cansustainable service systemsbe established?

How will actionplans be monitoredand evaluated?

When willfurtherplanning berequired?

How willpartners andusersparticipate inimplementationand evaluation?

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

49

including the preparation of atimetable and statement of allocationof responsibility among the partners;

• the establishment of systems andprocedures for monitoring andreporting on the implementation ofthe plan.

This has been further expanded by anumber of key agencies.TheInternational Council for LocalEnvironmental Initiatives (24) describessustainable development (local Agenda21) planning as integrating threeplanning traditions:

• strategic planning, which has beenused within the private sector toprovide long-term vision and goals;

• community-based planning, whichhas been used extensively withindevelopment to engage local residentsand service users in participatorydevelopment of local projects andprogrammes; and

• environmental planning, whichwas developed in the 1970s toensure that development projectstake environmental issues intoconsideration and that such projectstake measures to mitigate theenvironmental impact of theiractivities.

Methods and tools inlocal Agenda 21 planningThese approaches provide a wide rangeof planning methods and tools for usein the local Agenda 21 planningprocess. The common elements are:partnerships, community-based issueanalysis, action planning,implementation and monitoring andevaluation and feedback. Fig. 8 showsthe relationship of these elements inthe overall process.

The description of the local Agenda21 process developed by the UnitedKingdom Local GovernmentManagement Board also evokes similarthemes, defining local Agenda 21 as(32):

...a continuing process rather than asingle event. There is no standard“tick list” of things you must do forLocal Agenda 21. The process caninvolve a range of activities and toolsfrom which a local authority and itspartners can choose according to localpriorities and circumstances.

The United Kingdom LocalGovernment Management Boardidentifies six key features of the localAgenda 21 process in the UnitedKingdom divided into action in the



6

5

4

3

2

1

Action within the local authority

▼

▼Action in the wider community

Fig. 9. Steps in the local Agenda 21 process

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

Partnerships• Meetings,

workshops andconferences

• Working groups/advisory groups

• Roundtables• Environment city

model• Partnership

initiatives• Developing-world

partnerships andsupport

Awareness-raisingand education• Support for

environmentaleducation

• Awareness-raisingevents

• Visits and talks• Support for

voluntary groups• Publication of local

information• Press releases• Initiatives to

encouragebehaviour changeand practical action

Managing andimproving the localauthorities’ ownenvironmentalperformance• Corporate

commitments• Staff training and

awareness-raising• Environmental

management systems• Environmental

budgeting• Policy integration

across sectors

Integratingsustainabledevelopment aimsinto the localauthorities policies

and activities• Green housekeeping• Land-use planning• Transport policies and

programmes• Economic development• Tendering and

purchaser-providersplits

• Housing services• Tourism and visitor

strategies• Health strategies• Welfare, equal

opportunities andpoverty strategies

• Explicitlyenvironmentalstrategies

Consulting andinvolving thegeneral public• Public consultation

processes• Fora• Focus groups• “Planning for real”• Parish maps• Feedback

mechanisms

Measuring,monitoring andreporting onprogress towardssustainability• Environmental

monitoring• Local state of the

environment reports• Sustainability

indicators• Targets• Environmental

impact assessment• Strategic

environmentalassessment

51

local authority and in the widercommunity.

The two features related to the localauthority are:

• managing and improving the localauthorities own environmentalperformance; and

• integrating sustainable developmentaims into the local authoritiespolicies and activities.

The four features of the process in thewider community are:

• awareness-raising and education;• consulting and involving the general

public;• partnerships; and• measuring, monitoring and

reporting on progress towardssustainability.

Fig. 9 describes these features morethoroughly, teasing out the aspects ofdeveloping environmental, economic,health and social strategies that have tobe integrated into the planning processfor sustainable development.Intersectoral and community-basedwork through awareness-raising,consultation and partnerships is alsoneeded, as is concern for monitoring

and evaluation.In Fig. 10, health strategies are

featured in the development of localpolicies and are also part of theintegration of policy across sectors.Health impact assessment and localhealth profiles need to be part of theevaluation planned in consideringspecific action to promote sustainabledevelopment.

The Lisbon Action Plan (27) statesthat “We shall carry out systematicaction planning to move from analysisto action.” and that “We shall integrateenvironmental with social andeconomic development to improve thehealth and quality of life for ourcitizens.”.

The Lisbon Action Plan also clearlyindicates the key values underpinningthe local Agenda 21 planning process:

• the local authority should be the keyfacilitator and show leadership butnot domination;

• the process should involve the entirelocal authority, politicians, electedofficials and all departments andlevels of responsibility;

• consultation and partnership withthe various sectors of the communityare needed to make the action planrobust enough that it has a chance of

The players in localAgenda 21 projects are:planning departments,environmental healthdepartments,local authorities,health authorities,academic institutions,community groups,tenants’ groups,environmental actiongroups andtransport groups.



being implemented;• the community should not export its

problems;• planning should be systematic and

participatory in its move fromanalysis to action;

• planning should be integrated acrossenvironmental, social and economicsectors to improve health and qualityof life for all citizens; and

• planning should use a wide range ofmethods and tools forenvironmental, economic, social andhealth management.

Shape of a local Agenda 21 documentA 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 theseobjectives – and how performance and achievementswill be assessed; and

• set out a review process for the whole programme

The role of health in the localAgenda 21 processThe approaches to local Agenda 21planning require a commitment topartnerships and intersectoral working.Communities and organizations needto be involved actively in creatinga local Agenda 21. Health is afundamental dimension of Agenda21 and has a high profile withincommunities and organizations. Theactive inclusion of specific work onhealth and the consideration ofimpacts on health and the outcomes of

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

53

development is both part of Agenda 21and ensures wide communityparticipation in the development oflocal Agenda 21 plans.

Local Agenda 21 plans are generaldocuments: broad frameworks forchange. Detailed action on any onearea of the local Agenda 21 planrequires specific plans for that area.Agenda 21 advocates that municipaland city health plans and associatedhealth profiles be established. Theseplans need to address the challengesaffecting health and also support theobjectives of Agenda 21.

In developing the health aspect ofAgenda 21 work, local authorities canbenefit from the experience of citiesand projects working on the health for


all agenda. Many of these cities haveexperience in carrying out local healthprofiles at the city and communitylevels. They also have experience inorganizing and carrying out cityhealth plans together with experiencein developing processes forcommunity participation andintersectoral action, which are bothkey factors within local Agenda 21work.

The work developed by HealthyCities projects shows some of the bestmodels for how the health componentof local Agenda 21 should be pursued.The next section outlines theprocesses, context and steps developedwithin Healthy Cities projects to carryout city health plans.


This section describes thedevelopment of city healthplans for cities that wish to

promote a health agenda systematicallyin conjunction with local Agenda 21. Itis based on the experience of healthycity projects.

Formulating a city health plan is animportant process for a city becausethe plan:

• places the challenges related tohealth and the quality of life on theagenda of policy-makers within localgovernment, health authorities andother organizations;

• links health gains to environmentalissues;

1 V # ~ @ t T

City health planning• rationalizes scarce resources,

including people’s time and energy;• establishes a basis for monitoring the

progress of initiatives and evaluatingsuccess;

• develops a basis for budgeting for thedevelopment of appropriate servicesand programmes for health;

• demonstrates the commitment ofcity organizations to greatercommunity participation in localdecision-making; and

• can improve the experience of livingin cities, neighbouring areas andcommunities over time.

Effective planning is complex anddemanding. Crucially, it involves

55City health planning

The end product is a document thatcity organizations and communities areinvolved in producing and for whichwide consultation has beenimplemented. A city health plan:

• describes the current health status ofthe city population in all its diversity;

• outlines the key factors that promoteand limit the health of thepopulation;

• describes the aspects of health thatneed to be improved and goals thatneed to be reached;

• determines the key priorities;• details an overall framework for

change;• explains the operational plans for an

agreed time scale;• provides examples of good practice;

and• presents a process for monitoring

and evaluating achievements.

Benefits

The cities that have developed cityhealth plans have found that the taskhas facilitated creating a vision for ahealthy and sustainable communityand identifying the strategies needed tobring it about. It has helped to movehealth planning beyond the realm ofhealth care services or environmental

developing a climate with the politicalwill for planning for health, whichmeans that the strategies mustaccommodate the unique politicalcontext of cities and their organizations.

This can be time-consuming anddifficult, as there are no quick technicalfixes. It may also involve new ways ofworking for bureaucracies andcommunities. Some challenges may becommon to all countries and othersspecific to each country.

This section highlights:

• the nature and value of city healthplans;

• the likely challenges;• the processes and structures of

support that provide the foundationfor a city health plan and thereforemake it viable; and

• the steps needed to produce a cityhealth plan.

What is a city health plan?The WHO Healthy Cities project (19)describes a city health plan as:

...a key activity for theimplementation of Agenda 21[that needs] to be developed in thecontext of overall sustainableurban development.

A city health plan isa key tool for healthdevelopment. It is also animportant aspect of thegeneral development ofa city...[City health plans]link the health for allstrategy with a localanalysis of healthpriorities and set outthe commitments by localauthorities and otheragencies to improvehealth at the local level.City health plans are alsoa key activity for theimplementation ofAgenda 21 and need to bedeveloped in the contextof overall sustainableurban development.

Source: adapted fromCity health planning:the framework (19)


health departments, where it hastraditionally been located andinfluenced.

Cities also acknowledge that theprocess of preparing a city health plan:

• enables local government to examineits role in relation to the health ofthe public;

• aids communication betweenorganizations and promotespartnership;

• raises awareness of the factors thataffect health and the implications forpolicy and practice;

• provides the opportunity tocounteract inequalities in health;

• improves professional developmentand planning skills;

• facilitates closer links withcommunities and users of services;and

• creates the basis for services that aremore flexible and responsive toneeds.

Challenges

Introducing the change required tocreate and implement an effective cityhealth plan brings with it a series ofchallenges and threats of whichplanners must be aware. One of thesearises with people and organizations

who are comfortable working in wellestablished ways even if they know thatthis poses problems. This can lead toresistance to change. Another challengeresults if the social model of health andthe links between health and localAgenda 21 are not universally accepted,and as a result these are neglected.Yet another challenge is political ororganizational cultures that expectimmediate results, making it difficult toaccept the time scale involved inproducing a comprehensive plan,implementing it and identifyingmeasurable outcomes.

