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Healthy urban planning in European cities

HUGH BARTON1*,MARCUS GRANT1,CLAIRE MITCHAM2and CATHERINE TSOUROU3

1WHO Collaborating Centre for Healthy Cities and Urban Policy,School of Built and Natural Environment,University of the West of England,Bristol,United Kingdom,2Baker Associates,Bristol, United Kingdom and3Consultant,Padua,Italy

*Corresponding author.E-mail:hugh.barton@https://www.wendangku.net/doc/c65239422.html,

SUMMARY

This article describes the WHO‘healthy urban planning’(HUP)initiative as it has developed through the labora-tory of the Healthy Cities movement and evaluates the degree to which applicant cities successfully developed plans for HUP.The paper provides a brief historical per-spective on the relationship of health and planning and an overview of the ways in which urban spatial development affects health.It then turns to the WHO European Healthy Cities Network(WHO-EHCN)and explains the evolution of the HUP programme through Phase III (1998–2002)of the Healthy Cities Project,showing how the programme has grown from experimental beginnings to being‘mainstreamed’in Phase IV(2003–2008).Each city wishing to join the WHO-EHCN in this latter phase produced a programme for further development of HUP, and these were assessed by the Bristol Collaborating Centre.The paper presents the overall results,concluding that a signi?cant progress has been made and the most advanced cities have much to offer municipalities every-where in the best practice for integrating health into urban planning.

Key words:Healthy Cities;urban planning;healthy environment

INTRODUCTION

Health and urban planning are natural allies. Modern town planning has its roots in the unhealthy industrial cities of the nineteenth century:endemic problems of poor water supply,sanitation,light and air triggered a response in terms of not only infrastructure engineering but also urban design.The codes of street and building layout were designed to banish forever the dank houses and airless streets.

It is ironic,then,that the connection between health policy and urban planning became tenuous in the twentieth century.The original health objectives of clean air and water are deeply entrenched in planning and building control systems,but contemporary diseases of civilization have been ignored in many ways. Indeed,planning policies have facilitated if not actually fostered the powerful trends towards car-dependent,sedentary and privatized life-styles,with their negative effects on health. This paper highlights the important work of the Healthy Cities movement in seeking to reintegrate health and planning.The?rst section sets out the nature of the link and the problem of separation;the second section sum-marizes the evaluative methods used.The results are in two parts:an examination of the evolution of the WHO healthy urban planning (HUP)initiative,from inception,through pilot projects,to mainstreaming,and an evaluation of the progress made by the cities over Phase III (1998–2002)as evidenced by their applications for Phase IV(2003–2008).Subsequent

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discussion points to ?ve key elements in an ideal health-integrated planning system,con-cluding that health is a powerful motivator,capable of cutting across sectional interests in the process of city planning.

URBAN PLANNING AS A DETERMINANT OF HEALTH

The environment has long been recognized as a key determinant of health (Lalonde,1974;Whitehead and Dahlgren,1991;Marmot and Wilkinson,1999).The health-related professions increasingly recognize that promoting health solely through programmes of changing the be-haviour of individuals or small groups is not very effective,reaching only a small proportion of the population and seldom being maintained in the long term (McCarthy,1999;Lawlor et al .,2003).What is needed is a more fundamental,social,economic and environmental change.Urban planning as a mechanism of environ-mental control in?uences health in systematic ways.Figure 1sets out a settlement health map ,showing the various spheres of social and econ-omic life and the wider environment that are affected by the spatial planning of settlements (Barton,2005;Barton and Grant,2006).It was inspired in part by Whitehead and Dahlgren’s ?gure (Whitehead and Dahlgren,1991),of the

