Towards Healthy Cities (European Institute for Comparative Urban Research)

Towards Healthy Cities Comparing Conditions for Change

Alexander Otgaar, Jeroen Klijs and Leo van den Berg

Towards Healthy Cities

The European Institute for Comparative Urban Research, EURICUR, was founded in 1988 and has its seat with Erasmus University Rotterdam. EURICUR is the heart and pulse of an extensive network of European cities and universities. EURICUR’s principal objective is to stimulate fundamental international comparative research into matters that are of interest to cities. To that end, EURICUR coordinates, initiates and carries out studies of subjects of strategic value for urban management today and in the future. Through its network EURICUR has privileged access to crucial information regarding urban development in Europe and North America and to key persons at all levels, working in different public and private organizations active in metropolitan areas. EURICUR closely cooperates with the Eurocities Association, representing more than 100 large European cities. As a scientific institution, one of EURICUR’s core activities is to respond to the increasing need for information that broadens and deepens the insight into the complex process of urban development, among others by disseminating the results of its investigations by international book publications. These publications are especially valuable for city governments, supranational, national and regional authorities, chambers of commerce, real estate developers and investors, academics and students, and others with an interest in urban affairs. Euricur website: http://www.euricur.nl This book is a joint publication of EURICUR and the Institute for Housing and Urban Development Studies, two members of the Erasmus Centre for Urban Management Studies. It is one of a series to be published by Ashgate under the auspices of EURICUR, Erasmus University Rotterdam. Titles in the series are: Information and Communications Technology as Potential Catalyst for Sustainable Urban Development Leo van den Berg and Willem van Winden Sports and City Marketing in European Cities Leo van den Berg, Erik Braun and Alexander H.J. Otgaar Social Challenges and Organising Capacity in Cities Leo van den Berg, Jan van der Meer and Peter M.J. Pol City and Enterprise Leo van den Berg, Erik Braun and Alexander H.J. Otgaar The Student City Leo van den Berg and Antonio P. Russo European Cities in the Knowledge Economy Leo van den Berg, Peter M.J. Pol, Willem van Winden and Paulus Woets The Safe City Leo van den Berg, Peter M.J. Pol, Guiliano Mingardo and Carolien J.M. Spellier E-Governance in European and South African Cities Leo van den Berg, Andre van der Meer, Willem van Winden and Paulus Woets National Policy Responses to Urban Challenges in Europe Leo van den Berg, Erik Braun and Jan van der Meer Empowering Metropolitan Regions Through New Forms of Cooperation Alexander Otgaar, Leo van den Berg, Jan van der Meer, Carolien Speller Industrial Tourism: Opportunities for City and Enterprise Alexander H.J. Otgaar, Leo van den Berg, Christian Berger and Rachel Xiang Feng

Towards Healthy Cities Comparing Conditions for Change

Alexander Otgaar Jeroen Klijs Leo van den Berg European Institute for Comparative Urban Research, Erasmus University Rotterdam, The Netherlands

© Alexander Otgaar, Jeroen Klijs and Leo van den Berg 2011 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without the prior permission of the publisher. Alexander Otgaar, Jeroen Klijs and Leo van den Berg have asserted their right under the Copyright, Designs and Patents Act, 1988, to be identified as the authors of this work. Published by Ashgate Publishing Limited Ashgate Publishing Company Wey Court East Suite 420 Union Road 101 Cherry Street Farnham Burlington Surrey, GU9 7PT VT 05401-4405 England USA www.ashgate.com British Library Cataloguing in Publication Data Otgaar, Alexander H. J. Towards healthy cities : comparing conditions for change. -- (EURICUR series) 1. Urban health--Case studies. 2. Health promotion. 3. Health status indicators. 4. Health planning--Citizen participation. 5. Social responsibility of business. 6. WHO Healthy Cities Project. I. Title II. Series III. Klijs, Jeroen. IV. Berg, Leo van den. V. Institute for Housing and Urban Development Studies (Netherlands) VI. European Institute for Comparative Urban Research. 362.1'0425-dc22 Library of Congress Cataloging-in-Publication Data Otgaar, Alexander H. J. Towards healthy cities : comparing conditions for change / by Alexander Otgaar, Jeroen Klijs, and Leo van den Berg. p. cm. -- (EURICUR series) Includes index. ISBN 978-1-4094-2066-8 (hardback) -- ISBN 978-1-4094-2067-5 (ebook) 1. Community development. 2. Urban health. 3. Environmental health. I. Klijs, Jeroen. II. Berg, Leo van den. III. Title. HN49.C6O84 2010 362.1'042--dc22  2010028778 ISBN 978 1 4094 2066 8 (hbk) ISBN 978 1 4094 2067 5 (ebk) II

Contents

List of Figures    List of Tables   Preface  

1

Conditions for Investments in Healthy Cities  

2

Helsinki  

vii ix xi

1 17

3 Liverpool  

41

4 London  

55

5

75

Udine  

6 Vancouver  

91

7 Synthesis and Conclusions  

107

Index  

119

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List of Figures

1.1 The health field concept   3 1.2 Health determinants   4 1.3 Environmental press and competences   6 1.4 The three C’s for investments in healthy cities   10 2.1 The major districts of Helsinki   18 2.2 Population with a foreign background in Helsinki Metropolitan Area (left) and population and projections for different age groups (right)  19 2.3 The Helsinki Living Lab: Learning by Living   27 2.4 Vertical and horizontal projects in the Healthy Helsinki programme  37 3.1 Life expectancy at birth in large UK cities   43 3.2 Alder Hey: from hospital with a park to health park   50 4.1 Making the links for health   59 7.1 The three C’s for investments in healthy cities   107 7.2 Making the links for health   116

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List of Tables

3.1 The relative performance of the Liverpool economy   3.2 Sustainability partners of Alder Hey   4.1 Health indicators for Greater London and Great Britain  

42 49 56

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Preface

The development of healthy cities is a great challenge, not only for governments and health authorities, but also for other institutions, businesses and citizens. Public and private actors share a collective interest in a healthy urban environment. In view of ongoing urbanisation cities across the globe face the issue of how to make sure that the agglomeration advantages outweigh the agglomeration disadvantages. In order to remain competitive metropolitan areas need to develop in a healthy and more sustainable manner, reducing health inequalities and using the skills and competences of citizens to the full. The present book provides insight in the conditions under which investments in healthy cities are expected to be effective. Our analysis is based on an international comparative study which was carried out by the European Institute of Comparative Urban Research (Erasmus University Rotterdam) on behalf of five Rotterdam-based organisations united in the platform ‘Partners for Healthy Cities’: construction and infrastructure company Dura Vermeer, housing corporation Com·Wonen, healthcare provider De Stromen Opmaat Groep, school for intermediate vocational education Albeda College and the regional healthcare organisation Rotterdam-Rijnmond GGD. We would like to thank representatives of all five organisations for their support (Ben Pluijmers, Constant van Schelven, Piet Boekhoud, Vincent Roozen, Wil Heezen), but in particular Dura Vermeer Bouw Rotterdam director Joop van der Leeuw who took the initiative for setting up this platform. The case studies are based on interviews with more than 100 experts and representatives of organisations involved in healthcare and everything related to health. We want to thank all discussion partners (mentioned at the end of each chapter) for their contribution to this study. Moreover we are very grateful to several local contact persons who helped us to organise the site visits: Marianne Dannbom, Ruska Kylänen and Asta Manninen (Helsinki), Julia Taylor (Liverpool), Malcolm Souch and Neil Blackshaw (Londen), Stefania Pascut, Gianna Zamaro and Chiara de Poli (Udine) and Jessica Chen and Kira Gerwin (Vancouver). Finally we would like to thank our colleagues Lenneke Wester and Ankimon Vernède for their valuable contributions to the organisation of the project. Alexander Otgaar  Jeroen Klijs Leo van den Berg