Finally, power is an issue. Power is acontroversial but undisputed part ofcity and organizational life, and it isnecessary to determine who has it,where it comes from and how it can beharnessed to plans for change. Power isthe potential or capacity of a person ora group to influence other people orgroups, and power can be usedpositively or negatively. It is thereforenecessary to be aware of the positiveand negative uses of power and theimpact that each can have (box).

The relationship of city health plans

to other city planning

Some cities have no overalldevelopment plan for the future that

City health plans arenot health care plansas such but they arepart of a process to

“develop a collaborativevision of a healthy andsustainable communityas well as offeringconcrete means toreach that vision”.

Source: Municipal publichealth planning: a resourceguide (33)

57

incorporates all aspects of city lifebecause of the complexity of functionsand services, the population needs theyhave to meet and political challenges. Inthis case, city health plans and otheraspects of local Agenda 21 planningshould acknowledge and react to otherplans and be integrated into them,informing the operations of individualagencies and organizations. Eachcommunity, centred around either ageographical area or an issue, also needsto develop its own plans, ideally inconjunction with the city health plan.

Cities that have a detailed master plancovering all sectors should give health ahigh profile in the policy and socialagenda of this plan. A detaileddescription of other actions aimed atimproving health and the environmentshould form separate but linkeddocuments comparable to a city healthplan.

Foundations of the process ofcity health planningTwo important processes are requiredto successfully produce and implementa city health plan:

• intersectoral collaboration; and• community participation and

development.

Sources of power in organizations

Position or authorityThis is the power that an individual or group holds by virtue of theirrole or position within the organization. Their position gives them thepower to do certain things, organize work, allocate resources andinstruct others. This type of power is determined by the rules,regulations and resources of the organization and limited by your jobtitle.

Control of resourcesControl over resources, such as money, personnel, materials ortechnology can be an important source of power, particularly if theseresources are scarce. You may have power if you are the only person inthe department who is permitted to access the information databasesor if you have control of people and how they are deployed.

Social networksThe ability to gather information and mobilize resources and supportgives power. This may be acquired through your networks or bybuilding on the influence and power that others have. Social powerdepends on the range of connections you have inside and outside yourorganization – a case of “it’s not what you know, but who you know”.

Expert powerYou have expert power if you have a reputation for giving good adviceor for managing things well. This type of power is especially valuedamong professional groups but can also be seen in workers whoseexperience, expertise or knowledge of the “system” gives theminfluence. An administration worker who knows the grant-makingprocedures of the European Union inside out will have considerableexpert power, as does the person who understands the temperamentalphotocopier.

Control of informationInformation and its communication flow is critical to organizations. Itshapes our knowledge of the world we work in and the issues we aretackling. People who can open or close channels of communication,analyse, filter, summarize or access accurate and reliable informationwill have considerable power to shape knowledge in their organization.

Personal powerPersonal power comes from qualities such as charm, intellect, self-confidence, self-esteem etc. People with these qualities are often said tohave charisma although it is debatable how much of this is innate andhow much of this is developed. For example, self-confidence is alsoassociated with gender, race, disability, class and other factors wheresocial barriers and oppression can affect opportunities to develop self-esteem.

Source: adapted from Action for women’s health: making changesthrough organizations (34)



Intersectoral collaboration

There are many stakeholders in cityhealth plans, such as politicians,municipal organizations, voluntaryorganizations and communities. Allhave their own discrete focus on thefactors affecting health and their ownset of skills. City health planningdemands a new vision of health incities that recognizes a social model ofhealth and involves all stakeholders.There is often little collaboration, andeven when organizations have startedto develop mechanisms for partnershipthe local population does not recognizethis.

Twenty-first-centuryproblems

In exploring public beliefs abouthealth, the Province of Ontario(Canada) found that many residentspictured the government structures thatprovide them with services thus (35):

...In many cases governments havebecome a collection of verticalsolitudes with walls, narrow mandatesand incentives to pass the buck. It hascreated a multiplicity of programmes atthe community level that rarely workin a collaborative fashion.

Hancock (31) describes this asnineteenth-century governance: the

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

Nineteenth-century structures

Source: adapted from Hancock (31)

▼▼

▼▼

▼▼

Public Parks Traffic Public Planning Environmentalworks health health

Healthy city

Sustainability

Equity

Mobility

Energy

Food

59

early municipal departmentsoriginated from the development ofseparate strong disciplines. He pointsout that most of the problems faced inthe twenty-first century cut acrossthese neat boundaries (Fig. 10).Responding to these challengesrequires new structures that aredemocratic and collaborative.

In exploring new responses to thehealth problems found in cities, theWHO Healthy Cities project representsthe relationships between municipaldepartments, other bodies, thecommunity and the policyframework as pillars of health(16) (Fig. 11). Thishighlights the need forcities to extend ordevelop existingcollaboration, bothhorizontally within thecity and vertically withother levels ofgovernment and thewider community.

Intersectoralcollaboration oftendevelops naturallybetween grassrootsworkers in localities in

Community

City health plan

Hea

lth

an

dso

cial

sec

tor

National policies and legislation

Health for all/Agenda 21 strategy

Local policies and legislation

Bu

sin

ess

sect

or

Tran

spo

rt s

ecto

r

Eco

no

mic

sec

tor

Edu

cati

on

Ind

ust

ry

Envi

ron

men

t

Fig. 11. The pillars of health



which the benefits to the workers andcommunities are clear. Collaborationbetween departments within corporatestructures such as a city council orbetween corporate structures, however,can be problematic.


Mechanisms to support

intersectoral collaboration

An intersectoral steering committee is akey support for the intersectoral workwithin organizations of healthy cityprojects. Such a committee very clearlyindicates to the city organizations andcommunity groups that joint work isbeing taken seriously.

Commitment to intersectoralapproaches is also underpinned bydeveloping collaborative pilot projectsfor specific communities andorganizations. Examples includefunding of local projects in both Belfastand Horsens and the development of acity-wide policy on women’s health inGlasgow.

Healthy and Sustainable Preston

The Healthy and Sustainable PrestonSteering Group developed its work on asustainable society plan, examininghow it could achieve the strategicintegration necessary to achieve itsgoals. This was done by modelling howthe local council had restructured. Thecouncil restructuring brought togetherkey policy areas into singledepartments with a strategicmanagement core, thereby creatingsynergy within a flexible andcorporately led system.

The Healthy and Sustainable PrestonSteering Group recognized thatachieving successful externalnetworking and true intersectoralcollaboration requires adopting asimilar structure (Fig. 12) to minimizethe compartmentalizing effect oforganization boundaries, especially atthe strategic management core.

Many of the problems affectingcollaboration and integration forsustainability arise from the rigidboundaries that organizations andservice departments build aroundthemselves, and the Steering Groupsuggests two complementaryapproaches to tackle this.

Specific positive actions andexamples of good practice should bedeveloped. These are more likely tosucceed if community participation issupported and two or more policyareas are linked. Such examples couldinclude:

• fuel and energy efficiency;• access to green spaces;• affordable warmth;• reducing air pollution and preventing

respiratory illness; and• preventing crime and promoting

community safety.

Some of the influencesthat shape the level ofcollaborative workingwithin localgovernment corporatestructures are:

Management andorganizationalstructuresBlocks to new forms ofworking are often created bydepartmentalism andprotectionism. Success ismore likely wheremanagement systems areflexible and corporately led.

Political supportSuccessful integrationrequires a political lead withpositive member support andorganization.

Finance and resourceconsiderationThere will almost certainly bea lack of resources forcoordination or “new” forms ofwork. Competition with serviceactivity can often be a barrierto funding collaborative work.

Strategy competitionIn most local governmentsthere will be in place, ordeveloping, a range ofdifferent strategies, e.g., anti-poverty, communitydevelopment, economicdevelopment, housing, equalopportunity.

External factorsParadoxically, some of thespecial financing initiatives atEuropean and state/city levelsometimes force collaborationand partnership onto usuallycompeting departments andagencies.

Source: adapted from a personalcommunication from the Healthy and Sustainable Preston

Steering Group

61

Strategic departmentalintegration

Strategic apex

Management layers instand-alone departments

Middle line

Operating core

Fig. 12. Model for intersectoral collaboration

External networking

Strategicmanagement

core

Nationalorganizations

and fora

Europeanorganizations

andinitiatives

Communityorganizations

Localmunicipal

council

Localauthority

associations

Healthauthority

Environmentalhealth

Communitydevelopment Planning

Anti-poverty Economicdevelopment

Equalopportunities

Strategicmanagement

core

The Preston Steering Group suggeststhat the most successful actions embraceone or more of the following:

• involving the community to achieveparticipation and empowerment;

• developing structures to ensure localdelivery;

• pilot projects that can be mobilizedquickly and become “early winners”;

• small-scale, incremental but strategicdevelopment;

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



Step 1Determine the scope of the planning exercise anddefine goals and objectives. This should be doneby the initiating organization (such as themunicipality) in consultation with stakeholders. Itshould include preliminary educational campaigns togenerate public interest and support.

Step 2Create or designate a stakeholder group to coordinateand guide the overall planning effort and to integratethe results of discussions, research and planning intoan action plan or plans.

Step 3Establish distinct working group structures underthe supervision of the stakeholder group. Working

groups are given responsibility for each of theunique planning tasks. They may also beestablished to focus on distinct issues such ashousing, poverty etc.

Step 4Identify appropriate partners to participate inthe stakeholder group and its working groups.

Step 5Establish terms of reference for the activitiesof each group.

Step 6Develop a common community vision to guidethe entire planning process.

Six basic steps in the establishment of partnerships for planning

• targeting different strategies toaddress the concerns of differentcommunities; and

• practical examples of integrationthat politicians support and thathave wide appeal.

The second approach ensures thatthe city or local agencies are allworking towards a common agendaand have a common understanding ofthe need to develop integrated policies.The Preston Steering Group points outthat, in many places, sustainability is

seen only as an environmental conceptand that more work needs to be doneto ensure that the understandings fromthe United Nations Conference onEnvironment and Development informdevelopments in all policy areas,including environment, economy,community and health. The criticalfactor for integration is to leadpoliticians and decision makers withinauthorities to develop a clear vision forthe future that embraces the concept ofthe sustainable society.