determinants of health,and in part by the eco-system model of human habitats (Duhl and Sanchez,1999).The sphere of direct planning in?uence is the built environment:here de?ned broadly to mean the physical form and manage-ment of places:the buildings,spaces,streets and networks that make up human settlements.This sphere affects all the others to a greater or lesser extent,helping to shape some of the options that are open to individuals,social groups,businesses and state agencies.For example,through the provision (or lack of pro-vision)of appropriate space,it in?uences what can take place and how accessible those activi-ties are to different groups in the population.Each outer sphere affects the health and well-being of people ,represented by the inmost sphere (Whitehead and Dahlgren,1991;Marmot and Wilkinson,1999;McCarthy,1999;Lawlor et al .,2003)—the natural environment ,for example,through the cleanliness of air and water;the built environment through the avail-ability,convenience,safety and attractiveness of pedestrian and cycling facilities,parks and playing ?elds,and hence the propensity to take healthy exercise;local economy through inequalities in access to work and income;com-munity through supportive social networks (or their lack).The model can be used therefore to help understand the relationship between health and planning.

Many of the urban development trends pro-moted by the market and facilitated by planning authorities are pandering to our unhealthy instincts (Barton et al .,2000;National Heart Forum,Living Streets and CABE,2007).Despite more than a decade of of?cial advocacy of sustainable development,many conventions of the development industry remain trapped in a pre-Rio time warp.Across Europe,the expanding peripheral city areas exhibit a pattern of low-density,use-segregated,car-based devel-opment that not only uses land pro?igately but reduces the viability of local services,makes walking impractical because of distance and deters cycling.The fashionable of?ce,retail and leisure parks that spring up in the wake of road investment typically rely on 90–95%car use.The segregation of land uses is undermining the potential for integrated neighbourhoods and local social capital.Unsustainability is literally being built into our cities.

In this context,health is a casualty.The decline in regular daily walking and cycling

Fig.1:Human ecology model of a settlement.Source:Barton and Grant (2006).

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resulting in increased obesity and risk of dia-betes and cardiovascular diseases(Franklin et al.,2003).Social polarization of opportunity is exacerbated.People tied to locality—elderly people,children,young parents,unemployed people and immobile people—are increasingly vulnerable.The decline in local facilities,the reduction in pedestrian movement and neigh-bourly street life all reduce opportunities for the supportive social contacts so vital for mental well-being(Halpern,1995).Health pro-blems are being accumulated for the future, which will make the present problems of health service delivery look trivial by comparison. Given that the quality of the urban environ-ment is important for human health,it is puz-zling that‘direct assessments of the links between the built environment and physical activity as it in?uences health are still rare’(Handy et al.,2002).The research literature is divided between that focused on health out-comes(Halpern,1995;Aicher,1998)and that focused on planning interventions and behav-iour(Hedicar and Curtis,1995;Cervero and Kockelman,1997;Williams et al.,2000). Articles that make the connection explicit still promote the idea as innovative and newsworthy (Dube′,2000;Jackson et al.,2003;Barton et al., 2003a,b).

This lack of progress is in part because of the dif?culty in disentangling the in?uence of the built environment from related social,economic and personal variables in a rigorous way. Nevertheless,the evidence of the interconnec-tions is steadily building.In relation to physical activity,for example,we can now say with con?-dence that incidental foot and bike trips(to get to somewhere for a speci?c purpose)are affected by a number of spatial variables:distance,density, form and layout;and recreational physical activity is in?uenced by the accessibility of parks and other facilities,the provision of pavements/bike-ways and the perceived aesthetic quality of the neighbourhood(Handy,2005;National Heart Forum,Living Streets and CABE,2007).We can link rising asthma levels generally to traf?c-derived pollution(ozone),with some startling speci?c?ndings:in Atlanta when vehicle traf?c was kept arti?cially low during the Olympics in 1996,traf?c counts dropped by22.5%,peak daily ozone levels by27.9%,asthma emergency medical events by41.6%,whereas other emer-gency events were much the same as usual (Jackson and Kochtitzky,2001).

Rather tardily,the research community is

embarking on a more cross-cutting research in

this?eld.Its current relative paucity does not

mean that health and planning have not been

linked in practice.But normally this link is

implicit,not explicit,lacking a systematic or comprehensive approach.

METHOD

There are three stages to the evaluation of pro-

gress made towards a comprehensive approach

to integrating health and planning in the World

Health Organization European Healthy Cities

Network(WHO-EHCN).The?rst is through

participant observation in the development of

the HUP programme over a number of years.