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Chapter 1

Conditions for Investments in Healthy Cities

1  Introduction This book presents an integrated framework for analysing investments in healthy cities. It is based on an international comparative study that was carried out by the European Institute for Comparative Urban Research (Euricur) based at Erasmus University Rotterdam. The study has been commissioned by five Rotterdam-based public and private organisations under the flag of ‘Partners for Healthy Cities’. As in many other cities, actors in Rotterdam face the challenge of improving the health of its citizens. The average life expectation of people who live in Rotterdam is between 12 and 18 months shorter than the Dutch average, according to the Netherlands Environmental Assessment Agency based on national statistics (CBS). Cities such as Rotterdam are not only coping with unfavourable living conditions (e.g. in terms of air quality), but more in particular with a concentration of people with a lower socio-economic status (SES). At the same time, however, an urban environment also presents economic opportunities to its citizens. Metropolitan areas are the engines of national economies and places where new ideas are born, due to a high concentration of a relatively young and diverse population (e.g. Florida, 2003). Health can be seen as an important precondition to take advantage of these opportunities. The development of healthy cities is not only a task of the government, but also of healthcare providers, educational institutions, citizen groups, and private businesses. They all have a stake in creating a better urban environment that enables citizens to take advantages of agglomeration, not only in terms of health, but also in terms of social capital and jobs. In Rotterdam, the Partners for Healthy Cities have recognised their interest and role in this process, explaining their wish to gain insight in the experiences of other cities. One of the aims of this book is to identify examples of successful investments in healthy cities that include the involvement of non-governmental actors. The main question to be answered in this book is under what conditions public and private investments in healthy cities are effective. We will use an integrated approach to health in line with the Healthy Cities philosophy of the World Health Organization. In the present chapter we develop a research framework to be applied   Construction and infrastructure company Dura Vermeer, housing corporation Com·Wonen, healthcare provider De Stromen Opmaat Groep, school for intermediate vocational education Albeda College and the regional healthcare organisation RotterdamRijnmond GGD.



Towards Healthy Cities

to five case studies: Helsinki (Finland), Liverpool (UK), London (UK), Udine (Italy) and Vancouver (Canada). This framework is based on literature review and interviews with several experts in the Netherlands (see the list of discussion partners at the end of this chapter). The set-up of the present chapter is as follows. In the second section we discuss various views on health and its determinants. The third section concentrates on health in an urban environment, and introduces an integrated approach to healthy city development. In the final section we identify three conditions for investments in healthy cities to be analysed empirically in the five case studies that follow.

2  Health and its Determinants A Broader De.nition of Health Health is a multifaceted and complex concept that is studied on many different levels and by many different disciplines (Anderson, 1998). While in ancient and non-Western societies very broad definitions of health were common, the physical dimension of health has been very dominant for quite some time in the Western World. Health has often been described as ‘the absence of disease’ (Saylor, 2004; Bok, 2004). This definition corresponds to the long time dominant medical tradition whereby health improvements were pursued by fighting diseases and decreasing the risks of becoming ill. Also today many people use this narrow definition of health (Larson, 1999). The last decades the support for broader definitions of health also increased in Western cultures. Health is no longer seen as a purely medical concept but as an indicator of wellbeing. The absence of illness does not mean that somebody feels well while someone with a chronic disease can experience a high quality of life. Already in 1948 the World Health Organization (WHO) described health as ‘a state of complete physical, mental and social well-being, and not just the absence of illness’ (WHO, 1948; also see Bok, 2004). Although the WHO definition is widely used, there is also criticism. Larson (1999) and Bok (2004) argue that, according to this definition, no individual and certainly no population group can ever be completely healthy. In their view it makes more sense to define health in relative terms. Saracci (1997) points to the fact that health, defined in such a broad sense, is almost the same as happiness, thereby transforming every human problem into a health problem (Callahan, 2003). Moreover, it is also hazardous to include social well-being in the concept of health because there are no generally accepted norms for this. Bok (2004) points to the, historically proven, dangers when a society determines norms for social health. What is considered socially unhealthy in one (sub)culture at one point in time (like supporting a certain religion or the membership of a social movement) can in other (sub)cultures be considered as socially healthy. Callahan (2003) and Salomon et al. (2003) advocate the exclusion of social well-being from the concept of health.

Conditions for Investments in Healthy Cities



Despite the criticism on the definition of the WHO, it does offer a good start for understanding health and its determinants. Many points of critique on the definition relate to the way it is formulated or the applicability but they are, according to Saylor (2004), still no reason to reject the definition. More important than defining health is comprehending the factors that influence health. Insight into its determinants can help to develop interventions that contribute to public health. The Health Field Concept In 1974, the former Canadian minister of National Health and Welfare, Lalonde, presented a new perspective on health determinants which is still popular today. This so-called health field concept distinguishes four groups of health determinants (see Figure 1.1): • •

•

•

Human biology – All factors related to the human body itself (internally): age, sex and genetic (hereditary) characteristics. Environment – The determinants that are outside the human body (external) and on which individuals have limited or no control: the quality of air, water and the quality of the physical and social environment. Lifestyle – This includes the decisions made by individuals in terms of (un)healthy behaviour; being active, eating and smoking. A healthy lifestyle decreases the chance of getting ill. Healthcare facilities – The way healthcare is organised: availability, accessibility and quality. Often a distinction is made between cure (healing) and care (preventing illness).

The health field concept makes clear that the quality of healthcare is only one of the factors influencing health, implying that health interventions should not be limited to the healthcare system. They should also include improvements of the social and physical environment and stimulate healthy behaviour.

Figure 1.1

The health field concept

Source: ‘A New Perspective on the Health of Canadians’ (Lalonde, 1974), own illustration



Figure 1.2

Towards Healthy Cities

Health determinants

Source: ‘European strategies for tackling social inequities in health: Levelling up Part 2’ (Dahlgren and Whitehead, 2006).

Dahlgren and Whitehead (2006) further developed the health field concept into a more complex model depicted in Figure 1.2. This model makes clear that health is determined, first of all, by age, sex and constitutional (genetic) characteristics. These aspects of human biology constitute the core of the model. The four layers around the core categorise the other determinants of health. Closest to the core are the individual lifestyle factors. The three other layers include various determinants that could be seen as environmental factors in the terminology of Lalonde. The ability of an individual to take control of a health determinant decreases with the distance to the core. The first layer of the environment comprehends the social and community networks in which individuals participate. The second layer consists of living and working conditions such as housing, employment, agriculture and food production, water and sanitation and education. In comparison with the original health field concept, the healthcare organisation (healthcare services) moved lower down the hierarchy of health determinants. The outer ring contains general social-economic, cultural and environmental conditions that are most difficult for individuals to influence. The model of Dahlgren and Whitehead makes clear that health determinants are connected to one another. Let us give an example to explain this. If somebody wants to quit smoking, what factors, besides from personal motivation, can play a role? First of all behavioural scientists will confirm social networks (family and friends) play an important role in changing behaviour. General practitioners can

