1.0 people residing in cities. Urban planning
Health policy is generally assumed to be a concern for healthcare professionals but healthcare is a fundamental aspect of national and local policies. It is evident that solutions for the obesity epidemic in most countries are found through changes in policies related to food, recreation, transport, and retailing but not in policies related to health. The interrelation between health and planning in non-contagious disease is multi-variate and includes social, environmental, and economic aspects of town planning. Over the last twenty years, the World Health Organization (WHO)’s Center for Urban Health, Healthy Cities, and Urban Governance Programme has been exploring the relationship between health and city planning in order to assist the planners design a safer and healthier city.
2.0 Planning of Cities: A Determinant of Health
The environment has long been accepted as a key determinant of health and the place also has an effect on health (Macintyre et al., 2002), which is an important requisite for both conceptualization and policy development (Lalonde, 1974; Marmot & Wilkinson, 1999). The WHO has developed the Healthy City Approach through which Health for All and Local Agenda 21 principles and objectives for sustainable development could be accomplished in the urban conditions. The Healthy Urban Planning (HUP) approach enhances the physical, mental, environmental, and social well-being of people living and working in cities, through improvements in urban planning. The principles of HUP can help develop a healthy economy, environment, and society. HUP also contemplates the WHO’s definition of health: “Health is a state of complete physical, mental, and social well-being, not simply the absence of illness and disease”. As health is a primary essence of sustainable development, HUP places health considerations at the centre of regeneration, economic, and urban developmental efforts. The HUP approach is akin to planning for sustainable development as it does consider the importance of finding a balance between social, economic, and environmental pressures. The HUP aims to improve the quality of both built and natural environment in addition to the quality of life of people residing in cities. Urban planning specifically helps provide the infrastructure as well as a design that facilitate optimum health, which is accomplished through redesigning of older towns and application of principles of HUP to new developments.
The WHO European Healthy Cities Network in the European Sustainable Cities & Towns Campaign that was launched in 1997 marked the commencement of the HUP initiative as an act to incorporate the agendas for health and sustainable development. The collaboration between urban planners, healthy cities practitioners, and academic advisers led to the publication of Healthy Urban Planning – a WHO guide to planning for people that puts forth twelve health objectives for planners, which were expressed as questions including—Do planning policies and proposals promote and encourage factors such as healthy exercise, housing quality, social cohesion, access to employment opportunities, accessibility to social and market facilities, community and road safety, equity and the reduction of poverty, local low-impact food production and distribution, good air quality and protection from excessive noise, good water and sanitation quality, conservation and decontamination of land, and climate stability.
As a next step, a City Action Group on HUP was established to connect urban planners and health practitioners from various WHO Healthy Cities to work out practical modes for implementation of the advocated principles. The two key areas focused were the incorporation of health principles and objectives into strategic policies/documents and development of specific projects that incorporate principles of HUP such as intersectoral action and community participation. HUP also became a central theme in Phase IV of the WHO Healthy Cities Network in Europe (2003-2008). The objective was to include health considerations into city urban planning processes and to establish the essential capacity as well as a political and institutional commitment to achieving this.
There is evidence that shows the profound effect of urban planning on the risks and challenges to the health of the population (Grant & Braubach, 2010). Throughout the world, the impact of the built environment on health is well evidenced and widely accepted (Galea & Vlahov, 2005; Rydin et al., 2012). In spite of this, outside communicable diseases and interventions including proper sanitation and access to water, and examination of interventions that make an effort to influence public health through urban planning and design are hard to be found.
Across Europe, expansion of the peripheral city areas shows a pattern of low density, use of segregated car-based development dependent on high levels of use of fossil fuel. This urban planning not only uses land dissolutely but decreases the viability of local services, and also renders walking impractical due to long distances and discourages cycling because of the ease of motorized transport. The reduction in regular exercises such as walking and cycling can result in increased risk of obesity, diabetes, and cardiovascular diseases. People who remain tied to their locality, for instance, elderly people, children, unemployed people, young parents, and handicapped immobile people are vulnerable. The absence of local facilities decreases pedestrian movement and also limits opportunities for the social contact that plays an important role in mental well-being.
3.0 Levels of Health Integration in Urban Planning
The three distinct levels of integration of health and planning provide a simple classification of HUP development. The first level is basic and it encompasses recognition of the essential life support role of settlements that includes the provision of shelter, access to food and clean drinking water, fresh air, and effective sewage treatment. In Western Europe, this primary level of planning is taken for granted and is almost subliminal. Elsewhere, this is not always the case. Sprawling, high-density towns often lack basic services.
The second level encompasses environmental health and the recognition of many facets of settlement planning and design that affect health and well-being—a park in densely populated cities enhances physical activity, contact with nature and fresh air, and also adds an aesthetic delight.