Stakeholders in theplanning processdiffer for each city andcountry, but commoncategories could be:politicians, policydevelopers andplanners; public sectorservice providers;health, education,environment, transport,housing and welfareetc., voluntaryorganizations,interest groups andcommunity groups.Groups may need to beconvened to addressspecific elements of theplan as it develops.

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

63

Involvement of communities incity health planningThe development of wide rangingcommunity participation is a key factorfor the success of collaborativeapproaches to health planning inthe city. Representatives of citycommunities should be involved inthe process of developing, carryingout and evaluating a city health plan.Community participation in theplanning process has to be structuredclearly. It should be built into theframework for the plan rather thanbeing added as an afterthought.

Community participation

Community participation coversdifferent levels of activity andparticipation:

• communities merely legitimizingdecisions already taken;

• offering limited opportunities tocomment on plans that have alreadybeen established;

• enabling people to question andchange proposed ideas; and

• in-depth consultation with alloptions open.

These different levels of participationare considered in Table 4.

Community development

Healthy city and local Agenda 21initiatives need to shift the balanceaway from token involvement to fullpublic consultation and participation.

Achieving meaningful participationmeans changing organizations andsupporting the communities involved.Community development is animportant tool in realizing this,especially for disadvantagedcommunities, which have the poorestaccess to decision-making processes inthe city.

Community development has beendefined as a set of processes (36):

...directed in particular at people whofeel excluded from society. It consistsof a set of methods which canbroaden vision and capacity for socialchange, and approaches, includingconsultation advocacy andrelationships with local groups. It isa way of working which is informedby certain principles which seek toencourage communities – peoplewho live in the same area or who havesomething else in common – to tacklefor themselves the problems they faceand identify to be important, andwhich aim to empower them tochange things by developing their



Control Participant’s action Examples

High Has control Organization asks community toidentify the problem and make allkey decisions on goals and means.Willing to help community at eachstep to accomplish goals.

Has delegated authority Organization identifies and presents aproblem to the community. Defines limitsand asks community to make a series ofdecisions which can be embodied in a planwhich it will accept.

Plans jointly Organization presents tentative plansubject to change and open to changefrom those affected. Expects to changeplan at least slightly and perhaps moresubsequently.

Advises Organization presents a plan and invitesquestions. Prepared to change plan onlyif absolutely necessary.

Is consulted Organization tries to promote a plan.Seeks to develop support to facilitateacceptance or give sufficient sanctionto plan so that administrative compliancecan be expected.

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

Low None Community told nothing.

Table 4. Degree of participation, participant’s action and

illustrative modes for achieving it

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

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own skills, knowledge and experienceand also by working in partnershipwith other groups and with statutoryagencies. The way in which suchchange is achieved is crucial and soboth the task and the process [are]important.

Community development can be usedin different ways. One strand focuseson locality and advocates strengtheningcommunity networks, building self-help activities and developing localleadership. It brings in such ideasas enablement, support andempowerment. In this view,organizations such as local governmentand health authorities are essentiallybenign organizations that shouldrespond sympathetically and effectivelyto make resources available for localactivity and new local services and canbe challenged to do so. It does,however, leave intact the essentialfunctioning of the organization.

Community workers often feel morecomfortable with this view than do thecommunities they serve.

Another strand advocatescampaigning and struggling for socialchange against the policies andorganizations that create or supportdisadvantage.

Thus, people have differentapproaches to communitydevelopment work that have bothstrengths and weaknesses.

Community development and

health

There are many ways of responding tothe challenge of producing health, andmuch of that work has been basedwithin communities. Only a few of thechallenges relating to health can betotally solved from within thesecommunities.Community development in thecontext of health has received greatimpetus in recent years from thecommitment of health for all tocommunity participation andempowerment. As communitydevelopment and health have grown,the community and social servicesuse these methods increasingly, andthis way of working has graduallybeen adopted by mainstream healtheducation and promotion andcommunity nursing.

Healthy city projects are in agood position to define a strategicperspective for the work toinfluence the broader factors andcircumstances that influence localcommunities.

Principles for social action

The principles of theCentre for Social Actioneffectively summarize aset of values that shouldform the basis for workwith communities:

• All people have skills andunderstanding on whichthey can draw to tacklethe problems they face.Professionals should notattach labels to serviceusers.

• All people have rights,including the right to beheard, the right to defineissues facing them andthe right to take action ontheir own behalf.

• People acting collectivelycan be powerful. Peoplewho lack power andinfluence can gain itthrough working togetherin groups. Practice shouldreflect thisunderstanding.

• Individuals in difficultyare often confronted bycomplex issues rooted insocial policy, theenvironment and theeconomy. Responses tothis should reflect thisunderstanding.

• Action should strivethrough its work tochallenge inequality anddiscrimination in relationto race, gender, age,class, disability or anyother form of socialdifferentiation.

Source: adapted from Principlesand values (38)



This often involves:

• assessing community health needs;• developing a response that takes

account of all levels of actionnecessary to achieve a healthy city;

• developing policy;• promoting collaborative work

between communities and agenciesand organizations;

• supporting organizationaldevelopment to make communityinvolvement easier;

• influencing the purchasing decisionsof health and local authorities;

• influencing the decisions of localauthorities; and

• campaigning for national solutionsto problems affecting health.

Local Agenda 21 initiatives thereforeneed to engage with healthy cityprojects and health for all initiatives intheir cities so that they can utilize thisexpertise.

Communities and city health

planning

Representatives of communities in acity must be involved in the process ofdeveloping, producing and evaluatinga city health plan. This is easier toachieve if collaborative communitywork is already established.The healthy city projects that havecarried out city health planningexercises had spent a number of yearsdeveloping collaborative work withincommunities. This means thatrequests for community involvementin the process of developing a cityhealth plan are seen as a continuationof joint work and not as a tokenistexercise.

The Australian National LocalGovernment Environmental ResourceNetwork (NLGERN) has developed auseful process for forging partnershipbetween local government and thecommunity called CONSULTT. Theprocess is described in the box.

67

Clarifying the existing situation by: interviewing key players,

distributing a simple survey, reviewing literature and using this

information to prepare a discussion paper for circulation.

Opening up the issues to allcomers: by circulating the discussion

paper, attending community meetings, holding workshops for

special interest groups and presenting all ideas to a public forum.

Negotiating agreements on direction with the community

stakeholders before any commitments are made (credibility

vanishes if people believe they are only there to rubber stamp

other’s decisions).

Synthesizing contributions into a common strategy to achieve

the negotiated agreement.

Undertaking a test of the strategy in practice, either as a feasibility

study or as a trial run of the real thing, before the process is cast in

metal and citizens can no longer influence the process.

Learning from the practical implementation and reporting back to

the community and those whose task it will be to implement the

strategy.

Trenching the management solution in community and council

structures and then:

Taking it around again: repeating the whole process at stated

intervals, so that the system remains responsive and flexible.

En

The CONSULTT process

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



Steps in producing a cityhealth planIf the mechanisms for developing thefoundations for collaborative work andcommunity participation have beenestablished within a city, producing acity health plan requires progressionthrough a series of stages. Passagethrough these stages may not be linearbecause of prevailing conditions and

attitudes, and movement backwardsand forwards between them shouldbe expected. City health plans have adevelopmental, qualitative andvisionary perspective on the health ofa city and are not simple routes andmarkers, as demonstrated by therationale and definition for a cityhealth plan of the WHO Healthy Citiesproject (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 generaldevelopment of a city. The production of a city health plan sets out a city's vision of health and thesteps 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 allhealth 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 usualdecision-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 anda 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 planningas 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 cityhealth 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 andintegrated policies and strategies by which to achieve it.


69

The steps to a plan

A city health plan is much more thana fixed description or inventory ofproblems, resources and solutions. It isan opportunity to re-discover the factthat many people have a role to playin making cities healthier and moresustainable and that planning shouldbe a dynamic process involving manypartners.

The development of a city healthplan can be an educational process fororganizations and communities. It canlink together organizations andcommunities, developing largerprojects and collaborations from thesuccesses of smaller ones, and fromthese build confidence in the ability ofcollaborative work to provide usefulnew policy directions and models.

As the relationships in any city arecomplex, the process of the city healthplan must be decided pragmatically.Depending on the existingrelationships in a city, it may be betterto develop a comprehensive city-wideconsultation on health in the city anddevelop the plan from there. It may bemore appropriate to develop a plan forservice provision and a separatecommunity approach and fuse themlater (see the examples of Glasgow andBologna, pages 86 and 88). Either way,

several steps are essential (Fig. 13).

A vision

A vision involves raising awarenessand gaining commitment to thedevelopment of the plan and to thevision and the benefits expected topolitics, services and communities.


The management structure for theproject is clarified as well as thecomposition of the project team andthe roles and responsibilities of both.

Collecting data

Data are collected about health in thecity and the factors affecting it using acombination of approaches.

Determining priorities

The data collected are then analysed toagree on priorities.


The next step is to formulate goals,objectives, strategies and measurabletargets to address the prioritiesidentified in the previous step.

Drafting the city health plan

When the plan is drafted, it can then befed back into the process to make sure




Collecting data(internal analysis, community profile

and community consultation)

Determiningpriority issues

Developingstrategies

Drafting thecity health plan

Implementation,monitoring and

evaluation

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

Foundations for the successful development of the plan

A vision(awareness-raising and gaining commitment)

Innovators and developersbuild and support the early

stages of the process

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

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that it meets people’s needs andexpectations.

Progress is monitored, achievementsare reviewed and feedback is given inan ongoing process to ensure that thestrategies are implemented.

One of the problems of describingdevelopmental work by steps is the factthat work needs to be seen to have abeginning. The beginning can bedifficult to pin-point precisely. Thefoundation work described earlier(pages 54–63) includes how to supportorganizations in working together, thedevelopment of structures to allowcommunities to participate actively inmaking decisions and the developmentof a vision and support for new work.This foundation work has to bedeveloped and supported by a group.

New and innovative approaches toproblems in the city are usuallydeveloped locally in the interfacesbetween organizations andprofessions.

Concern about health in a city oftenbrings together like-minded people

across agencies and communities inhealth for all and healthy city projects.They then brainstorm for ideas andexamples of work that seem to addressproblems similar to those in their city.This group of innovators and enablerssupports much of the earlydevelopmental work. These groupsneed to include senior actors in cityservices, as they have access topoliticians and management and keyfigures from communityorganizations.