Conditions for Investments in Healthy Cities



help the person with advice and medication. But perhaps more important is the working environment: a smoke-free environment makes it more difficult to light up a cigarette. This only has an influence, of course, if the person involved has a job. If the person is unemployed, acquiring a job could play an important role in changing behaviour. Lastly, the factors in the outer layer play a role, such as the duty on tobacco and a declining social acceptance of smoking in public. This example makes clear that all factors (together) play a role in adopting a healthy lifestyle and improving health. The health field concept and the model of Dahlgren and Whitehead help us to understand that the environment is an important health determinant. The quality of the environment not only has a direct influence on health (e.g. in the case of pollution), but also a more indirect influence via the behaviour of people. Ideally the environment stimulates healthy behaviour: making the healthy choice the easy choice. On the other hand, the environment is also determined by the behaviour of people: individual (spatial-economic) behaviour ultimately determines the development of social networks and a healthy environment. Wilkinson and Marmot (2003) state that there is a two-sided relationship between health and the (physical and social) environment. Health is often a precondition for healthy choices that benefit the individual and his or her environment. Environmental Press and Competences An important aspect in the relation between the environment and health concerns the degree to which people are able to cope with the environmental press they experience. Environmental press can be positive (activating) or negative (deactivating). According to Lawton (1973) the wellbeing of people depends on the balance between the level of environmental press (high or low) and their competences (high or low), as indicated in Figure 1.3. The model distinguishes between situations in which people are marginally outside of their comfort zone and situations in which people are actually demonstrating negative behaviour. Within the comfort zone people can aim for maximal comfort (with enough pressure) and maximal performance (with maximum pressure, without leading to stress). The dotted line represents the points where there is balance between competences and pressure from the environment. The assumption is that the wellbeing of people can be improved by aligning (sudden) changes in the environmental press with changes in competences. When people find themselves on the right side of the comfort zone, their competences are too limited to translate the pressure they experience to positive behaviour. In the most negative scenario this leads to disablement, which means, in a broad sense, the inability to participate in society (see Verbrugge and Jette, 1994). When people are on the left side of the comfort zone, the environment presents too little pressure for their relatively strong competences. This is comparable to a situation of a highly talented student who is not challenged by the lessons. These circumstances can



Figure 1.3

Towards Healthy Cities

Environmental press and competences

Source: ‘Ecology and the Aging Process’ (Lawton and Nahemow, 1973). Reprinted with permission.

lead to boredom, negative behaviour and sometimes a feeling of powerlessness (Seligman, 1975). Imbalances between competences and environmental press can often be taken away by people themselves. There is only a very small group of people who have such low competences that the pressure from the environment has to be kept low permanently: organisations need to take care of them continuously. For other people, however, sudden changes in competences or environmental press (caused by events such as the birth of a child or the death of a relative) can disturb their balance temporarily. What matters in such situations is a person’s ability to regain control, also referred to as the internal locus of control (Rotter, 1966). Organisations are advised to provide services that strengthen this ability.

Conditions for Investments in Healthy Cities



3  Healthy Cities Health Geography The environment in cities is clearly different from the environment in nonurban areas. In health geography urban and suburban areas have been identified as environments with specific health conditions. The concentration of lower income groups in cities explains why urban dwellers have a relatively short life expectancy: a phenomenon known as the urban health penalty (Andrulis, 1997; Vlahov et al., 2004). On the other hand urban sprawl – the increasing popularity of suburban living – results in increasing car usage, social isolation and a decrease of social capital, with a negative impact on health (Frumkin et al., 2004). An urban environment is not only negative: it also offers urban health advantages such as a broader supply of healthcare facilities (Vlahov et al., 2005). Differences in health and life expectancy can not only be observed between urban and non-urban environments, but also between various urban areas. It appears that neighbourhoods with a low social-economic status (SES) tend to score low on health indicators (Van Lenthe et al., 2005). Inhabitants of low SES neighbourhoods generally have less healthy lifestyles than high SES neighbourhoods, especially with regard to physical activities and smoking (Van Lenthe and Mackenbach, 2002, 2006; Van Lenthe et al., 2006). In the Netherlands people with a low SES live four years shorter than people with a high SES. The difference between low and high SES is even considerably higher if we look at the number of years people experience good health: 15 years (NIGZ, 2006). Various studies indicate that geographic health differences are caused by differences in the composition of the population: health and SES go hand in hand. It is difficult to improve health indicators in low SES neighbourhoods as many people with an increasing SES leave the area as soon as they are able to, again making room for people with a lower SES. Research demonstrates that this migration pattern is indeed influenced more strongly by SES than by health considerations (Van Lenthe et al., 2006). Another reason why some urban areas score low on health is the quality of the physical and socio-economic environment: this is the contextual explanation for geographic health differences. An important environmental factor is the (experienced) safety in an area: a relevant condition for physical activities (Van Lenthe et al., 2004). The Dutch Institute for Public Health and the Environment (RIVM) recognises both the compositional and contextual explanation assuming a ‘complex interaction between the individual and the environment’ (RIVM, 2006). Kawachi and Berkman (2000) reason that individuals contribute to social cohesion (the contact with neighbours, the degree to which people place value on living in a certain neighbourhood and the degree to which people know each other), but that their health is simultaneously influenced by the degree of social cohesion. Their research shows that people in neighbourhoods with less social cohesion run a significantly higher risk of becoming unhealthy, also when the composition of



Towards Healthy Cities

the neighbourhood (SES) is taken into account. Bernard et al. (2007) claim that compositional and contextual explanations of health are so intensely intermingled that it is very difficult (and not very useful) to try and separate them. Environmental Influences on the Health of Citizens The assumption that the urban environment is an important determinant of health is not new. In the nineteenth century, in the time of the hygienists, there was much attention for the influence of basic facilities, such as a sewage system, on public health. After a temporary decrease of attention, the subject has returned on the agenda of policy makers and scholars (e.g. Handy et al., 2002). For example, Den Hertog et al. (2006) conclude that physical activity can be stimulated by developing neighbourhoods with high building densities, amenities at walking distance and parking places that are spatially detached from dwellings. Green zones appear to discourage walking as they raise the perceived distance. Also in the US there is much attention for the influence of the built environment on behaviour. Confronted with the continuous expanding of urban agglomerations (suburban sprawl), which increases the amount of car usage, smart growth is now advocated, leading to compact, pedestrian-friendly areas with a diversity of functions. Several studies show that there is not only a relationship between the urban environment and behaviour, but also between the urban environment and health (Handy et al., 2002; Frank and Engelke, 2001; Frumkin, 2003; Ewing et al., 2003; Frumkin et al., 2004; Policy Link and the California Endowment, 2007). Relevant aspects of the urban environment are, among others, the access to nature, the design of buildings, the design of public space and the design of neighbourhoods or districts (Frumkin, 2003). Health impact assessments can be applied to measure the effect of changes in the urban environment (through interventions) on health, although admittedly these effects are difficult to quantify (Van Lenthe et al., 2005). It is often difficult to prove that health improvements are actually caused by interventions in the urban environment (Veerman, 2007). A good health impact assessment requires insight in the starting situation and the direct influence of interventions on behaviour. An Integral Approach to Healthy Cities: The Healthy Cities Programme In 1988, the World Health Organization (WHO) launched the Healthy Cities Programme which has the goal to improve the health of urban dwellers, and particularly lower income groups, by investing in urban living conditions. This approach is based on the idea that the urban living environment is a complex whole of mutually dependent factors, for which not only the government but also other actors are responsible (De Leeuw, 2007). The Healthy Cities Programme identifies 11 qualities of a healthy cities: (1) A clean, safe environment of high quality (2) a stable ecosystem (now and in the long run) (3) A strong community (4) A high degree of participation by the