The third level involves the complete integration of health into the planning process. It is not only a matter of units of public health working in collaboration with planners but also involves the contribution of housing officials, greenspace managers, and regeneration and transport planners. If the long-term health of a population is thought to be a fundamental aspect of urban planning, then the methods of pursuing economic objectives without adopting unhealthy settlement form have to be found (Barton, 2009).
4.0 Healthy Urban Planning in Glasgow
The initial efforts of HUP in Glasgow were towards the health integration into strategic planning documents and as a result, the 2005 Glasgow & Clyde Valley (GCV) Structure Plan Alteration was put forth, which recognizes the importance of urban planning in the delivery of the health agenda in Scotland. There is a close-knit relation between a majority of areas with greatest health deprivation and the established planning policies made to improve employment, regeneration, and environment, which are also the key determinants of the health, well-being, and quality of life of a population. The 2005 GCV Structure Plan Alteration did identify some communities which had the greatest need as well as potential to create a healthier environment through recognizing the actions required in order to improve the physical and housing conditions in these areas.
The GCV Joint Committee in association with the local Health Boards developed a Common Health Action Programme which does complement both the Structure Plan as well as health policy documents through demonstration of the consistency of sustainable land use planning and health policy and by the provision of a general context for continuous collaboration and supervision of progress. It plans to achieve this through the establishment of an Integrated Programme and Key Actions to address challenges in the each of the areas such as sustainability, economic regeneration, social inclusion, and the environment.
Glasgow City Plan 2 does provide a detailed guidance regarding the shape, form, and direction of development in the City. For the first time ever, health and health improvements have appeared in the Plan and it is integrated all throughout the document and identifies where exactly planning can have an influence on the health and well-being of people. For instance, it includes links to housing, transport, green space, and access to jobs and services. The Strategic Environmental Assessment for this Plan also considers the implications of the City Plan on the health.
Further, sponsorship of training on Health Impact Assessment (HIA) as a tool for integration of health into spatial planning was done. As a result, HIA was commenced on the East End Local Development Strategy (EELDS), which was in a very initial draft stage. A 2-day participatory stakeholder event was held that included representatives from the health, planning, community planning, Scottish Enterprise, housing, and the local community members. Stakeholders were given the following
1. Baseline information regarding the health of residents in the local community
2. A list of social determinants of health relevant to the EELDS
3. Examples demonstrating how health was considered in other regeneration projects,
4. A presentation to educate participants about the EELDS and
5. A site visit to the location of concern. There were evidence-based suggestions in the report and more than hundred of these suggestions were adopted into the forthcoming drafts of the EELDS.
The HIA was effective in influencing the document and the process of conducting the HIA was as important in supporting a common language for communication. The HIA also has led to the adoption of further innovative techniques regarding community engagement within the planning system. As a result of the great success of the HIA of the EELDS, Glasgow City Council (GCC) has adopted HIA as an effective tool for integration of health into its strategies, proposals, plans, and projects, most of which are traditionally non-health related. HIA has also been employed to explore the lunchtime experience of secondary school students. Another development from the HIA of the EELDS is the concept of integrated infrastructure. Growth was hindered by outdated sewerage systems combined with surface runoff systems. Sustainable Urban Drainage Systems (SUDS) should be in place in order to ensure that surface runoff does not penetrate the sewers. Traditional SUDS have taken the form of collecting ponds that are surrounded by a fence, but integrated infrastructure brings in a canal network that is integrated with a green network and an active network. Thus, SUDS not only serve the purpose of handling with the runoff, but also help connect the green space and provide an opportunity for people residing in the city to include physical activity in a pleasant environment along with their daily routines.
According to the global report of the WHO Commission on Social Determinants of Health, Closing the Gap in a Generation, there should be refreshed debate at national and city levels and has placed equity in health on top of the agenda at a European level. This is a predominating value of the health strategy in the European Union, although it is less evident with regards to EU economic policies. During the international conference that marked the end of phase IV of the WHO European Healthy Cities Network in 2008, the city mayors did sign a declaration that reaffirms a commitment to equity which has been considered as a golden thread throughout all the phases of the project since its commencement in the year, 1987. They also gladly accepted their local leadership role in promoting “Health and Health Equity in All Local Policies”.
In reality, there has been obligating evidence, which shows that health inequalities are still not reducing. The WHO/HABITAT report Hidden Cities (WHO/UN-HABITAT, 2010) has exposed great inequalities in urban settings across almost every continent. Mackenbach does highlight one of the great disappointments of public health because of the persistence of socioeconomic inequalities in health even throughout the highly developed welfare states of Western Europe (Mackenbach et al., 2008; Mackenbach, 2012). Within the WHO-EHCN, there is evidence from the author’s evaluations of both phases III and IV that demonstrate improvements in monitoring health inequalities and a better understanding of the requirement to tackle the socioeconomic determinants (Ritsatakis, 2009). It is understood that political commitment is not always translated into processes that will improve health outcomes and reduce health inequalities over time.