The foundation and early steps ofcity health planning work needsupport (Fig. 14). This is especiallyimportant in the early days of projectsand plans, when they are vulnerable topressure from service departments thatperceive threats to their territory orfrom communities that are trying toshape the project policy.

Guiding the development of thisarea of work is difficult, as theparticipants in the process vary.Communication with members ofhealthy city projects (contact the WHOHealthy Cities project for details ofprojects in your area) can indicate theproblems and successes of this work.

Healthy Cities project

WHO Regional Office

for Europe,

Scherfigsvej 8,

DK-2100

Copenhagen,

Denmark.

Tel. +45 39 17 17 17Fax +45 39 17 18 60E-mail

[email protected]


Implementation, monitoringand evaluation


A visionDeveloping political commitment

City health plans attempt to develop atype of major organizational changethat is generally difficult to achieve.Organizations and departments arecompetitive entities that like todominate their territory, to delineatetheir boundaries and to allow people inonly on their terms. The support oflocal politicians can circumvent some ofthese problems, as the politicians canoften mediate in internal rivalries.

Local political support andinvolvement have been crucial in settingup healthy city projects, as they providean entry gate into decision-making inthe city. Strong political commitment tothe development of intersectoral workon health is essential. This is also truefor work on sustainable development.

The management or steering groupsof healthy city projects operate at thehighest levels within the cityadministrative and political structures,and senior politicians usually participatein these groups. Membership of such agroup gives them access to senior peoplein other organizations such asuniversities, health authorities andregional authorities and also reinforcesthe fact that the issues being dealt withare serious and substantial.

If healthy city projects also supportand/or fund community-level work,this is beneficial. Local politicians cansee the work in progress and involvethemselves with a successful project,thereby gaining respect in their localarea.

One of the problems with this typeof work is the long lead time foroutcome. A strategy for informing localpoliticians of the time scale foroutcome is essential to prevent loss ofcommitment over time.

Partnerships for city health

planning

The work of the healthy city projects inall their different settings has beensuccessful because broad partnershipshave been formed at city level tosupport and develop their work.

The vision of working together for ahealthy city and holding a commonaim seems to provide a neutral playingfield for the work of organizations andcommunities. This also appears to betrue for the challenges related tosustainability. Nevertheless, developingsuch intersectoral groups is never easy,regardless of their level oforganizational support. When a projectbrings together core organizations atthe city level, very clear aims and

▼

Foundations

A vision


Collecting data

Setting priorities


Drafting the plan

Implementationand monitoring

73

objectives for the partnership arerequired.

The fact that the WHO HealthyCities project requires participatoryand collaborative project structureseases the problem of supporting thedevelopment of the vision for a cityhealth plan within the services andcommunity. A healthy city project teamusually carries out or coordinates thiswork.

Developing the vision

Explaining the vision, aims andbenefits of a city health plan withinorganizations requires a developmentgroup with access to seniormanagement. Members need to have asound background in the concepts,models and processes of health for alland a keen understanding of localorganizational dynamics.

The development of the city healthplan must have professional supportfrom the start. The team needs to haveexpertise in strategy and policydevelopment across city serviceprovision (health, environment,economics, education, etc.) and theability to organize awareness-raisingevents in both service and communitysettings. The composition and supportof this team can be crucial to success.

The following approaches can be usedin developing a vision for the cityhealth plan:

• consultation documents to becirculated to service organizationsand community groups;

• briefing seminars for management;• public seminars to explore new

visions for the city’s health;• community-based vision workshops

for both community members andservice providers;

• discussion of city health in localmass media;

• developmental workshops acrossservice agencies to explore thebenefits of collaborative work;

• seminars synthezising the ongoingwork in the city that alreadysupports this approach.

No city is a desert in this sense, andthere is an opportunity for creativelicence in putting together communityaction and new service development toshow what can be achieved. The aimsof this work are to raise awareness ofthe opportunities that could arise fromthe plan, to gain support from the cityservices and the community for theidea of a plan and to raise awareness ofthe potential benefits to the city.

“The vision is for afuture in whicheconomic prosperity,social justice andprotection of thenatural environmentare pursuedsimultaneously tosecure good healthand enhance well-being for all people,now and forgenerations to come.”

Source: Liverpool city healthplan (40)



Managing the projectManagement structure

As everyone living and working in thecity is responsible for creatingsustainable and healthy cities, themanagement of the city healthplanning process needs to reflect this.The management structure differs bycountry and city, but the managementmust reflect the values of participationand cooperation.

Preparing a city health plan requiresa steering group and a project team.

Steering group

The steering group needs to have clearterms of reference for the relationshipwith its funding partners and the otherstakeholders. The steering groupoversees the work of the project andprovides its links into and between theparticipating agencies and thecommunity. The organizations andgroups whose work affect public healthshould be represented. Members needto be in senior positions in theirorganizations to enable the project toobtain funding and support.

The members should represent thecommunity, services, politics andacademe and include experts inplanning, public health, strategydevelopment and health promotion.

The box on page 71 shows themembership of a typical project.

Time and effort has to be spent insupporting, educating and developingthis group. It is imperative that theyunderstand well the aims, processesand benefits of the plan. Thedevelopment of clear committee rulesis also important in such a diversegroup as this. Steering committeemembers from agencies have to havethe mandate to commit their agency totackling the challenges that arise as partof the planning process. One model isshown in Fig. 14.

Project team

A skilled organization is needed todevelop collaborative projects; this isnot a part-time task for an overworkedcivil servant. A team is required whosemembers understand the intricacies ofthe relationships between the partners,not just the organizational stakeholdersbut also community, academic andvoluntary stakeholders.

This is not a convenient place to putexcess staff waiting for retirement.Project coordinators and developmentworkers need to be intelligent andthink clearly, educated at least to degreelevel and have a practicalunderstanding of the social and

▼

Foundations

A vision


Collecting data

Setting priorities


Drafting the plan


75

political model of health andexperience with collaborative workwithin an organization. They need tobe allowed to develop work bothwithin and outside the fundingorganizations.

If the health plan team is basedwithin an organization, the team needsto be positioned within the strategydevelopment section or the chiefexecutive’s department. If the team isbased in the local authority, the teamneeds to form strong links with thepublic health function within the city.It should not be thought of as anextension of a health promotion orenvironmental health department. Thecity health plan team will have a set ofspecific tasks to develop and supportthe plan. These could include:

• serving the steering group;• taking responsibility for developing

the planning process and the plan;• organizing the development of the

range of consultations and visionworkshops;

• coordinating the consultationprocess within the organizationsand community;

• organizing a communication andpublic relations strategy for the planand carrying it out; and

• educating participants about theaims and goals of the plan.

Space and financing

A separate office space is required of astandard that reflects the importanceand the values of this work. The officeshould be easily accessible for membersof the public as well as staff from thepartner organizations.

Membership of the steering group

of a typical collaborative health project

• Chair of the health authority• Chair of the regional authority• Senior politicians from the regional

and local authorities• Director of public health• Academic professor of public health• Director of environmental health• Director of health promotion• Director of planning• Representatives of the local voluntary associations• Representatives of the local tenants’ associations• Representative of the community health councils• Representatives of the local health-based

nongovernmental organizations• Representatives of the healthy city working groups

(such as women, environment and poverty)• Representative of local community health projects• Representative of the strategic planning department

of the local authority



Localgovernmentdepartments

Healthauthority

Voluntary sectorand community

groups

AcademicsectorSteering

group

Administrativesupport

Planninggroup

Projectteam

Projectworkinggroups

Communitysupport

unit

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

Making andkeeping partners

If the process ofdeveloping interestand support has beenpositive, the city willhave a city health planproject with anintersectoral steeringgroup. Severaldevelopmental stagesin the formation arerequired to get this far.

1. The group has anagreed aim or vision.This is based onresearch into thehealth indicators andthe factors that affecthealth in the city.

2. The group hasagreed objectives andkey issues to be takenforward and hasstarted to draft plansto achieve them.

3. Membership criteriafor the steering groupare agreed.

4. The group hasagreed on the roles,responsibilities andreporting mechanismsof the partners in thesteering group.

77

The project has to have a reasonablelevel of funding that is protected forthe life of the project. It should haveaccess to short-term developmentmoney from statutory agencies andother sources, but the partners need tojointly fund the project and view it aspart of their core services. This isimportant in working with theagencies. The plan must be seen as acentral part of the process ofdeveloping strategy in the city. Thiscannot be achieved if the project isperceived to be short term withtransient staff.

The project team also has to be surethat they work collaboratively tooptimize development. One way ofdoing this is to make sure that theproject has enough money for salariesand seed projects (especiallycommunity ones) but not for largejoint projects. To fund these, theproject has to build intersectoralalliances, thereby reinforcing thephilosophy, values and utility of theproject’s work.

Time scale

The state of health of a city cannot bechanged overnight; there is no quick fixin this type of work, and a sensibletime scale and targets have to reflect

this. Helping to facilitate change inorganizations takes years and notmonths; making a healthy city takesdecades and not years.

This type of project must have timeand support to develop. Credibilityneeds to be built for collaborative workboth within the partner organizationsand at the grassroots level. A range ofsuccessful collaborative activities aroundhealth is required to gain credibility indeveloping a city health plan.

The state of health of acity cannot be changedovernight; there is noquick fix in this type ofwork, and a sensibletime scale and targetshave to reflect this.


Collecting dataDeveloping a plan for the health of acity requires being aware of the currentstate of health in the city. Thisnecessitates a city health profile, whichshould provide a broad picture ofhealth by examining all the factors thataffect health outcomes in the city.

In most cities the health authoritiesproduce a range of figures related tohealth. These are usually illness anddeath statistics that indicate the state ofhealth in the city. Producing a cityhealth profile requires this informationbut also the range of other routinelycollected data in the city to provide abroad overview of the state of health.

Data should be included on poverty;housing conditions; access to transportand food; provision of health and

▼Foundations

A vision


Collecting data

Setting priorities


Drafting the plan



social services; employment figures andeconomic statistics; and statisticstraditionally related to health. The datashould be presented according to class,gender and geographical area.

Examples of broad descriptions ofthe factors that affect health in citiescan be found in healthy city projects ascity health profiles for specific areas(41,42). The WHO Healthy CitiesProject Office has also produced aguidance document on health profiling(43).