Conditions for Investments in Healthy Cities



population in decisions that impact their life, health and well-being (5) All basic conditions are met (food, water, shelter, income, safety, work) (6) Access to a broad variety of experiences and means with possibilities of contact, interaction and communication (7) A diverse, vital and innovative economy (8) Connection to the past, to the cultural and biological heritage (9) A urban form that is in accordance with all the previous points (10) An optimal level of an access to healthcare facilities (11) A high health status of the population. This list makes clear that public health essentially depends on the attractiveness of a city in economic, social and environmental terms (Van den Berg et al., 1999). Employment, social cohesion, accessibility, the quality of the built environment and affordable housing are important ingredients of an attractive city and sustainable development in the broader sense of the word (Hall and Pfeiffer, 2000; Hancock, 1993, 1999). An integral approach to the development of healthy cities implies coordination and cooperation between the various actors that have a stake in the city. Freudenberg (2005) argues that governments, market actors and civil society have the ability to improve urban living conditions, taking into account the ‘enduring structures’ (economic systems, religion, government, culture, geography) in which they function. The WHO explicitly advocates the involvement of nongovernmental actors in health promotion: ‘There is a clear need to break through traditional boundaries within government sectors, between governmental and nongovernmental organisations, and between the public and private sectors. Cooperation is essential; this requires the creation of new partnerships for health, on an equal footing, between the different sectors at all levels of governance in societies’ (WHO, 1997, 3). This increasing need for cross-sector cooperation raises the importance of organising capacity as a determinant of healthy and sustainable urban development (Van den Berg, Braun and Van der Meer, 1997). Lemmers and Peters (2002), for instance, advise public actors to make, for each health project, an analysis of the actors that offer added value, for example because they provide access to certain target groups, expertise, networks or financial means. In 1999, Kolthof (1999) concluded that the involvement of the private sector in the WHO Healthy Cities Programme of the WHO is somewhat disappointing: 17 of the 26 cities that were researched had not yet involved the private sector, 15 were however planning to do so. The research also shows that the cities that involve companies often do this on an ad hoc basis. Nonetheless the cities were positive about the added value of involving the private sector, not only for the city but also for the companies themselves.

4  Conditions for Investments in Healthy Cities: The Research Framework Literature review and interviews with experts in the field of public health and urban development have helped us to identify the three C’s for investments in healthy cities: Citizen empowerment, Corporate responsibility and the Coordinated improvement of urban health conditions (see Figure 1.4). The central hypothesis

Towards Healthy Cities

10

Figure 1.4

The three C’s for investments in healthy cities

Source: The authors.

in our study is that these three conditions are critical factors for improving the health conditions in cities. Citizen Empowerment In the end citizens are responsible for their own health. They choose their style of living: what they eat, what they drink, how they commute, how they spend their leisure time, etc. Governments, community organisations, healthcare organisations and other non-governmental actors cannot force people to adopt a healthy lifestyle: they can only try to create an urban environment that stimulates people to live a healthier life: ‘making the healthy choice the easy and attractive choice’. Our proposition reads that the most effective and cost-efficient way to improve the health of citizens is to empower them. Ideally urban dwellers become coproducers of their own environment through active involvement in the development and implementation of interventions. Such empowerment makes citizens intrinsically motivated to enhance their way of living, which helps to reduce the demand for healthcare and the associated costs in an increasingly individualised and ageing society. One of the main challenges for urban actors is to enhance the ability of people to take and keep control of their lives taking into account their values, preferences, competences and other individual or group characteristics such as income and social status. Corporate Responsibility The second condition we consider relevant for investments in healthy cities is corporate responsibility. Our hypothesis is that non-governmental actors (companies, housing corporations, educational institutions, etc.) have an interest in the development of healthy cities. According to this philosophy corporate responsibility is not a matter of philanthropy or window dressing, but rather an integrated element of an organisation’s strategy (Van den Berg, Braun and Otgaar, 2004). The healthcare sector is challenged to cooperate with non-governmental actors that are able to create an urban environment that empowers citizens. We assume that companies and other stakeholders can only take their responsibility if the healthcare sector and the government are willing to take a step back.

Conditions for Investments in Healthy Cities

11

Coordinated Improvement of Urban Health Conditions Citizen empowerment and corporate responsibility are both related to the third condition: a coordinated improvement of urban health conditions. The physical, social and economic circumstances in which people live are key determinants of their ability to take and keep control of their own lives. We hypothesise that the interaction between all determinants is a critical issue in the development of healthy cities. Urban health problems are not the result of one single condition; they are caused by an accumulation of interrelated determinants. The coordinated improvement of health conditions requires a comprehensive vision and strategy that recognises the complex interplay between determinants. Ideally such a vision and strategy result in public and private investments assuming a shared responsibility of public and private stakeholders.

5  Research Method The relevance of the three conditions will be assessed by analysing a range of initiatives in the five selected cities (Helsinki, Liverpool, London, Udine and Vancouver). The empirical analysis is based on desk research and semi-structured interviews with key informants. In each case study (Chapters 2, 3, 4, 5 and 6) we first provide a general profile of the city discussing the most relevant context factors. After that we review various initiatives to improve urban health conditions. We test the empirical applicability of the three conditions by analysing if and how urban actors try to meet the conditions we formulated. In Chapter 7 we summarise our research findings and draw conclusions.

References Anderson, N.B. (1998), Levels of Analysis in Health Science: A Framework for Integrating Sociobehavioral and Biomedical Research, Annals of the New York Academy of Sciences, 840, 563–76. Andrulis, D.P. (1997), The Urban Health Penalty: New Dimensions and Directions in Inner-City Health Care, in Inner City Health Care, Philadelphia: American College Physicians, No. 1. Berg, L. van den, Braun, E. and Meer, J. van der (1997), The Organising Capacity of Metropolitan Regions, Environment and Planning C: Government and Policy, 15, 253–72. Berg, L. van den, Braun, E. and Otgaar, A.H.J. (2004), Corporate Community Involvement in European and US Cities, Environment and Planning C: Government and Policy, 22, 475–94.

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Bernard, P., Charafeddine, R., Frohlich, K.L., Daniel, M., Kestens, Y. and Potvin, L. (2007), Health Inequalities and Place: A Theoretical Conception of Neighbourhood, Social Science & Medicine, 65, 1839–52. Bok, S. (2004), Rethinking the WHO Definition of Health, Working Paper Series, 14(7), Harvard Center for Population and Development Studies. Callahan, D. (2003), What Price Better Health? Berkeley, US: University of California Press. Dahlgren, G. and Whitehead, M. (2006), Levelling Up (part 2): a discussion paper on European strategies for tackling social inequities in health, Copenhagen: WHO Regional Office for Europe. Ewing, R., Schieber, R.A. and Segeer, C.V. (2003), Urban Sprawl as a Risk Factor in Motor Vehicle Occupant and Pedestrian Fatalities, American Journal of Public Health, 93(9), 1541–45. Florida, R. (2003), Cities and the Creative Class, City & Community 2(1), 3–19. Frank, L.D. and Engelke, P.O. (2001), The Built Environment and Human Activity Patterns: Exploring the Impacts of Urban Form on Public Health, Journal of Planning Literature, 16(2), 202–18. Frumkin, H. (2003), Health, Equity and the Built Environment, Environmental Health Perspectives, 113(5), A290–A291. Frumkin, H., Lawrence, F. and Jackson, R. (2004), Urban Sprawl and Public Health: Designing, Planning, and Building for Healthy Communities, Washington, US: Island Press. Hall, P. and Pfeiffer, U. (2000), Urban Future 21: A Global Agenda for TwentyFirst Century Cities, London: E&FN Spon. Hancock, T. (1993), Health, Human Development and the Community Ecosystem: Three Ecological Models, Health Promotion International, 8, 41–7. Hancock, T. (1999), People, Partnerships and Human Progress: Building Community Capital, Health Promotion International, 16(3), 275–80. Handy, S.L., Boarnet, M.G., Ewing, R. and Killingsworth, R.E. (2002), How the Built Environment Affects Physical Activity: Views From Urban Planning, American Journal of Preventative Medicine, 23(2), Supp. 1, 64–73. Hertog, F. den, Bronkhorst, M., Moerman, M. and Wilgenburg, R. van (2006), De Gezonde Wijk: een onderzoek naar de relatie tussen fysieke wijkkenmerken en lichamelijke activiteit, Amsterdam: EMGO Instituut. Kawachi, I. and Berkman, L.F. (2000), Social Cohesion, Social Capital and Health, in Social Epidemiology, edited by L. Berkman and I. Kawachi. Oxford: Oxford University Press, 174–90. Kolthof, E. (1999), Local Networking for Health: A Study into the Involvement of Private Business In Healthy Cities, University of Limburg, Research for Healthy Cities Clearing House. Lalonde, M. (1974), A New Perspective on the Health of Canadians. Ottawa, Ontario: Government of Canada. Larson, J. (1999), The Conceptualization of Health, Medical Care Research and Review, 56, 123–36.