Being aware of these locally generated evidence on barriers and vital success factors, the WHO Regional Office for Europe took a pledge at the 2009 Annual Business and Technical Meeting held at Rennes, France, to support their network cities with more rigorous and determined efforts in order to achieve the prerequisites for equity in health. The initial drafts of the new guidelines were presented at the 2010 Annual Business and Technical Meeting held in Sandnes, Norway. The feedback from various cities was incorporated into a revised framework that was presented at the 2011 Annual Business and Technical Meeting held in Liege, Belgium. The final framework required for action—Healthy cities tackle the social determinants of inequities in health were presented and discussed at the 2012 (World Health Organization, 2012b). Annual Business and Technical Meeting held at St. Petersburg, Russian Federation. It is also complemented by a WHO report that briefs on the role of local government in addressing the social determinants of health (World Health Organization, 2012a).
This guidance related to city-based interventions helps tackle the whole gradient health inequalities and draws attention to international evidence and especially the phase IV evaluation. To summarize, the action points include
1. Enhancement of local governance and processes for both the place and people,
2. Increase the institutional capacity in order to deliver change,
3. Improve the knowledge base to measure and monitor progress,
4. Health equity should be incorporated in all local policies,
5. Interventions that can sensitize the mainstream city services, and
6. Specially targeted programs. During the phase V (2009–2013), a subnetwork of 25 cities was committed to advance these action points in a systematic and comprehensive method, sharing and developing best practice for decision-makers in Europe and beyond.
This evaluation concludes that the understanding of the significance of urban health planning through the Healthy Cities movement has developed significantly over the period of phase IV, but still has a long way to go. It is to be noted that the Healthy Cities program can be efficacious in the promotion of the vital importance of linking health and planning as well as in dissemination and development of good practice. In most urban places, it has helped in the transformation of the political and professional agenda, integration of health within sustainable development and the planning of the human environment. However, there are several cities that are still struggling with the more strategic and holistic level of approach. The two common reasons seem to be that they could be hampered by internal institutional barriers and an evolving spatial form which is driven by the fact ‘what the market can deliver’. This type of barriers act against any kind of integrated working and it is not just HUP that will be disfavored. Every city can suffer from this to an extent, as a large complex organization and it can be realized that the successful cities are those that engage with a broad range of stakeholders and form a wide-ranging partnership by providing a continuous bulwark opposed to sectoral silos.
The Level 3 brought in a heavy responsibility with many current policy assumptions that was widespread across Europe such as business parks and retail parks that will need careful and honest review. The integration of health and planning, therefore, needs a basic change in its organizational structure in most cities. This kind of transformation can be done through a programme that can promote knowledge exchange and a reflective discourse on the values between public health professionals and planners (Pilkington et al., 2008). It is understood that in democratic communities, it all depends on the strong unanimity amongst the population. In addition, it does require an effective top leadership that is willing to rethink the established policy. A strong commitment to a Health in all Policies approach would be able to concentrate minds.
There is certainly an opportunity for the health commission to support the HUP approach and help mainstream HUP throughout Glasgow. Though most Glasgow planners do understand the links between planning and health, this is not universal and the lacking understanding may create barriers. The health commission may encourage their partners to embrace the principles of HUP and conduct seminars and disseminate papers in order to ensure that there is a better understanding throughout Glasgow of the way this can lead to a more healthier and sustainable city. Although the Commonwealth Games did have the potential to act as a catalyst and help address most of the determinants of health, learnings from the previous international sporting events do indicate that these events are not sufficient to ensure improved health. In order to help in developing a legacy of health improvement, an HIA of the Games needs to be conducted. It is also recommended that the health commission needs to encourage partners to take on board suggestions from the HIA to develop and accommodate plans in light of these suggestions. The health commission should consider the ways it could help to ensure that health criteria are built into the planning of development briefs and assessment processes. The health commission needs to consider how it can encourage the meaningful use of HIA for future policies, plans, and developments in Glasgow, including both large public sector developments and private developments. It needs to enable the meaningful involvement of communities in decision making about their local areas. As we know, the green spaces and other public spaces contribute towards the vibrancy of local neighborhoods, they provide an opportunity for social interaction, especially when created and maintained in ways that meet the community needs. It is recommended that the health commission should consider how planning can be employed to protect public spaces and also to develop new ones. It should involve local community members in the development of their own city. Lastly, it is also recommended that the health commission supports the city’s continued involvement in the national as well as international networks with a purpose of sharing their learning and experience, good practices and to develop collaborative work.