Such collaborative productionshighlight the social, environmental andeconomic basis of health in cities. Theyare very useful overviews, but otherpictures of health in the city are neededto develop the city health plan.Community health profiles and needsassessment exercises provideinformation about people’s perceptionof the health issues in their local areas.

Community-based assessment of

health needs

In addition to the quantitative materialprovided by the large-scale data thatare collected routinely, a picture of howcommunities perceive their health andthe factors that affect it is required.This can be accessed by carrying outcommunity-based assessment of health

Sample data froma city healthprofile

Demographic data

Population density

Population change

Age groups

Gender

Ethnicity

Socioeconomic data

Education levels

Income distribution

Occupations

Benefit recipients

Employment

Health data

Mortality by cause

Morbidity by cause

Notifiable diseases

Mental health

Immunization rates

Accident figures

Health behaviour

Environmental data

Environmental

quality indicators

Environmental

monitoring

Risk assessment data

Pollution data

Service provision

Transport services

Health and social

services

Education and leisure

Community support

and networks

needs and health-profiling exercises.These give a rich picture of health andhealth needs in communities.

A wide range of methods are used,including local implementation ofvalidated health assessment forms (44)and the use by communities of focusgroups and rapid assessment methods.Examples of these types of work can befound throughout the Healthy Citiesand health for all networks.

Developing and supporting this typeof work demands skills that may needto be brought in to the project team.Attention needs to be paid to the scaleof this work.

• Is an assessment needed in allcommunities in your city?

• If not, who chooses therepresentative communities?

• Time scales have to reflect the needto develop support in thecommunity.

• Volunteers may need to be trained.• The community should have a voice

in the choice of methods, and thismay mean a period of education anddiscussion.

Community assessment is importantbecause it can encourage support forjoint work at a local level. The

79

assessment usually involves localworkers and communities with thesupport of academics or externalconsultants. Most community profilinguses residents as interviewers orenablers. This strengthens thecommitment of communities to theprocess and the outcome. The materialsproduced are good examples of thestrength of community developmentapproaches (45).

Producing reports

Just as how the research is carried out isimportant, the way such reports areproduced, disseminated and actedupon is also important. The knowledgeand experience of local communitieson the factors that promote or restricttheir ability to achieve good healthshould be respected. Communitiesshould understand how the results ofthe research will be used.

Reports should be designed andprinted to a reasonable standard. The

launching of the results of the researchas a publication, video, play or a comicbook should be used to generatefurther interest in the topic.

Once the data about the city andcommunities have been collected, theresults should be fed back to theagencies and communities that havebeen involved as part of the ongoingopenness in developing the plan.

The data collection provides thehealth plan steering group with a widerange of information about the city’shealth and the factors that shape it.Levels of disease and illness, poverty,the broader environment and serviceprovision and their interrelationshipshould be explored in the city healthprofile. Differences in health status andits relationship to socioeconomic statusand geographical and environmentalfactors should also be teased out; allof this should be grounded byinformation on citizens’ views aboutthe factors affecting their health.



Setting prioritiesThe city and community healthprofiling and needs assessmentproduce a wide range of information.This material needs to be collated andcategorized and then the prioritychallenges for the plan need to bedetermined.

Simplifying the data

Organizing the data into generalthemes can aid in setting priorities.This is best carried out by a groupcomprising the project team and somemembers of the steering group andcommunity researchers. This processcan take a while, so a day should be setaside for this.

The project team should produce anoverview of the data and draw up someprovisional categories to be discussedwith the group. Possible categoriescould be:

• the physical environment• the social and cultural environment• community safety• women’s health• children’s health• accidents• specific diseases (such as cancer)• health education.

The health issues and data should thenbe placed in these categories.

Setting priorities is very difficult asmany forces are always competing forincreased budgets and time. Acombination of techniques should beused to reach a list of priorities that canbe taken forward by the city and itsagencies.

Use of experts

Many data collected regularly by thecity agencies will be compared withnational and regional figures. Localitiesin the city may also be compared. Thismeans that differences between the cityand other areas can be highlighted andused to help in setting priorities.Service departments may already havestatutory responsibilities and fixednational priorities such as reducingdeaths from heart disease or improvingwater quality. Specialist help fromagencies and universities may be usedto discern trends in local data and toconduct comparative assessments ofdata, but this should not be the onlyapproach.

After the city health profile ispublished and the data are simplified, aseries of public consultations should beorganized for a number of reasons:

▼

Foundations

A vision


Collecting data

Setting priorities


Drafting the plan



• to allow public dialogue on thefindings of the profile and to validatethe findings from the communitysurveys;

• to allow the public to identify theirpriority issues; and

• to keep the public aware of theprocess of producing the city healthplan.

The consultations should take a varietyof forms, such as large public meetings,small local focus groups, meetings withcommunity leaders, meetings withdepartment heads and discussiongroups with staff teams and inter-agency groups.

When this process is completed, allthe stakeholders in the city healthplanning process should be consultedto formalize the priorities for the plan.This process has three stages. Smallgroup meetings are held with serviceproviders and communities separatelyto explore their priority issues. Thenthese findings are compiled for thesteering group so that the priorities forthe plan can be categorized and ranked.Finally, a public forum should feed thepriorities back and reach a consensuson them.

▼

Developing strategiesWhen the priority themes and issueshave been determined, they should beconverted into strategic targets the healthplan can address systematically.

The health plan has to addressproblems organizationally andsystemically with a long-termperspective. It has to work acrossorganizations and groups, actingsynergistically and integrating effortsby different stakeholders to achievecommon aims. This means that it hasto be linked to local formal planningprocesses and be consistent with them.

The broad intersectoral groupdeveloped for setting priorities should beinvolved in the continuing developmentof the plan. Representatives from theservice departments should not be theonly ones shaping the strategies.The wider the group developing thestrategies, the better the chance that newand innovative collaborative work willdevelop. In addition, this enhances thecommitment from the community andall the stakeholders.

This document describes the stages ofthe development of strategic plans usingaims, objectives, strategies, targets andprogrammes.

Foundations

A vision


Collecting data

Setting priorities


Drafting the plan



Aims

Aims are general statements about atheme that outline an outcome. Aimsshould be broad and compatible withthe vision and philosophy of theplanning process.

For example, one of the key themes todevelop from the priority-setting mayhave been food security. The aim for thehealth plan for this theme could be:

To ensure through services andprogrammes that people have bothphysical and economic access to thefood they need for a healthy life.

The priority issues for this themecould be:

• food and poverty• food safety

Guidelines for developing strategies

The following issues should be considered in order to develop effectivestrategies:

• The issue should be thoroughly understood. It may be that some extratime is needed to explore the context surrounding the issue such ascurrent policies, attitudes of key players and social factors.

• There should be a clear understanding of the characteristics of the targetgroups 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 avoidduplication) and those that have been previously successful.

• The strategies should be achievable but not at the expense of discardingchallenging strategies for the sake of easily achievable ones.

• Strategies should provide “early wins” (short-term achievements) so thatboth the local government and the community can see the efficacy of thetime spent in planning.

• Strategies may include formalizing an already existing process and givingit direction.

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


• nutritional awareness• access to shops• food quality• heart disease• obesity• community gardens• local food partnerships.

These priority issues would providethe platform from which to developthe objectives for the plan.

Objectives

Objectives are commitments toproduce a specific outcome by aspecific time. All the actions necessaryto produce the outcome are shown in astrategy in clear, manageable steps.Objectives need to be achievable for thestakeholders involved.

For example, one of the priorityareas under the theme of food securitywas local food partnerships. Anobjective for that area could be:

To nurture local food partnershipsthat influence where, when and atwhat price people can buy their food.

Objectives also need to be developedfor the other priority issues as well asstrategies by which the objectives willbe reached.

Strategies

Strategies are the plans for achievingthe objectives. The strategies are anopportunity to build on the strengthsof the intersectoral group managingthe plan. The proposals should notjust be rooted within the departmentalservices but should give options forthe development of new workingrelationships across local government,the voluntary sector and communitystakeholders.

A strategy framework

The five action areas of the OttawaCharter provide a useful frameworkfor conceptualizing overall strategy:

• building healthy public policy• creating supportive environments• strengthening community action• developing personal skills• reorienting health services.

Table 5 provides examples of possiblestrategies for realizing the objective ofnurturing local food partnerships thatcould be mapped onto this framework.

Targets

Strategies need to identify measurabletargets as part of their development.Setting targets is a difficult and complex


process; they need to:

• be achievable• be specific and measurable• have a timetable• have the support of the stakeholders.

A wide range of types of targets can be

Table 5. The Ottawa Charter for Health Promotion (12) as a frameworkfor strategy development using the example of food partnerships

Healthypublic policy

Supportiveenvironments

Communityaction

Personalskills

Reorientinghealth services

Develop a retailplanning policythat supportslocal-scaleshopping

Provide planningsupport forcommunitymarket gardens

Local purchasingpolicy for freshfruit andvegetables

Lobby retailsector to considerthe needs of thepoor

Municipal andhealth authoritiesmake availableland forcommunity marketgardens

Local food auditscarried out bymunicipality andcommunity

Agencies tosupport local foodforum

Food growing andcooking as part ofschool curriculum

Communitytransport schemes

Development oflocal bulk-buyand foodcooperativeschemes

Using wasteland asallotments andmarket gardens

Skill-sharingschemes, youthand elderlypeople workingtogether

Development oflocal economytrading schemes

“Get Cooking”trainingschemes

Good eats on alow-budgetcourses

Marketgardening,managementand marketingcourses throughcommunityeducation

Health centres tohave gardensand vegetableplots

Healthpromotiondepartments tofund fruit andvegetableinitiatives aimedat children anddisadvantagedcommunities

Hospitals tosupport localmarket gardensby purchasinglocally

specified to address health in a cityusing a social model. For example,targets can be:

• technical: for example, air quality,reducing sulfur dioxideconcentrations in the air by10% over the next 12 years;

85

Drafting the city health planThe next stage is drafting the plan.The plan is a document that is thevisible result of the long and complexwork of the project team andintersectoral steering group. The draftplan is the first result of this workmany people see, and high-qualitywriting and production are important.

The plan should be written andedited for a general nontechnicalaudience and should be presentedclearly with distinct sections. A cityhealth plan should be written in theactive voice: “we will do it” rather than“it will be done by this department”.Illustrations and diagrams improve theimpact of the plan. It should bedesigned by a graphic designer and notjust typed and should be tested on itspotential readership.