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Lawton, M.P. and Nahemow, L. (1973), Ecology and the Ageing Process, in The Psychology of Adult Development and Aging, edited by C. Eisdorfer and M.P. Lawton, Washington DC: American Psychological Association. Leeuw, E. de (2007), Global and Local (Glocal) Health: The WHO Healthy Cities Programme, Global Change & Human Health, 2(1), 34–45. Lemmers, L. and Peters, L. (2002), Publiek-private samenwerking, in Tijd voor gezond gedrag. Bevordering van gezond gedrag bij specifieke groepen edited by J. Jansen, A.J. Schuit and F.J. van der Lucht. Bohn Stafleu Van Loghum/ RIVM, 216–24. Lenthe, F.J. van, Brug, J. and Mackenbach J.P. (2005), Neighbourhood Inequalities in Physical Inactivity: The Role of Neighbourhood Attractiveness, Proximity to Local Facilities and Safety in the Netherlands, Social Science & Medicine, 60(4), 763–75. Lenthe, F.J. van and Mackenbach, J.P. (2002), Neighbourhood Deprivation and Overweight: The GLOBE Study, Int J Obes Relat Metab Disord, 26, 234–40. Lenthe, F.J. van and Mackenbach, J.P. (2006), Neighbourhood and Individual Socioeconomic Inequalities in Smoking: The Role of Physical Neighbourhood Stressors, Journal of Epidemiol Community Health, 60, 699–705. Lenthe, F.J. van, Martikainen, P. and Mackenbach, J.P. (2006), Neighbourhood Inequalities in Health and Health-Related Behaviour: Results of selective migration, Health & Place. Lenthe, F.J. van, Schrijvers, C.T., Droomers, M., Joung, I.M., Louwman, M.J. and Mackenbach, J.P. (2004), Investigating Explanations of Socio-Economic Inequalities in Health: The Dutch GLOBE study, Eur J Public Health, 14, 63–70. NIGZ (2006), Wat kan uw gemeente doen aan sociaal-economische gezondheidsverschillen? Richtlijnen voor een wijkaanpak, Uitgeverij NIGZ, Woerden. Policy Link and the California Endowment (2007), Why Place Matters: Building a Movement for Healthy Communities. RIVM (2006), Geografische verschillen in gezondheid, VTV-2006, 24 June 2006. Available at: http://www.rivm.nl/vtv/object_document/o5459n30053.html. Rotter, J.B. (1966), Generalized Expectancies for Internal versus External Control of Reinforcement. Psychological Monographs: General and Applied, 80, 609. Salomon, J.A., Mathers, C.D., Chatterji, S., Sadana, R., Üstün, T.B. and Murray, C.J.L. (2003), Quantifying Individual Levels of Health: Definitions, Concepts and Measurement Issues, in Health Systems Performance Assessment: Debates, Methods and Empiricism, edited by C.J.L. Murray and D.B. Evans. Geneva, Switzerland: WHO, 301–18. Sarraci, R. (1997), The World Health Organization Needs to Reconsider its Definition of Health, BMJ. Saylor, C. (2004), The Circle of Health: A Health Definition Model, Journal of Holistic Nursing, 22, 97–115.

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Seligman, M.E.P. (1975), Helplessness. San Fransisco: Freeman. Veerman J.L. (2007), Quantitative Health Impact Assessment: An Exploration of Methods and Validity, Rotterdam: Erasmus University Rotterdam. Verbrugge, L.M. and Jette, A.M. (1994), The Disablement Process, Social Science and Medicine, 38, 1–14. Vlahov, D., Gibble, E., Freudenberg, N. and Galea, S. (2004), Cities and Health: History, Approaches, and Key Questions, Academic Medicine, 79(12), 1133– 38. Vlahov, D., Galea, S. and Freudenberg, N. (2005), The Urban Health ‘Advantage’, Journal of Urban Health, 82(1). Wilkinson, R. and Marmot, M. (2003), The Solid Facts: Social Determinants of Health, 2nd edition, WHO Regional Office for Europe, Centre for Urban Health. World Health Organization (1948), Constitution. WHO, Geneva, Switzerland. World Health Organization (1997), Jakarta Declaration on Leading Health Promotion into the 21st Century, [Online]. Available at: http://www.who.int/ hpr/NPH/docs/jakarta_declaration_en.pdf.

Discussion Partners Frank van den Beuken, Gemeente Rotterdam, dS+V Bas Bodzinga, De Stromen Opmaat Groep Piet Boekhoud, Albeda College Josine van den Boogaard, GGD Rotterdam-Rijnmond Ole Bouman, Nederlands Architectuurinstituut Aat Brand, Gemeente Rotterdam, Dienst SoZaWe Lex Burdorf, Erasmus MC / CEPHIR Joop ten Dam, NIGZ Reind van Doorn, GGD Rotterdam-Rijnmond Frank van Genne, Hanzehogeschool Groningen Ferdinand de Haan, NIGZ Jan Jansen, NIGZ Jaap Korteweg, Dura Vermeer Evelyne de Leeuw, WHO Healthy Cities, Deakin University Joop van der Leeuw, Dura Vermeer Bouw Rotterdam Frank van Lenthe, Erasmus MC Harry van Ommen, Gemeente Rotterdam, Dienst SoZaWe Henk Oosterling, Erasmus Universiteit Rotterdam Carolien de Pater, GGD Rotterdam-Rijnmond Ben Pluijmers, Com·Wonen Ron Pullen, Gemeente Eindhoven, voormalig directeur GGD Eindhoven Vincent Roozen, GGD Rotterdam-Rijnmond Constant van Schelven, De Stromen Opmaat Groep

Conditions for Investments in Healthy Cities

Paul Smits, Maasstad Ziekenhuis Dick van Well, Dura Vermeer Chris Zevenbergen, Dura Vermeer Business Development Edwin Zwerver, De Stromen Opmaat Groep Frank van Zutphen, Ecorys

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Chapter 2

Helsinki

1  Introduction In this chapter we apply our research framework – the three conditions for investments in healthy cities – to the programme Healthy Helsinki. After a general profile of the city – describing the most relevant context factors – we first analyse the position of Healthy Helsinki in relation to other initiatives such as the innovation strategy, Forum Virium and Helsinki Living Labs. Next we present our analysis of the programme Healthy Helsinki and the projects that come under this heading. 2  General Profile An Introduction to the City of Helsinki and its Region Helsinki, the capital of Finland, is located in the south of the country, on the shore of the Gulf of Finland. With 576,632 inhabitants it is by far the most populated city of the country, being the centre of the Helsinki Region that counts more than 1.3 million citizens. The two neighbouring municipalities, Espoo and Vantaa, rank second and fourth in the list of largest cities in Finland, providing homes to 238,000 and 192,000 people respectively. Together with Kaunianinen (a small enclave in Espoo) and Helsinki they constitute the Helsinki Metropolitan Area, which is the core of the Helsinki Region. Helsinki belongs to Uusimaa, one of the 20 regions into which Finland is divided. The city itself can be subdivided into 54 neighbourhoods (for planning purposes) as well as into 8 major districts and 34 districts (Figure 2.1). Unofficially, Helsinki can also be divided into four geographic areas: central Helsinki (combining the southern part of the central district with the southern district except Lauttasaari), west Helsinki (the western district plus Lauttasaari), north Helsinki (the northern and northeastern major districts and the northern part of the central major district) and east Helsinki (the eastern and southeastern major districts). The district Östersundom has only recently (January 2009) been added to Helsinki.