In addition,self-identi?ed cities reported on

progress were interviewed individually and eval-

uated through discussion as part of a mutual

learning exercise.Some of the results and con-

clusions were set out in earlier publications

(Barton et al.,2003a,b).

The second stage,in late2005,involved the

evaluation of52city applications for Phase IV

of the Healthy Cities project.The raw material

of this evaluation was the written applications

supplied to the Bristol Collaborating Centre by

the WHO Regional Of?ce for Europe.They

essentially show how far the cities had come

during Phase III and by the start of Phase IV.

The applications were,on occasion,sup-

plemented by telephone calls to applicants to

clarify particular statements.Where feasible,

the accuracy of the written material was com-

pared with the personal or reported knowledge

of the applicant city and their programmes.

With certain exceptions,there was consistency

between the applications and reality.Where

there was discrepancy,the actual performance

was invariably better than the application suggested.Some applicant cities where English

was not their native tongue had problems in

conveying complex ideas with clarity.Overall,it

is therefore likely—given the number of cities particularly in eastern Europe where no exter-

nal check was available—that the results under-

play the actual quality of the work going on.

The assessment of the applications involved

three speci?c tests:the apparent level of under-

standing of HUP;the degree of involvement of

planning agencies;and the quality of the pro-

gramme to strengthen HUP.The way these

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were assessed by the researchers is explained later.

The third stage is the evaluation of progress made by the end of Phase IV.This is the subject of another paper presented at the International Healthy Cities Conference in Zagreb in Autumn2008(Barton and Grant, 2010).

THE DEVELOPMENT OF THE WHO HUP INITIATIVE

The WHO HUP initiative was borne out of a growing conviction that urban planning and related activities signi?cantly in?uence the determinants of health(Duhl and Sanchez, 1999).Healthy Cities projects throughout Europe have sought,with limited success,to involve urban planners in their work since the late1980s.The baseline was established in1998 through a questionnaire survey.Respondents were the heads of urban planning departments in38cities participating in Phase II(1993–1997)of the WHO-EHCN.The survey found that regular cooperation between planning departments and health agencies occurred in only25%of cases.Nearly one-third of planning heads considered that planning policies were actually incompatible with health in certain ways—especially rigid standards of zoning and design.Other anti-health issues highlighted were excessive levels of motorized traf?c,the focus on private pro?t and public budgets, social segregation and the lack of attention to the everyday needs of citizens(Barton and Tsourou,2000).

The foundations for the HUP initiative were laid in the mid-1990s with the participation of the WHO-EHCN in the European Sustainable Cities and Towns Campaign.The links between health and sustainable development formed an important element in the work of the Campaign (Price and Dube′,1997)and provided an oppor-tunity to begin to explore the relationship between health and urban planning. Meanwhile,urban planners across Europe were becoming increasingly aware of the importance of sustainable development,which emphasizes the need to tackle social,environmental and economic issues in a coordinated way.Their work in this area led planners to reconsider issues of the quality of life,well-being and,ulti-mately,health in cities.

In1998,WHO began to work with urban planning practitioners and academics from across Europe in a more concerted way.A?rst step was to publish Healthy Urban Planning—A WHO Guide to Planning for People(Barton and Tsourou,2000).It makes the case for health as a central goal of urban planning policy and practice,highlighting the role of planners in tackling the environmental,social and economic determinants of health.It dis-cusses the relevance of the Healthy Cities movement to urban planners,drawing attention to the principles of equity,sustainability,inter-sectoral cooperation,community involvement, international action and solidarity.The book translates concepts and principles into practical ideas.It was produced in cooperation with a number of cities and academics who met to discuss the content at a seminar in Milan,Italy in October1999(WHO Regional Of?ce for Europe,1999).The group agreed12key health objectives for planners.The list provides a close parallel with the12goals of sustainable development:

(i)promoting healthy lifestyles(especially

regular exercise);

(ii)facilitating social cohesion and supportive social networks;

(iii)promoting access to good-quality housing; (iv)promoting access to employment opportunities;

(v)promoting accessibility to good-quality facilities(educational,cultural,leisure,

retail and health care);

(vi)encouraging local food production and outlets for healthy food;

(vii)promoting safety and a sense of security; (viii)promoting equity and the development of social capital;

(ix)promoting an attractive environment with acceptable noise levels and good air

quality;

(x)ensuring good water quality and healthy sanitation;

(xi)promoting the conservation and quality of land and mineral resources;and

(xii)reducing emissions that threaten climate stability.

