Municipal Public Health Planning Framework - Part A

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4. Environments for health: A systems approach to municipal public health planning

Page content: 4.1 MPHP Planning process | 4.2 Health outcomes | 4.3 Environmental dimensions | 4.4 The built environment and wellbeing: The need to integrate urban planning and health planning

The first step in embracing a systems approach to planning for health and wellbeing is to consider the overall impact on health and wellbeing of factors originating across any or all of four environmental dimensions - built, social, economic and natural.

Figure 2 Environments that affect health

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4.1 MPHP planning process

The MPHP is the planning connection between state and local government and other local stakeholders, including the community, in planning for health and wellbeing. Taking a systems approach to developing MPHPs means ensuring that all relevant inputs into the planning process are taken into account. Critical inputs are:

• Best public health planning practice, including research into improving these practices.
• State and federal public health policies and priorities and the need to integrate government effort at the local level.
• Local government corporate priorities, political mandates and governance issues.
• Community participation including providers, stakeholders and the many communities that make up the municipality, including the need to use community resources wisely.

The synthesis of these critical inputs through the planning process produces an output in the form of an MPHP, and improved public health outcomes.

In summary, government policies, local government corporate circumstances and governance issues, best practice, and the municipal community, all inform the development of the MPHP and ongoing planning processes. This is illustrated in Figure 3 below.

Figure 3 Systems Approach to MPHP Planning Process

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4.2 Health outcomes

4.2.1 Local government and health outcomes

Successful public health programs lead not only to the prevention and reduction of disease and disability, but also to the creation of environments in which people can lead productive and rewarding lives. Public health programs differ from other health programs in that they focus on improving the health of populations through personal, social and environmental change rather than individual treatment. The action taken reflects this.

Health systems around the world are embarking upon reform processes based on approaches to population health planning, the notion of investment for health, and preventive strategies and health promotion. Central to this approach is the focus on population rather than the individual, the causes of illness rather than treatment, and a strong scientific basis in measurement of outcomes.

Health outcomes are achieved via action that is informed by the fields of epidemiology, environmental and social research:

• They rely on work that draws on research into risk behaviours, such as smoking, that form areas of proven association with the susceptibility to disease or ill health.

• The settings for public health inquiry are the place or social context in which people engage in daily activities and in which environmental, organisational and personal factors interact to affect health and wellbeing.

• Risk factors such as social, economic or biological status provide an entry point to, or a focus for health promotion strategies and actions.

• Disease prevention covers measures that not only prevent the occurrence of disease but also arrest its progress and reduce its consequences once established.

• Investments for health are the resources explicitly dedicated to the production of health and health gain, based on the determinants of health and developed as healthy public policy. One example is the health goals and targets defined and set at both state and national level.

4.2.1 Local government and health outcomes

In order to have a greater influence on improving health outcomes, a range of professionals within local governments must be involved in public health across all strategic planning functions. This includes the technical, economic, environmental and social planning areas, as well as health and human services.

The public health mandate is very broad and complex, involving a multitude of concerns. It follows that public health cannot be the preserve of one agency, professional group or level of government, but must be the responsibility of agencies at all levels. MPHPs provide a means by which local governments, in partnership with the Department of Human Services, service providers, other stakeholders and the community within the municipality, can plan public health services and programs. MPHPs aim to improve coordination, reduce unnecessary gaps, provide a framework for innovative local public health programs, and enhance local responsibility and accountability for performance of municipal public health outcomes.

In terms of health outcomes, the priority issues of MPHPs should continue to reflect the following:

• Health protection services such as food safety, immunisation, infectious disease notification, water quality and environmental health.

• Health development issues that can be advanced by local government (within state-wide frameworks), such as prevention of injuries, cancer, cardiovascular diseases, drug and alcohol use, tobacco control and nutrition.

• Population health strategies that address the preventive needs of population groups considered being at risk. This includes strategies to address child and family health, aged care, youth health, and the health of vulnerable groups.

• Public health emergency requirements.

• Community capacity building and community wellbeing These should be grounded in work occurring at a state level.

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4.3 Environmental dimensions

'Environments for Health', the conceptual framework that underpins the systems approach to public health planning, states that health and wellbeing is affected by factors originating across any or all of four environmental dimensions (as illustrated in Figure 2 above).

This is supported nationally through the Environment Protection and Biodiversity Conservation Bill 1999, which defines environment as including:

"a) Ecosystems and their constituent parts, including people and communities; and

b) Natural and physical resources; and

c) The qualities and characteristics of locations, places and areas; and

d) The social, economic and cultural aspects of a thing mentioned in paragraph (a), (b) or (c)."