Content of a city health plan

The WHO Healthy Cities Project Office(19) suggests that a city health plancontain the following information:

• the political status of the plan;• the process of developing the plan;• the principles on which the plan is

based;• the findings of the health assessment

based on the health profile;


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• behavioural: reducing the percentageof 18-year-old girls who smoke by10% within 10 years; and

• process: increasing the level ofcollaborative work between the localauthority and the health authorityby 15% over the next 8 years.

Targets are important in ensuring thatthe aims and objectives of the plan areachieved and should be set for allstrategies. Hand in hand with thestrategies and targets go thedevelopment of programmes toallocate the tasks.

Programmes

Programmes are the work plans for thetargets. They are not usually includedin the actual health plan but areseparate publications from the agencyor team responsible for achieving thestrategic targets. The programmes needto outline:

• the parameters of the task;• the actions to be taken;• who will be implementing

the actions;• the resources that are necessary;• an appropriate time frame; and• criteria for monitoring and

evaluation.

Foundations

A vision


Collecting data

Setting priorities


Drafting the plan



• the background of andrelationships with previous policyand legislation;

• priorities chosen, and the reasons,methods and criteria used;

• the strategic aims, including targets;• the plans and action to be carried

out by each sector and level ofgovernment; and

• follow-up and the process formonitoring, evaluation and review.

The links between the health plan andother city plans should be shown.

Consultation and feedback

on the draft plan

Comments and amendments to adraft plan are an important part ofthe intersectoral and developmentalapproach to this work. A strategyfor distributing, reviewing andcommenting on the draft plan shouldtarget a number of sectors, including:

• members of the servicedepartments in all the city agencies(management and all levels of staffshould have the opportunity todiscuss and comment on the plan);

• local politicians as individuals andlocal political structures, such as the

committees on policy and resourcesand on joint planning;

• boards of other organizations, thehealth authority, local businessforums and large local employers;

• community health workers andpublic health departments;

• community groups and agencies;• local mass media, to generate public

interest and debate; and• the general public, including making

the plan easily accessible at publiclibraries and community centres.

Summary documents should beproduced in different forms andlanguages. The project team shouldalso develop and support a range oforganizational and community-basedfora and seminars from which tocollect feedback. The plan needs to gothrough a number of versions before itcan be presented to the statutoryagencies for adoption as policy.

Adoption by the agencies, partnersand stakeholders is not the end of theplanning process but the beginning ofthe next phase of planning for ahealthier city. The lessons learned fromthe process and from the monitoringand evaluation of the policy should befed into the next version of the plan.

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Implementation, monitoringand evaluationImplementation

A health plan is only as good as itsimplementation. The first step ingetting the plan implemented inmunicipal organizations is to get itaccepted as policy. This means thatan identified person or section inthe administration has to takeresponsibility for overallcoordination and monitoring.

The project team should developa framework that ensures thecoordination among the group ofofficers and workers who areresponsible for implementing andmonitoring all the programmesincluded in the city health plan.

The steering committee for the planshould then become the coordinatingbody for the health plan. This helps toensure that the stakeholders continueto own the plan and that the plan isnot hijacked by one agency or group.

The coordinating body shouldreceive regular reports from theperson or section that has overallresponsibility for the plan and fromthe group of programme coordinators.The coordinating body can thenensure progress for programmes.

Monitoring

Structures to record and report theaction taken to implement the healthplan are needed, and mechanisms toallow reporting within and betweenstakeholders should be developed.

A regular accounting system shouldbe set up for reporting performanceand progress. This could be builtaround the regular meetings of thecoordinating group and should also becollected and published as part of anannual review.

This review should be carried out bya subgroup of the coordinating bodyand should:

• assess progress towards the visionand aims of the plan;

• describe the state of local health inrelation to national figures;

• determine whether targets have beenmet and strategies implemented;

• discuss successes and failures; and• examine whether plan targets should

be reassessed.

The monitoring strategy shouldinclude the development of structuresfor regular feedback to and from thecommunity. This can take the form ofcommunity conferences, local focus


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Foundations

A vision


Collecting data

Setting priorities


Drafting the plan



An excellent actionplan provides noguarantee thatproblems will besolved, that needs willbe met, or that the lifeof a community willbecome moresustainable. Indeed,one of the majorhurdles that localgovernment mayencounter inestablishing a localAgenda 21 planningprocess is thescepticism its residentsand service users mayfeel towards moreplanning and moreplans.

Source: adapted from Thelocal Agenda 21 planningguide: an introduction tosustainable developmentplanning (24)

groups and input into communitygroups of many types. A similarstructure should be developed forservice departments and key figures inthe organizations, such as politiciansand managers.

Regular information-sharingreinforces interest and commitment tothe plan and its processes. As part ofthat, a public relations strategy needs tobe developed to support and notsupplant the more time-consuming butrewarding feedback and consultationstructures.

Evaluation

The progress towards achieving thestrategic targets should be evaluated atthe end of the designated time frame toassess the effectiveness of the plan. Thisis more comprehensive than regularmonitoring and comes at the end ofthe planning cycle. The indicators

chosen should be measurable, valid andeasy to collect and should show whetherthe action has had the expected result.

They should also be useful inexploring how well the planning andstrategic development process worked,the impact of the strategy within thecommunity and the agency in both theshort and longer term and the outcome:the change in the wellbeing of thecommunity.

Evaluation is necessary for a numberof reasons. The value of this approachto health development can be assessed.Evaluation can point to successes andfailures, allowing successes to bereplicated and failures to be modified.Evaluation also provides sources offunding and other resources withinformation that supports theircontinuing involvement and createsthe basis for further developmentand change.

89Examples of city health planning

This section provides examplesof city health planningprocesses. The steps and

processes described have been usedin developing city health planningaround Europe. They are intended as aguide to be adapted to suit the needsof each city. The examples have similarsets of steps but in slightly differingorders, reflecting the needs of theircities.

City health planning within healthycity projects has a flying start on themodel presented in this document, asthe foundations and early steps (a

1 V # ~ @ t T

Examples ofcity health planning

vision and managing the project)are usually assured by the city’scommitment to the principlesof health for all. Structures topromote collaboration andappropriate management aretherefore already in place. Thissection explores the experiences offour European healthy cityprojects that have carried out cityhealth planning exercises. Thedetailed descriptions of theprocesses can make it easier tounderstand the work involved andthe potential outcomes.


Glasgow: starting with aservice-based planThe city of Glasgow, Scotland(population 750 000) started thedevelopment of its city health planwith a model to be used as a plan forthe agencies in the city. This was to beused to gain more support forcollaborative work and to establish afirm foundation from which to developa community perspective on planningfor health in the city.

The process of developing the plan(Fig. 15) can be viewed as circular,beginning within and feeding back intothe most powerful decision-makingcommittees of the city.

The process started by obtainingcommitment from the most importantdecision-making fora in the city. High-level commitment to the idea wasnecessary to provide access to seniormanagement in the service agencies.

The planning team conducted aseries of meetings to develop anoverview of the work of the agencies.

The City of Glasgow alreadycollected an extensive range of healthand social statistics, and these were fedinto the process. The agencies

themselves provided overviews oftheir work and how it relates to abroad picture of health. A draft citydocument was produced over a yearbased on these and personalinterviews.

After extensive consultation theHealthy City Project steering group,the local authority and healthauthority approved the draft.

The draft was again circulated forupdating and comment by all theservice agencies.

This process of developing the planwithin the agencies took about threeyears from start to launch, but it wasonly possible because of the strongcollaborative structure and high-levelcommitment the project has worked toachieve and develop over its lifetime.

The launch of the document was notthe end of the process but thebeginning of the task of building widercommunity participation anddevelopment for the plan.

After the plan was adopted andlaunched, a strategy for monitoring,review and development was put inplace to monitor strategic targets andtake forward the collaborative work.

The process of developingthe plan within theagencies took about threeyears from start to launch,but it was only possiblebecause of the strongcollaborative structure andhigh-level commitment theproject has worked toachieve and develop overits lifetime.

91

Fig. 15. Glasgow’s process of

developing a service-based city

health plan

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Consultation between theproject team and the steeringgroup on the process fordeveloping a city health plan.

Heads of departments of allagencies in city, local authority,health authority and city councilidentify departmentalrepresentatives.

Introductory meeting with departmentalrepresentatives (half day). Outline philosophybehind the plan, discuss sociopolitical modelsof health, the state of health of the city andthe process of developing the plan.

From this meeting representatives takeon the task of drafting a report (A) abouthow health is perceived, supported anddeveloped by their service agency.

Second developmentmeeting (half day) exploreshow all city services affectpeople’s health.

From this meeting, representativesprovide a report (B) describing thereferences to health outcome inthe planning documents of theirorganization.

From the two meetings and reports(A and B), the city health plan teamproduces a draft document describingoverall city service provision and theirrelationships to health outcomes.

Third development meeting(half day). This meeting looksat the draft document andexplores opportunities forintersectoral work to improvehealth outcomes in the city.

Individual interview with eachdepartmental representative onstrengths, weaknesses, opportunitiesand threats for further healthwork in their department. This allowsthe health plan team the opportunity toget a real picture of how health work isviewed in the department.

City health plan team drafts a cityhealth plan from the reports, workingdocuments, interviews and dataabout the city.

Draft report presented to steering group fordiscussion and approval. This also remindssteering group members of their responsibilityto support and promote the draft plan in theirpolitical and service areas.

Draft plan circulated to allparticipating agencies forconsultation.

Comments and amendments.

Second set of interviews with departmentalrepresentatives to clarify departmentalplans on health and targets about healthoutcomes that will be part of the final plan.

Final draft plan produced,incorporating comments anddiscussion with representatives.

Final draft re-circulatedfor consultation.

Final plan produced andpresented to steering groupfor approval.

Plan presented to policy and resource committeesof local authority, health authority and city councilfor acceptance as policy for the organizations.

Public launch of city health plan.

Monitoring, evaluation and developmentof community consultation on this planand development of structure forintegrated service and community plan.

Supporting anddeveloping worktowards the nextversion of the plan.

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The process begins

The next planning cycle

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All meetings are managedand reported by the projectteam: all interviews arecarried out by the projectteam. Attention is paid tothe need for the projectteam to develop a goodoverview of city servicesand their work.


This document is presented tothe project steering group andthen circulated to all servicedepartments for informationand comment.