Urban planning,in this light,is seen as a key means of promoting health and well-being. Equivalently,human health,well-being and quality of life are seen as central purposes of urban planning.

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The meeting and the book provided the momentum for the formation of the WHO City Action Group(CAG)on Healthy Urban Planning.The city of Milan agreed to lead and support the work of this group and hosted the ?rst meeting at the Politecnico di Milano Technical University in June2001(WHO Regional Of?ce for Europe,2001).Senior urban planners and HC co-ordinators from11 cities across Europe attended the meeting, making a commitment to begin a process to integrate health issues more fully into their work.The initial membership of the group included cities from all parts of Europe: Gothenburg(Sweden),Horsens(Denmark), Sandnes(Norway),Belfast and Shef?eld(United Kingdom),Milan(Italy),Seixal(Portugal), Vienna(Austria),Geneva(Switzerland),Zagreb (Croatia)and Pe′cs(Hungary).

From2001,this group of cities,working with specialist WHO advisors,was the focus for WHO’s developing work on HUP(WHO Regional Of?ce for Europe,2001;WHO Regional Of?ce for Europe,2002;Barton et al., 2003a,b).Group meetings provided a forum for sharing knowledge and experience of exactly what HUP implies in practice and how it affects day-to-day planning processes and outcomes. These planners developed understanding not just of each other’s differences and unique per-spectives but of their common situation and of how many European cities can draw on the experience of one city.The CAG provided the groundwork for subsequent expansion of the HUP programme.In Phase IV(2003–2008)of the WHO-EHCN,HUP was one of the four core themes for cities to develop.The other three were health impact analysis,physical activity and healthy ageing.HUP is still a new departure for many municipalities.The next section evaluates how far the whole network had learnt through Phase III and rose to the challenge of Phase IV.

PROGRESS MADE BY THE START OF PHASE IV

By the end of2005,52cities had been assessed for the membership of Phase IV.Each city was judged according to what improvements it planned above and beyond what had already been achieved.In some cases,cities had little tradition of land use planning(as in Seixal,reported earlier)and therefore started from a

low level.In others,there was a well-developed

planning system but no established Healthy

Cities programme which might already have

built bridges between planning and health agencies.In a few,especially in Scandinavia,

there were both appropriate legal systems for

planning settlements and established planning/

health links.It was possible for cities in any of

these groups to perform well according to assessment criteria referred to in the Methods

section.

UNDERSTANDING

The level of understanding of HUP was

assessed by three tests,each of which relied on

different parts of the application and thus

helped to check on the signi?cance and

reliability of any particular facet:

?the range of relevant planning policy areas

that were identi?ed for action(using the list

given earlier in this paper);

?the nature of the activities promised under

the HUP heading:were they expressly about

promoting change in the built environment,

with health as an explicit driver for that

change?;

?the degree of explicit linkage between HUP

and the other main themes:for example,was

HUP seen as part of the healthy ageing

agenda?

All the cities were,of course,completely aware

that their plans for the development of HUP

were to be scrutinized.However,they did not

know exactly how this would happen,so the opportunity for game-playing was reduced.The

character of the answers generally suggests that

applicant cities made a direct and honest

response to the cues in the application form.

In relation to the?rst criteria,the applicants

were not formally asked to re?ect the full range

of health objectives in their application,but

speci?c aims and programmes might be

expected to cover a number of relevant areas.

The range encompassed helps to show the understanding of the multi-faceted nature of the

health-planning relationship.Forty per cent of

applicant cities mentioned at least half of the12

WHO-ECHN objectives referred to earlier. However,30%mentioned no more than2out

of the12.Housing quality and accessibility to

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services were the objectives most commonly identi?ed.Objectives of employment,food and climate change were all conspicuous by their absence from the vast majority of applications (Figure 2).