By including consideration of people and their communities, this holistic definition provides an opportunity to map the relationship between environments and health and wellbeing.

Figure 4 Environmental Dimensions and Corresponding Council Action Areas [Adapted from Wills, J. (1995, December). A new public health agenda. Australian Municipal Journal, p. 18.]

Figure 5 Examples of the Influence of Environmental Dimensions on Health Issues

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4.4 The built environment and wellbeing: The need to integrate urban planning and health planning

4.4.1 The built environment defined | 4.4.2 Built environment, health and wellbeing | 4.4.3 Questions to ask of urban planners

This document has clearly demonstrated the interrelated impacts on health of factors in the social, economic, natural and built environments. The present section will outline in more detail the link between urban planning and health, and the need to integrate these planning approaches. Special attention is given to this issue, because:

• Urban planning and health planning are key activities of state and local government (see Section 3.3);
• These planning processes frequently occur in isolation;
• There is a concerted international effort by WHO to highlight and build on this relationship.

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4.4.1 The built environment defined

The built environment has been defined by Health Canada as:

"... part of the overall ecosystem of our earth. It encompasses all the buildings, spaces and products that are created, or at least significantly modified by people. It includes our homes, schools and workplaces, parks, business areas and roads. It extends overhead in the form of electric transmission lines, underground in the form of waste disposal sites and subway trains and across the country in the form of highways."

The built environment contains "the basic services that are needed to keep a society running", otherwise known as infrastructure. Infrastructure is seen as essential to health and includes services delivered physically (roads, communications, provision of drinking water mains, sewerage systems and so on), and utilities such as electricity and gas. Furthermore, the built environment can include broad features of urban layout, such as cityscapes (building heights, shapes and overall density) and streetscapes (width, tree cover, housing density, and the diversity of building uses). Provision of transport facilities for road, rail, tram, bicycle, pedestrian, air and sea traffic forms a key component of infrastructure (Health Canada).

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4.4.2 Built environment, health and wellbeing

A strong link exists between the built environment, health and wellbeing. The built environment forms the backdrop to our lives. As we pass through buildings and spaces, we generate meanings, which we 'read' as we pass through them. The built environment impacts on our senses, our emotions, our opportunity to partake in physical activity, and the way we participate in community life. Our sense of community and general wellbeing are affected as a result. Built environments can vary across a range of characteristics, such as the quality of infrastructure, public spaces, a sense of safety and amenity, availability of healthy foods and health-affirming services, community norms and so on, which influence individual and collective behaviour. Health disadvantage is exacerbated in socially and economically disadvantaged settings.

When we speak of urban planning, we are not just referring to buildings, but also about the notion of conservation. Furthermore, notions of heritage and conservation are linked to sustainability, not only of natural environments, but also human communities. Health promotion, as detailed in the Ottawa Charter, is concerned with highlighting and building on the connection between ecologically sustainable development and human wellbeing, by fostering the creation of supportive environments and healthy public policy.

Physical and social environments play major roles in the health of communities. Since a principal focus of the planning profession is the design and creation of sound places for people, planning and public health professionals are intrinsically linked. Urban planning is a form of primary prevention and a contributor to health outcomes.

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4.4.3 Questions to ask of urban planners

Urban planners must accept that their decisions have consequences, both intended and unintended, that could potentially lead to ill health within communities. However, there are techniques and skills that planners can use to promote the building of strong, healthy neighbourhoods, towns and cities. Some universally applicable questions that can be asked are:

• What are the potential unintended consequences of the planning efforts?

• Are the planning efforts addressing the symptoms of a problem, or the root causes? For example:

  • Are housing programs that are aimed at people on low incomes simply displacing this population, or are they truly working to solve the underlying issues behind the scarcity of safe, clean, affordable housing?

  • Will planning serve to enhance the social inclusion and participation of women with children, people with disabilities and older people (through provision of local services, well-lit streets, and accessible buildings, footpaths, streets and transport), or extend their isolation?
    
• Are planning efforts working on behalf of healthy urban public policy? A system must be in place that enforces checks and balances between policy-makers, policies and plans.

• What are the direct and indirect effects of planning decisions? How will these decisions affect the built, natural, social, political and economic environments? Politicians, planners, government officials and citizens must all be able to understand fully the reasoning and implications behind policies, that is, asking questions that look at the whole picture.

Asking these kinds of questions in urban planning practice promotes critical analysis of decisions about the future of cities. Such questions are indispensable to the process of healthy urban planning and sustainable development (See Duhl & Sanchez, 1999: http://www.who.dk/healthy-cities/UrbanHealthTopics/20020116_1).

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