Bologna’s health andenvironmental planBologna joined the WHO HealthyCities project in 1994, building onwork taking place in the city since1991. This work had developed thecommunity capacity for health action,which led to the development of a self-protection health project and theopening of a health shop. This workinvolved the local community activelyin gathering and producinginformation on health.

This collaboration at the local levelis reflected in the activities anddevelopments at the municipal level.The Municipality of Bologna hassigned the Aalborg Charter, joined theEuropean Sustainable Cities & TownsCampaign and the WHO HealthyCities project and initiated a localAgenda 21 process in 1996.

The Environmental Department isresponsible for local Agenda 21,coordinating collaboration both withinthe municipal board and at the locallevel. The commitment towards localAgenda 21 and the Bologna HealthyCity Project are clearly shown in thepolitical plan for the city for the years1995 to 1999, in which the main goal isthe development of long-term actionplans towards sustainability.

The objectives for the healthy cityprocess include building strategic linkswith other sectors and organizationsthat substantially influence health andstrengthening national alliances andsupport systems. The goal is to achievea comprehensive city health profile andto plan to tackle such challenges asequity and sustainable development.

Because the principles and practiceof health for all and local Agenda 21overlap substantially, the Municipalityintends to integrate environmentalissues and health in developing acomprehensive municipal health andenvironmental plan. The local Agenda21 team and the Healthy City ProjectOffice are analysing the environmentalfactors in the city and preparing a cityhealth profile.

Environmental indicators

The Agenda 21 team has alreadydeveloped a set of 80 environmentalindicators divided into three categories:status, pressure and response (Fig. 16).The challenges identified are air andnoise pollution, water resources, use ofenergy, waste disposal, transport,industrial activities, urban waterplanning and misuse of resources. Thisset of indicators will constitute apermanent database that will be

93

Environmental indicators

Pressure

Energy consumption

Water consumption

Soil consumption

Waste disposal

....................

Status

Concentration of SO2,NO2 and O3

Concentration of heavymetals in waters

Contaminated areas

..........................

...........................

Response

Green spaces

Wastewater-treatmentcapacity

Waste disposal

Transport services

...........................

Sustainability index

updated regularly. From this, asustainability index based on 12indicators will be developed.

As the indicators were beingdeveloped, a series of public

consultations and seminars were heldin Bologna to develop a citizens’ forumfor local Agenda 21. This forum, whichhas representatives from environmentalgroups, trade unions, the Artisans’

Fig. 16. Bologna’s environmental indicators


Source: adapted from a personal communication from S. Fontanelli


Confederation, the Industrialists’Confederation, the professionalassociations, the Consumers’Association and other voluntarygroups, will be involved in all

significant stages of the preparation ofthe local Agenda 21 plan. The citizens’forum will be involved with the localAgenda 21 team in developing anddetermining the 12 environmental

Healthy City Project

1991 Start of the self-protection

health project

1993 Opening of the health shop

1994 Joined second phase of the

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

local Agenda 21 team

1997 City health plan

Local Agenda 21

Signed the Aalborg Charter

Start of the local Agenda 21 process

Analysis of the environmental situation

Bologna is appointed as the coordinating city

for the Italian members of the European

Sustainable Cities & Towns Campaign

Local Agenda 21

Health and environmental plan for Bologna

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

Source: adapted from a personal communication from S. Fontanelli

95

Aims of the healthshop

Identify and integratethe environmentaland social aspectsthat could affecthealth.

Reach out to thepopulation in thevarious areas of thetown in a new andmore direct way,encouraging healthierlifestyles andbehaviour.

Create healthnetworks as well asa database by meansof informationtechnology.

indicators for the sustainability index.The tasks and priorities for the actuallocal Agenda 21 plan will be discussedwith the citizens’ forum, and theirsuggestions and priorities will be takeninto account. The final document willrepresent a collaborative effortbetween the community and theagencies and will provide a good basefor working together in implementingthe plans.

A city health profile and social

equity indicators

Bologna’s Healthy City Projectcompleted the first city health profilein 1995 and is now working onselecting a set of indicators of socialequity. This is seen as an importantstep in developing coordination ofintersectoral action for health. Thedevelopment of a set of indicators willhelp in the future definition of anindex of social sustainablility andcapacity. This objective is still muchmore difficult to achieve for health and

social challenges than it has beenfor environmental challenges.The Healthy City Project team isdeveloping methods and initiatingdiscussions with the communityabout what challenges they perceiveto be the most important.

It is hoped that the health shop canbe used as an important tool infinding and integrating the social andenvironmental factors affecting healthin communities. A health network isbeing developed that will bedecentralized in the nine districts ofthe city, enabling these communitiesto be reached in a new and moredirect way. This network will have thehealth shop as a focal point.

The health and environmental plan

The health and environmental plan(Fig. 17) will be based on the findingsfrom the city health profile and theenvironmental reports and will serveas a guide for the priorities for actionto be developed.



Liverpool: developing acollaborative planThe City of Liverpool felt strongly thatdeveloping health plans should not beseen as a one-off exercise that will set inmotion all the work needed to solve acity’s health and environmentalproblems at once. Instead a health planshould be viewed as a process ofconsultation, data-gathering andanalysis, mobilizing the resourcesrequired to make key improvementsand open new channels ofcommunication between differentsectors and communities in the citythat can learn to work together on acontinuing basis.

In Liverpool, the consultation withthe service organizations and thecommunity has been tightlycoordinated with the planning process.The health plan is a five-year strategyto improve the quality of life andhealth in the city. The plan has long-term and short-term targets and aimsto get everyone moving in the samedirection to take action on theunderlying causes of ill health inLiverpool and to achieve the levels ofhealth described in the document onhealth strategy for England (46).

Liverpool became one of the firstcities to participate in the WHO

Healthy Cities project in 1988.During the first phase of funding, theLiverpool Healthy City Project wasdevoted to getting organized and toestablishing commitment among allagencies to the philosophy, strategy andprinciples of health for all. During thesecond phase of funding, the Projectbecame involved in developing its owncity health plan.

In 1993, new arrangements andstructures were put in place for publichealth in the city, thereby bringingpublic health within the mainstreamplanning processes of the keyauthorities (Fig. 18). The Healthy CityProject was revised with a brief to setup task groups on priority healthchallenges in the city. These task groupswere made accountable to a newlyformed Joint Public Health Team andto the Joint Consultative Committee.

The role of the task groups was todevelop strategic and operational planstowards the development of an overallcity health plan. Task group topic areasincluded the national health promotionpolicy key topic areas of cancer, hearthealth, sexual health and accidents. Afifth task group was set up on housingfor health to address the underpinningfactors of ill health such as poverty.Housing was considered to be an

The vision is for afuture in whicheconomic prosperity,social justice andprotection of thenatural environmentare pursuedsimultaneously tosecure good healthand enhance well-being for all people,now and forgenerations to come.

97

extremely good indicator of poverty.Members of the task groups included

representatives from the healthauthority, the Liverpool City Council,the voluntary sector, the TradesCouncil, the City Health PromotionDepartment, community healthcouncils, universities, the Chamber ofCommerce and the communities of thecity themselves. About 150 people wereinvolved in developing the city healthplan.

The draft city health plan waslaunched for consultation in January1995. The plan was produced in anumber of versions and used in anumber of settings with facilitators toensure accessibility for all groups. Avideo was also made to aid groupdiscussion. Responses were elicited byquestionnaires and letters.

The analysis of the consultationrevealed that people widely supportedthe plan. City residents understood thelinks between the underlying causes ofill health and the main causes ofpremature death and illness and agreedthat tackling these would have thegreatest impact on health. Theenvironment was ranked as the first ofthe top ten concerns expressed by localpeople. This included the environment– in general and specifically in relation

to air pollution and the desire for aclean, green city. This was followed bypoverty and unemployment, mentalhealth, housing, access to healthservices, education and training, youngpeople having more influence in thecity, diet and nutrition, accidents andtransport.

Comments from the consultationwere then included in the revised cityhealth plan, and the final version of theplan (40) was launched on 7 April 1996to coincide with World Health Day,which focused on healthy cities in 1996.

The city health plan reflects the needto address the wider socioeconomic,environmental, political anddiscriminatory determinants of illhealth. Action is being taken, forexample, to tackle the problem ofwidespread poverty in the city. Thisaction includes using new money suchas European Union Objective 1funding to target areas of the city withthe intention of creating new work.Existing resources are being redirectedtowards city regeneration andinvestment in the economy, and thecity is working towards balancedtargets for environmentalsustainability.

The plan is already influencingmainstream activity in the Liverpool

The plan was madeavailable in full draftformat, as a summaryguide, as translatedversions of thesummary guide inseven differentlanguages, on audio-tape in differentlanguages, in Braille, inlarge print, in articles innewspapers, indiscussions on radioand in free newsheetsto every home in thecity.



Taskgroups

Identify problemsand establishpriorities

Draft cityhealth plan

Consultation shapestargets and final plan

City health plan

New programmes andcollaboration to tackleproblems

Monitoring, evaluationand feedback

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Develop strategic andoperational plans

Fig. 18. The health

planning processCity Council and Liverpool HealthAuthority. Some action has alreadybeen incorporated, and consequentlythe city is working and thinkingdifferently. Gone are the old ways ofthinking only about the present, short-term crisis management, exclusive waysof working and centralization ofplanning.

The new ways of thinking and actingrevolve around long-termneighbourhood planning, partnershipsbetween agencies and local people,local action and cooperation, outputthat can be measured, concern forfuture generations and an increasedunderstanding of health challenges andthe impact on health of various policiesand actions.

The impact of the plan on health willbe measured. Indicators will bedeveloped for measuring progress overthe next five years of the plan, and areview of progress will be publishedannually.

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99

Intersectoral planning forhealth in BelfastBelfast started its process of developinga health plan (Fig. 19) with a very clearrationale and structure (47):

Since many different factorscontribute to health, responsibility forits production rests with a wide rangeof individuals and agencies, eachhaving a role to play individually andcollectively in the production of goodhealth in our city. Government has astrong role to play through itseconomic and social policies.Employers, large and small, have arole to play through their impact onthe environment, the products theysupply, the jobs they provide and theconditions under which theiremployees work. Planning for health in the citytherefore becomes the responsibilityof all relevant sectors within the city,which impact upon it, environmental,social, education, housing and healthcare sectors.