  This case study is based on interviews with various stakeholders in January 2009.

18

Figure 2.1

Towards Healthy Cities

The major districts of Helsinki

Source: City of Helsinki Urban Facts

Between 2002 and 2007, the population of Helsinki remained relatively stable with an increase of about 5,000 people during this period (City of Helsinki Urban Facts, 2007a). In comparison with other major European cities the share of people with a foreign background is small: only 9.5 per cent. Nevertheless, as indicated in the figure below, the share of foreign nationals and Finnish nationals born abroad has increased considerably since 1990. The city has welcomed new residents from EU member states (particularly from neighbouring Estonia) but also from African countries such as Somalia. About 9 per cent of the population is fluent in another language than Finnish or Swedish, the two official languages (City of Helsinki Urban Facts, 2008a). Expectations are that the share of people ‘with a migrant background’ will further increase to about 25 per cent in 2020.   Herttoniemi (Hert.) is the living lab of Healthy Helsinki. It belongs to the Southeastern district.

Helsinki

19











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Figure 2.2

Population with a foreign background in Helsinki Metropolitan Area (left) and population and projections for different age groups (right)

Source: City of Helsinki Urban Facts

Another demographic trend concerns the ageing population: the number of 65 yearolds in Helsinki is expected to grow from about 78,000 in 2006 to approximately 120,000 in 2025, an increase of more than 50 per cent (City of Helsinki Urban Facts, 2008c). Economic Development The last 15 years the Helsinki region has recovered from a deep economic crisis that hit the region (and Finland in general) in the early 1990s with a maximum unemployment rate of 13.1 per cent. After this crisis the electronics industry (ICT) became a leading export industry for Finland, joining traditional industries such as the paper and pulp and metal industry (Tukiainen, 2003). This structural change appeared to benefit metropolitan regions and in particular the Helsinki region, with knowledge intensive industries, telecommunication and business-to-business services as the main engines of economic growth (Susiluoto and Loikkannen, 2001; City Office of Helsinki, 2002). Between 1988 and 1999 the ICT sector gained a larger share in regional production (from 17 to 23 per cent), while the share in employment increased from 10.7 per cent in 1990 to 14.5 per cent in 2000

20

Towards Healthy Cities

(Tukiainen, 2003). The success story of Finland’s ICT sector is undoubtedly related to the success of mobile phone manufacturer Nokia, which was founded as a paper manufacturer in the 19th century and started to produce telephones in the 1960s. Other leading Finnish companies in this sector are Sanoma (media), TeliaSonera (telecommunications, the result of a merger between the Swedish company Telia and the Finnish company Sonera) and Elisa (telecommunications). Also after the burst of the IT-bubble in the beginning of the 21st century Helsinki succeeded in improving its international competitive position. In an international comparison of 45 European metropolitan regions, the Helsinki region ranked 10th on employment growth and 8th on production growth between 2001 and 2005; and 5th on expected employment and production growth between 2006 and 2011 (Laakso and Kostiainen, 2007). In 2007 the unemployment rate in the City of Helsinki was 6.1 per cent. Most jobs are provided by the service sector (85 per cent) in which community services take a share of 42 per cent (that is almost 36 per cent of all jobs) (2004 data, City of Helsinki Urban Facts, 2007a). In the Finnish political system there are only two governmental layers with elected representatives: the state and the local government. In addition there are several regional bodies to coordinate national policies on an intermediate level. Municipalities operate with a high degree of autonomy in planning and service delivery and the right to levy taxes (also on income). Income from taxes is used to deliver a wide range of public services, including education, healthcare, social welfare, culture, environmental and technical infrastructure, and water supply. Particularly in the sparsely populated rural parts of Finland – where population is declining – the quality and accessibility of public services has become an issue, explaining the national demand for multifunctional walk-in health centres, homebased nursing and mobile internet solutions (OECD, 2005). Administrative Organisation Helsinki’s administrative organisation comprises 36 departments and several boards and committees that all fall under the political responsibility of the mayor and four deputy mayors. In total, the municipality provides employment to more than 38,000 people of whom more than 50 per cent are active in the field of social affairs and public health (City of Helsinki Urban Facts, 2007b). The share of the public sector in the regional economy is close to the average of 45 large European metropolitan regions (Laakso and Kostiainen, 2007) One of the deputy mayors is responsible for social affairs and public health, giving directions to the social services department and committee, the health committee and the Health Centre. Healthcare is delivered through 26 health stations (primary care), five home care service areas, three dental care units, four acutecare hospitals, four long-term care hospitals and six psychiatric hospitals. Together they constitute the Health Centre which provides employment to more than 8,500 people in the city, mostly nurses (66.9 per cent) (Health Centre, 2007). While more healthcare is needed due to an ageing population, the number of employees that

Helsinki

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reach retirement in the coming years will increase (2,274 people between 2008 and 2020). Apart from the facilities operated by the Health Centre, there are three hospitals in the city operated by the Hospital District of Helsinki and Uusimaa (a regional body). In total the City of Helsinki spends 26.7 per cent of its budget (more than €1 billion) on healthcare, of which 60 per cent through the Health Centre and 40 per cent through the Hospital District. Healthcare expenditures per inhabitant have increased from €1,170 in 2000 to €1,653 in 2007. In real prices (taking into account inflation) this implies an increase of more than 17 per cent. Only a small part of the budget (€69.8 million) is covered by income through fees: the health sector is mainly funded by public tax money. Since 1999, a Healthy and Safe City advisory committee has the task to promote coordination in the city’s efforts to promote safer and healthier lifestyles. This committee is chaired by the deputy mayor for social affairs and public health, and includes representatives of the planning department, the cultural office, the sports department, the youth department, the education department, the social services department and the health department (Health Centre). Also the Helsinki Police and the alcohol and drug treatment and prevention organisation A-Clinic are involved. One of the committee’s objectives is to develop incentives – together with NGOs – that stimulate people to adopt a healthier lifestyle. Health and Social Conditions Finland is an egalitarian society in which all citizens have access to basic services. In Helsinki there are no neighbourhoods with severe deprivation. The city’s Healthy and Safe City advisory committee, however, is concerned about the increasing social segregation which manifests itself in health inequalities: healthy people get healthier, while unhealthy people get unhealthier. Since the turn of millennium, health differences between population groups have grown in Helsinki: social status (education, the labour market position and financial situation) increasingly determines health. On average higher-educated men live 7.8 years longer than lower-educated men, while the difference for women is 4.2 years. These differences are bigger than elsewhere in the country. Although no child has to live in poverty, about 10 per cent is depressed due to a lack of affection and attention. There are also geographic health inequalities. First of all, the average life expectancy for Helsinki residents (74.3 for men years and 81.3 years for women) is one year shorter than for the Finnish average. The reason is that the city attracts also people with a low socio-economic status from the country side, and this status is often inherited by their children. In addition, people who live in the central area live five years shorter than those who live in the southern parts of the city. According to the Health Centre, ‘these area differences are explained by differences in suicide, accident and coronary heart disease mortality as well as in mortality caused by violence and alcohol’ (Health Centre, 2007, 7). Some areas of Helsinki are in a more favourable position than other parts of the city. This is reflected in the unemployment rate, the educational level of the