General understanding of HUP was judged by the degree to which applicants conveyed rec-ognition of the integrated nature of land use/transport systems and the impact on health.

Most of the cities giving a good coverage of objectives also demonstrated a good overall understanding.Conversely,those identifying few objectives demonstrated poor understand-ing;the most common limitation was that they had not made the jump from a view of public health as purely about the co-ordination of ser-vices and campaigns,to one which was about the creation of a healthy urban environment.Twenty-?ve per cent of the cities showed weak or very weak understanding.The strongest cities not only demonstrated a coherent and well-developed understanding,but also linked together the three Phase IV themes:i.e.HIA was seen as a tool which could expressly be used to promote HUP,whereas HUP was seen as a process which could assist healthy ageing.Thirty per cent of cities showed a good or excel-lent level of understanding.

INVOLVEMENT

Healthy Cities units in most municipalities are off-shoots of health departments and staffed by medical or public health practitioners.Planning agencies have not traditionally been involved.Phase IV acted as an incentive to broaden the management of the Healthy Cities programme.Without proper representation of planning

agencies at a senior decision-making level in the programme,it is very dif?cult to achieve health-integrated plans.

A signi?cant proportion of Healthy Cities steering groups had no obvious representation of planning agencies (Figure 3).This includes all the ‘weakest’group of cities,as identi?ed in the assessment of understanding.However,a few of the strongest cities also lacked represen-tation.It may be that in some cities,effective power resides with the of?cers ‘at the coal-face’(and at that level,there is effective co-operation)rather than with the steering group or management group (who may follow not lead).

THE PROGRAMME

The programme for promoting HUP is the crux of the assessment.However,the evaluation process is not simple.The good applications,with relevant and coherent programmes and clear mechanisms for further building mutual understanding between health and planning professionals,are straightforward to assess.The poor applications,with no coherent approach,are also straightforward.But between lie many applications,over half of the total,which display some appropriate ideas without being suf?ciently clearly argued or illustrated to judge their real merit.A majority of cities do have speci?c projects with a strong HUP dimen-sion—in relation in particular to the topics of housing,accessibility,open space,regeneration and/or walking and

cycling.

Fig.2:HUP objectives identi?ed in the

applications.

Fig.3:Analysis of the involvement of planning agencies and of?cers.

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Although some of these projects are positive and innovative,others are not suf?ciently tuned to a broad view of health.They appear spliced into the programme:perhaps from other agencies,without integrating the health angle.For example,some open-space projects are focused on issues of wildlife habitat preser-vation (valuable as that is)and do not address human recreational needs (with the accompany-ing health bene?ts)in any systematic way.

About a third of cities have gone the extra step and are integrating health objectives into their spatial strategies.Some cities have explicit ‘bottom-up’programmes of community plan-ning or public involvement in policy-making,enhancing social capital/empowerment.A very positive feature is that many cities have coher-ent programmes for the training and awareness-raising of staff,sometimes across organizational divides.

OVERALL ASSESSMENT

The 52Phase-IV applications can be divided into ?ve groups (Figure 4).

Seventeen applications are very strong.These are from cities with a good understanding of HUP who also put forward an innovative,impressive or comprehensive programme.Sixteen applications are of good quality but are from cities with a less complete apparent

understanding of HUP.However,they show other strengths,such as a very good understand-ing in speci?c areas or they demonstrate the knowledge of their weaknesses,and their pro-posed activities address these.Others may lack current understanding but have demonstrated a good start in joining the WHO-EHCN and are pointing in the right direction.

Nineteen applications range from poor to very weak.These cities have been unable to demonstrate a real understanding of HUP in the application.Representation of planners in the core group is usually lacking,and the propo-sal may be vague or inadequate.The cities in this group usually do not display awareness of these weaknesses and consequently provide no remedy.