An aim and objectives for the cityhealth plan were developed from thisphilosophy.


Aim

The aim of the city health plan is tocreate a vision for the health of thepeople of the city across all sectors and todevelop integrated policies and strategiesby which to achieve it.

Objectives

The objectives of the plan are:

• to develop a city health profile,including qualitative and quantitativedata that will describe the health of thepeople of the city and the conditionsin which they live;

• to make visible the challenges relatingto health: for example, the currentplanned health activities and policiesof statutory sectors and the facilitationof new integrated approaches to andcoordination of all health and health-related activities within the city;

• to enable communities in the city toparticipate and influence decision-making processes about health and theprovision of health-related publicservices;

• to provide a rational basis fordecision-making, geared towardsinvesting in health and reducinginequalities in health; and


Development of a city health profiledescribing health status, socioeconomicstatistics, environmental statistics andcauses of poor health

Development of a draft city health plan

Statutory organizations:explore their contributionto health in the city andsummarize current policiesand plans that affect health

Voluntary organizations:produce a report on theirexisting services andtheir effects on health

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Development of monitoring and evaluation frameworks to be carried out

Time scale in months

start 1 2 3 4 5 6

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

Process measures, outcome and timescales are provided for each stage of the

• to develop a monitoring andevaluation framework that willindicate the progress of strategies foraction and measure the outcomes.

planning process. Overall and specificoutcomes for the plan are also outlined.The overall outcomes desired bythe city health plan are:

• a common direction towards healthin the city for all agencies; and

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Community involvement

A series of seminars onthe issues around healthin the cityleading to theproduction of aconsensusdocument thatinforms discussionwith statutory agencies

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over the lifetime of the plan and its strategies

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Production of city health plan andaction strategy

From a series of inter-agency andcommunity meetings, a city healthplan with action strategies andtimetables is produced.

This is then put into operationover the next five years.

8 9 10 11 12 13 14 15

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• improved coordination and synergyresulting from the process willenhance individual programmes.

The specific outcomes desired by the city health plan are:

• integrated policies evident in thefuture planning cycles of statutoryorganizations;

• increased coordination betweensectors on appropriate servicedelivery to meet community needs;



• evidence of change in the policy ofstatutory organizations that investin good health;

• action strategies with time scalesand indicators that will lead toimprovement in people’s quality oflife in such areas as environmentand health, poverty and health,social networks for health andappropriate services;

• community involvement in futureplanning and development of policyand service in local areas;

• strengthened communityparticipation in statutoryorganizations;

• ethnic minority communities beinginvolved in assessing needs anddeveloping action plans;

• an increased understanding of thewider dimensions of communityneeds and of the range of skills andresources within communities;

• new partnerships formed with thestatutory, voluntary, communityand private sectors at thecommunity, city, country andEuropean levels to sustain long-term action;

• the development of locality healthplans;

• community needs being evident,both in policy changes and strategiesfor action;

• the development of supportstructures for negotiation;

• increased satisfaction fromcommunities on delivery of services;

• evidence of collaboration betweengovernment departments thatsupports the long-term viability ofcommunities;

• evidence that socially excludedgroups are being involved inplanning policy and programmes;

• evidence that organizations aredeveloping and building sustainablepolicies and programmes inpartnership with communities; and

• evidence of capacity-building withincommunities.

Similar to all the city health plansdeveloped within healthy city projects,the fundamental work of gainingcommitment and having support andstaff to carry out this work is part ofthe project.

103References

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2. Health for all targets – the healthpolicy for Europe. Copenhagen,WHO Regional Office for Europe,1991 (European Health for AllSeries, No. 4).

3. Topfer, K. Our cities, our future. In:Price, C. & Tsouros, A., ed. Ourcities, our future: policies and actionplans for health and sustainabledevelopment. Copenhagen, WHOHealthy Cities Project Office, 1996,pp. 1–4 (document no. EUR/ICP/HCIT9401/MT04(A)).

4. Mega, V. The wellbeing of cities andcitizens in Europe. In: Price, C. &Tsouros, A., ed. Our cities, ourfuture: policies and action plans forhealth and sustainable development.Copenhagen, WHO Healthy CitiesProject Office, 1996, pp. 15–37(document no. EUR/ICP/HCIT9401/MT04(A)).

5. Mumford, L. What is a city?Architectural record, 82: 1937.

6. Davis, K. The urbanisation of thehuman population. In: Le Gates,R.T. & Stout, F., ed. The city reader.London, Routledge, 1997, pp. 1–11.

7. Newman, P. & Itzin, C., ed. Gender,culture and organisational change:putting theory into practice. London,Routledge, 1995, pp. 1–7.

8. Women in the city: housing, servicesand the urban environment. Paris,Organisation for Economic Co-operation and Development, 1995.

9. Sandercock, L. & Forsyth, A. Agender agenda: new directions inplanning theory. In: Le Gates, R.T.& Stout, F., ed. The city reader.London, Routledge, 1997, pp. 407–420.

10. Constitution of the World HealthOrganization. In: WHO basicdocuments. 40th ed. Geneva, WorldHealth Organization, 1994.

11. Whitehead, M. & Dahlgren, G.What can be done aboutinequalities in health? The lancet,338: 1059–1063 (1991).

12. Ottawa Charter for HealthPromotion. Health promotion, 1(4):iii-v (1986).

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27. The Lisbon Action Plan: fromCharter to action. Brussels,European Sustainable Cities &Towns Campaign, 1996.

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30. Tansey, G., & Worsley, T. The foodsystem. London, EarthscanPublications, 1995, pp. 14–15.

31. Hancock, T. Planning and creatinghealthy and sustainable cities: thechallenge for the 21st century. In:Price, C. & Tsouros, A., ed. Ourcities, our future: policies and actionplans for health and sustainabledevelopment. Copenhagen, WHOHealthy Cities Project Office, 1996,pp. 65-88 (document no. EUR/ICP/HCIT9401/MT04(A)).

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United Nations Centre for HumanSettlements. The Habitat agenda: draftstatement of principles andcommitments and global plan of action.Istanbul, UNCHS (Habitat II), 1996.

Furtherreading

Further reading


Environmental health in urbandevelopment: report of a WHO ExpertCommittee. Geneva, World HealthOrganization, 1991 (WHO TechnicalReport Series, No. 807).

Health challengesThe urban health crisis: strategies forhealth for all in the face of rapidurbanization. Geneva, World HealthOrganization, 1994.

Research Unit in Health andBehavioural Change, Changing thepublic health. London, Wiley, 1989.

City health plans and city healthplanning. Copenhagen, WHO HealthyCities Project, 1994.

Jacobson, B. et al. The nation’s health.London, King Edward’s Hospital Fundfor London, 1991.

Allen, P. Off the rocking horse: how localcouncils can promote your health andenvironment. London, Green Print/Merlin, 1992.

Draper, P. Health through public policy:the greening of public health. London,Green Print/Merlin, 1991.

Health for all starter pack. Liverpool,UK Health for All Network, 1993.

PovertyRobbins, D. Observatory on nationalpolicies to combat social exclusion.Brussels, European Commission(DG V), 1994.

Thake, S. & Staubach, R. Investing inpeople: rescuing communities from themargin. York, Joseph RowntreeFoundation, 1993.

Sinfield, A., ed. Poverty, inequality andjustice. Edinburgh, University ofEdinburgh, Department of SocialPolicy and Social Work, 1993 (SocialPolicy Series, No. 6).

Communities against poverty: resourcepack. Glasgow, Strathclyde PovertyAlliance, Strathclyde Regional Council,1994.

Poverty and healthWilkinson, R. G. Unhealthy societies.London, Routledge, 1996.

Benzeval, M. et al., ed. Tacklinginequalities in health: an agenda foraction. London, Kings Fund, 1995.

109

Laughlin, S. & Black, D. Poverty andhealth: tools for change. Birmingham,Public Health Trust, 1995.

Women’s healthHer share of misfortune – women,smoking and low income. Edinburgh,Action on Smoking and Health, 1993.

Graham, H. Hardship and health inwomen’s lives. London, Harvester/Wheatsheaf, 1993.

Doyal, L. What makes womensick: gender and the political economyof health. London, Macmillan,1996.

Women’s health towards a better world.Report of the first meeting of theglobal commission on women’s health,13–15 April 1994. Geneva, WorldHealth Organization, 1994 (WHO/DGH/94.4).

FoodFood and low income: a practical guidefor advisers and supporters working withfamilies and young people on lowincomes. London, National FoodAlliance, 1994.

Leather, S. Less money – less choice.Poverty and diet in the UK today. In:National Consumer Council, ed. Yourfood – whose choice? London, HMSO,1992.

RaceSmage, C. Health and ethnicity: acritical review. London, Kings FundInstitute/SHARE, 1995.

HousingBurridge, R. & Ormond, D., ed.Unhealthy housing: research, remediesand reform. London, E and FN Spon,1993.

Lawrence, R. Strategies for housing andsocial integration in cities. Paris,Organisation for Economic Co-operation and Development, 1996.

Bhatti, M. et al. Housing and theenvironment: a new agenda. London,Chartered Institute of Housing, 1994.

CollaborationWiner, M. & Ray, K., ed. Collaborationhandbook: creating, sustaining andenjoying the journey. Amherst, HWilder Foundation, 1992.

Further reading


Wilcox, D. Guide to effectiveparticipation. Brighton, PartnershipBooks, Delta Press.

Fieldgrass, J. Partnerships in healthpromotion: collaboration between thestatutory and voluntary sectors. London,HEA/NCVO, 1992.

Speller, V. & Funnell, R. Towardsevaluating healthy alliances. London,HEA/Wessex Institute of Public HealthMedicine, 1994.

Information on the InternetLocal Sustainability: the Europeangood practice information servicehttp://cities21.com/europractice

International Institute for SustainableDevelopmenthttp://iisd1.iisd.ca/contents.htm

Sustainable Cities Programmehttp://unep.unep.no/unon/unchs/

scp/scphome.htm

European Partners for theEnvironment Sourcebookhttp://www.epe.be/EPE/

sourcebook/SB_Contents.html

WHO Healthy Cities Genevahttp://www.who.ch/programmes/

WHOProgrammes.html

WHO Healthy Cities Copenhagenhttp://www.who.dk/tech/hcp/

index.htm

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“The prerequisites andprospects for healthcannot be ensured bythe health sector alone. ”

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