Towards Healthy Cities

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population and the composition of the housing stock (owner occupied versus rental housing and apartments versus detached or terraced housing). Although socioeconomic differences between areas are still small compared to other European cities, they are slowly increasing. The transition to a knowledge-based economy results in increasing unemployment and income differences between the highereducated and the lower-educated (Rautavaara, 2002). Furthermore, unemployment not only correlates with the average educational level, but also with the average age: a higher concentration of older people implies more structural unemployment. Particularly districts in the eastern part of the city and in the northwest are dealing with an accumulation of socio-economic problems. These areas also have the highest concentration of ‘recent immigrants’. Many of these immigrants do not speak Finnish (or Swedish), which is probably related to the fact that it is one of the most difficult languages to learn. In view of the expected increase of immigrants in the next decade the question is if Helsinki will succeed to avoid the concentration of ethnic minorities.

3  Initiatives to Improve Urban Health Conditions Healthy Cities Until 2004 Helsinki was member of the Finnish Healthy Cities network. This network was set up in 1996 as part of the WHO Health for All programme. Although the city hosted an international Healthy Cities conference in 1988 – the first meeting of national coordinators – it has never participated in the international network. After Turku, the first capital of Finland (1809–1812) and ‘traditional rival’ of Helsinki, succeeded to become the country’s first ‘healthy city’, Helsinki decided not to become a formal member of the network, but rather to implement the healthy city philosophy without membership. In line with this philosophy the city developed the concept of neighbourhood houses: about 30 local meeting places and action centres run by volunteers and coordinators paid by the city. The [neighbourhood] houses bring together enthusiastic people of different ages and ethnic backgrounds who take part in developing cultural, social and physical activities. Almost all neighbourhood houses focus on providing a healthy future for local young people. Rising crime rates have opened a debate on the decline in moral and social values, and the solution is considered to be local and social, at least in part. Neighbourhood houses have worked to develop relationships between young people and adults to pass on values and to reduce antisocial behaviour such as drug use. Success depends on the ability to see youth as the great hope of our cities, rather than a threat, and to offer them a better future. (Lafond et al., 2003)

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The neighbourhood houses project was managed by the Healthy and Safe City advisory committee, as part of an anti-drugs strategy that aims to stimulate young people to spend their time (and money) on other activities that are better for their health (e.g. sports and culture). The role of the private sector, however, has been very limited in this project, as in most healthy cities projects in Finland. The Innovation Strategy After the burst of the internet bubble, policy makers in Helsinki came to the conclusion that the region had to rethink the regional economic strategy. Although the competitive position was still strong, most stakeholders realised that action was needed to secure that position. To discuss the challenges for the region, the Mayor of Helsinki invited key stakeholders from different sectors, under the umbrella of Helsinki Club: a strategic think-tank for the region. In 2003 this platform came to the conclusion that cooperation between the various actors had to be improved in order to promote innovation and to secure the region’s competitiveness. Until then innovation was mainly stimulated by facilitating connections and technology transfer between knowledge institutions and companies, e.g. via business incubators. The participants of the Club agreed that more coordination and ‘radical new partnerships’ were needed (Culminatum, 2005). With the financial support of the National Technology Agency of Finland (TEKES) a new innovation strategy was formulated which identified four pillars (Culminatum, 2005; Holstila, 2008) and 25 action proposals: •

•

•

Improving the international appeal of research and expertise – The region wants to become attractive for students and researchers by providing better infrastructure (in the broadest sense of the word) and services and improving international marketing. In order to become more competitive on a global scale, three universities will be merged into one ‘world class university’ named after the famous Finnish architect Aalto in which innovation is stimulated through interaction between the disciplines of technology; economics and business, and art and design. Interestingly, the new university will be partly financed by the business sector through a foundation that will invest €200 million. Reinforcing knowledge-based clusters and creating common development platforms – As the speed of innovation goes up and product life cycles become shorter there is an increasing need for a setting in which technology/ service developers and users come together (open innovation). One of the initiatives under this heading is a cluster project for digital content and services in the Pasila district of Helsinki. The development of Living Labs such as Healthy Helsinki also relate to this objective. Reform and innovations in public services – The Innovation Strategy defines a new role for the government in addition to promoting technology transfer: improving public service delivery through technological

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•

innovation. The idea is that reform in public services will not only enhance the quality of public welfare services (including health, social and educational services) but also open up new business opportunities since local administrations are important customers. Support for innovative activities  This pillar concerns the traditional role of the government: stimulating technology transfer.

To reach the third objective the Helsinki region can count on substantial financial support from national programmes such as the FinnWell healthcare technology programme, managed by TEKES. These programmes have been set up in response to the lack of innovation in public services across Finland. The challenge is that public officers do not always see how innovation fits in their task to secure public interests, while innovation also involves risks which they generally want to avoid. Moreover the autonomy of municipalities in the Finnish political system does not encourage coordination in the adoption of new technologies. Some municipalities spend a lot of money on reinventing the wheel, while other municipalities are simply too small to bear the costs of innovation. The strategy is implemented by Culminatum, the regional development company. The steering group of this company comprises several outside experts representing among others the Finnish National Fund for Research and Development (SITRA), TEKES and Nokia. Many of the actions that have been proposed require cross-sector and inter-municipal cooperation. One of the initiatives that has been put in place to facilitate private-sector participation is the foundation of Forum Virium. Forum Virium In 2004, the directors of Nokia and the Finnish Broadcasting Company discussed the competitiveness of Helsinki in relation to the development of new digital services. They arrived at the conclusion that in order to improve the region’s position, cooperation with other companies, knowledge institutions, governments and citizens was needed. With the support of national organisations such as SITRA, TEKES and the Technical Research Centre of Finland (VTT) they set up the platform Forum Virium. Its mission is to create ‘internationally competitive digital services for consumers and clients in the Helsinki Metropolitan Area through cooperation between corporations, public institutions and citizens’ (Forum Virium website, www.forumvirium.fi). Key members on behalf of the private sector are Nokia, TeliaSonera, Tieto (IT services), Logica (IT services), Destia (construction), YIT Group (construction) and Finnish Broadcasting Group. In 2005 the newly elected Mayor of Helsinki – a former businessman – decided to support Forum Virium on a structural basis which made it possible to hire permanent staff to coordinate projects and programmes. The Mayor had two reasons to support Forum Virium: 1) to improve the quality of public services;