The development of the cities in the HUP CAG in Phase III provides insights into the way cities can progress from a weak one to a strong one.Three lessons stand out.The ?rst is the critical importance of cross-sectoral co-operation.Collaboration between health and planning agencies is the starting point,but needs also to embrace transport,housing,regen-eration,economic development and recreation.In Gothenburg,for example,a health group was established within the City Planning Authority to consider the health implications of planning proposals,drawing on expertise from other departments.In Milan,a pilot process was undertaken to introduce an intersectoral approach to developing three regeneration pro-jects in the city,linking social and environ-mental interventions systematically.

The second lesson is the importance of pro-ducing a health-integrated spatial plan which involves the wider community in the issues.In Sandnes,health was fully integrated into the new municipal comprehensive plan (the main management document for all municipal activi-ties).Health represented one of the three key themes of the plan,and is being implemented through a range of practical initiatives,with a focus on citizen participation.In Horsens,health was a central objective of all municipal activities and was integrated into urban plan-ning processes.Neighbourhood regeneration and community empowerment activities have provided an important vehicle for implementing the health-oriented goals of the general munici-pal plan.

The third lesson is about the potential for radical change.In Belfast,where planning

and

Fig.4:Categorizing the city applications.

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health have been institutionally divorced,the Northern Ireland Of?ce of the United Kingdom Government Department of the Environment and Belfast Healthy Cities made a joint approach to promote and integrate health into a wide range of local and regional plans and pol-icies.Tools such as strategic environmental assessment and a quality of life matrix were developed to assist this process.In Seixal, Portugal,there was little experience of town planning.Health provided a new motivation to promote it,and an interdepartmental working group was established to guide the integration of health into the emerging development plan and to implement this concept on a practical level.

CONCLUSION

The WHO-EHCH HUP initiative provides a classic example of the development of a new principle,triggered by top-down encouragement and spread by networks of mutual support.For those municipalities that have only recently embarked on the journey,health is proving a powerful motivator for addressing planning issues that have not previously been faced, drawing in new constituencies of political support.For example,in Seixal,the health agenda has encouraged planning policies to protect allotments from development and to tackle problems of social exclusion(and related health inequalities)on isolated estates. Nevertheless,in many cities,there are dif?culties because vertical departmental remits deter colla-borative working—as one planner commented:‘There are a lot of islands in this municipality’. Some municipalities—especially in northern Europe—have had health embedded in planning policy-making for some years.In these situ-ations,interagency cooperation is the rule and not the exception,and the main planning docu-ments re?ect health priorities not only in their context but in decision-making processes that place a premium on building social capital.

Both the more experienced and the less experienced cities agree that health-integrated planning is valuable.Healthy opportunities are created.Planning policies become better,more responsive to community needs and more strongly supported.

An ideal health-integrated planning system has?ve key elements.The?rst is acceptance of interdepartmental and interagency collabor-ation so that health implications can be properly explored and integrated solutions pursued across institutional remits.The second is strong political backing,which helps to ensure a con-sistent approach and the resources needed.The third is full integration of health with environ-mental,social and economic concerns in the main statements on land-use planning,trans-port,housing and economic development policy:placing health at the heart of plan-making.The fourth is the active involvement of citizens and stakeholders in the private,public and voluntary sectors in the policy process.The ?fth is a toolbox of planning techniques that fully re?ects health objectives and makes them explicit:quality-of-life monitoring,health impact assessment,strategic sustainability assessment,urban potential studies.

The WHO-EHCN experiment in HUP is not alone.Other cities around Europe are progres-sing in the same direction.Health arguments are increasingly being made explicit in planning policy debate(Breeze and Lock,2001;Jones, 2002).Practitioners are grappling with the dif?-culties of assessing health effects(Morgan and Mahoney,2001).But the WHO-EHCN does demonstrate both the power of the idea in chan-ging minds and opening new avenues and the necessity of a sustained,progressively more sys-tematic approach.Health is a powerful motiva-tor,capable of cutting across vested interests in a way that sustainable development may not be able to.

FUNDING

This article is based on an evaluation commis-sioned by the WHO Regional Of?ce for Europe.

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