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and 2) to further promote the redevelopment of the Pasila district enabled by the relocation of the port. Initially the companies in Forum Virium agreed on six project areas: traffic services, healthcare, learning, retail trade, multi-channel distribution and the digital home. After an evaluation of the programme in 2008 the number of focus areas has been reduced to four: traffic, wellbeing, education and media. Healthy Helsinki is Forum Virium’s main programme in the field of healthcare and wellbeing. Development programmes are horizontal themes and methods that relate to all themes. One of these programmes is the Living Lab programme. Another one is the public-private consumer project which concerns the development of the Pasila district into a test environment for digital services. The first service created by Forum Virium Helsinki that has reached the users is a photo and video diary service developed for day care centres. The service allows the day care personnel to take photographs and record videos of the day’s events, and share them online with the children’s parents. The service was developed quickly. ‘From the moment when we came up with the idea, it took only four months until the service was ready to be piloted by four day care centres and hundreds of parents. Feedback from user surveys indicated that the user experiences were exceptionally good. Later that year the service was commercialised and introduced to other countries. Two years have passed and by now the service has been used by more than 300 day care centres and over 10,000 parents in Finland, Britain, Singapore and the United States’ (Forum Virium, Point of View, 6.11.2008). Another result of the 2008 evaluation is the ambition to enlarge the number of members. With financial assistance of the city, a special programme for smalland medium-sized firms (SMEs) has been set up to encourage this large group of companies to participate. Moreover, Forum Virium has recognised the need to promote the involvement of foreign companies: these firms become increasingly important for the regional economy, but they do not necessarily share the Finnish tradition to cooperate and they find it difficult to participate in platforms in which Finnish is the language spoken (as in Forum Virium). Helsinki Living Labs Healthy Helsinki is an example of a Living Lab. Forum Virium was involved in the development of living labs before the term became widely accepted in Europe. The concept of living labs was introduced by William J. Mitchell (MIT, Boston) and enables researchers, companies and governments to test innovations in a complex real-life environment. ‘Living labs move research out of laboratories into reallife contexts to stimulate innovation. This allows citizens to influence research, design and product development. Users are encouraged to cooperate closely with researchers, developers and designers to test ideas and prototypes. Functioning   The most western part of the Central major district (see Figure 2.1).  See www.connectedday.com.

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as Public-Private Partnerships, especially at regional and local level, living labs provide some advantages over ‘closed labs’: They stimulate new ideas, provide concrete research challenges and allow for continuous validation of research results.’ Living labs empower the citizens as users of products and services. Their implementation requires a shift from user-centric models to user-driven models, in which users become co-producers together with the public sector, business and academia. A European Network of Living Labs was launched during the Finnish Presidency of the EU in 2006. Since its creation the number of members has increased from 20 to more than 150. In November 2007 several stakeholders in the Helsinki Region (including Culminatum, Forum Virium, the City of Helsinki, SITRA, TEKES and VTT) created an umbrella organisation for living labs in Helsinki: Helsinki Living Labs. This organisation promotes the exchange of knowledge between the various initiatives in the region and provides easy access to these projects for businesses and public-sector organisations. Its database of case studies shows that there are at least four living labs in the region that deal with health and social conditions: •

•

•

Healthy Helsinki – a joint initiative of the City of Helsinki and Forum Virium. Although it is officially a project with a four year duration (2008–2011), it has the ambitions to become a comprehensive Living Lab programme with several interrelated projects. Its mission is to develop new digital services for welfare through user-driven models. The aim is to empower citizens by raising their awareness about the importance of their own wellbeing and their own responsibility to take care of themselves. Loppukiri – a new kind of housing arrangement for aging citizens based on neighbourly and self-help developed by the Active Seniors Association. The Loppukiri community consists of the residents of the building organized in working groups that take care of different activities: a week’s working shift comes for each group of approximately ten persons about once in six weeks. The community is a true living lab environment where ideas are developed, implemented and tested collaboratively. For example, working in collaboration with the architects and construction company, residents played an important part in designing their own flats and common areas with solutions appropriate for their needs. The aim of the community is to share their experiences and encourage and help others to build on similar projects (www.loppukiri.fi). Novarca – a platform for real life learning and Living Lab testing. Real life learning means learning through experience, problem solving, research and active development. The main context is the client’s home, workplace and Novarca. From a pedagogical point of view Novarca is based on networking and collaborative learning as Physiotherapy and Business Administration

 Source: http://ec.europa.eu/information_society/newsroom/cf/itemlongdetail. cfm?item_id=3000.

Helsinki

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students work together to support better health and work ability according to the needs of the surrounding areas. The closeness and engagement in the customer relationship gives the students the possibility to test new service applications and create new services and businesses (www.novarca.fi). The goal of the Active Life Village (former Well Life Center) is to produce innovations for the improvement of wellbeing. The focus is on the development of the whole value chain of welfare services. Well Life Center is first and foremost a creator of cooperation through a supportive innovation environment. Because partner organisations are closely involved in the mutual development, they all benefit from the innovations created and the subsequent knowledge and competence spill over. Well Life Center belongs to the Laurea Living Labs network and it is the home of the CaringTV. Philips InnoHub for Nordic and Baltic companies is one element of Well Life Center’s offering (www.activelife.fi).

The city of Helsinki considers the development of living labs as part of the efforts to further improve the competitive position. An urban environment that facilitates real-life testing not only attracts and retains businesses and knowledge institutions (generating income and employment), but also helps to improve the quality of public and private services in the city, which essentially makes the city more attractive. Below we take a closer look at the living lab called Healthy Helsinki.

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The Helsinki Living Lab: Learning by Living

Source: Trends in innovation policy: Helsinki towards a Living Lab (Holstila, 2008)

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4  Healthy Helsinki The Healthy Helsinki programme aims to improve the conditions for citizen empowerment. It clearly focuses on health promotion and disease prevention rather than care and cure, showing evidence of a broader health definition. Strategic aims are to diminish diseases, to increase the subjective perception of health and wellbeing, to reduce health inequalities and to cut the growth of healthcare costs. It promotes a healthier and more active lifestyle with a more proactive approach to health. Increased use of digital services and wellbeing technologies can help to reach these goals. Officially, Healthy Helsinki targets all citizens (in line with the health for all philosophy), but its main focus is on so-called ‘couch potatoes’: ‘The Healthy Helsinki programme develops services which make it easier for people to promote their health. Cuddling up on the comfortable couch seems irresistible especially in the dark winter season, but with the support provided by this programme, the passive life of a couch potato is soon replaced by selfmotivated exercise and a healthier lifestyle.’ The main question to be tackled is how to stimulate people to adopt a healthier lifestyle. The programme should provide insight on how particular groups respond to different ‘triggers’ such as competition and the interaction with (virtual) peer groups and communities (including a household). The programme does not intent to change the physical environment (which is attractive in Helsinki), but focuses more on the social and virtual environment, for instance by looking at the application of e-genitors (a virtual parent, somebody you can talk to, etc.) and informal care networks. Technological innovation is not an objective in its own right, but rather just one of the instruments to reach social objectives; also social innovation is needed. It is also not the aim to build new facilities, but rather to improve the legibility of existing opportunities to exercise: adding elements to people’s mental maps of their immediate environment. The Healthy Helsinki programme was prepared in 2007 in response to the need for digital services in the public sector in view of the ageing population (increasing demand for healthcare), the growing lack of human resources in delivering healthcare, and the increasing health inequalities. The programme fits in the City’s strategy to find new solutions to ‘control and redirect the health service demand’ and to support inter-departmental cooperation for the development of products and services in a customer-driven process. Moreover, the municipality understands that new forms of partnerships with the private sector are needed to secure the quality and accessibility of public services. After all 36 departments had been consulted, four departments accepted their role in the programme’s implementation: the City of Helsinki Health Centre, the Education Department, the Social Services Department, and the Sports Department. For individual projects also other departments are involved, such as the Youth Department. The objectives of Healthy Helsinki have been defined in consultation with the four   Source: www.forumvirium.fi.

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city departments but not with the participating companies since firms tend to look first and foremost after their private interests, and the initiators wanted to avoid ‘sales pitches’. Several workshops have been organised to identify the main issues such as an ageing population, growing health inequalities, the problem of alcohol abuse, the lack of personnel in healthcare, etc. The programme is administered by Forum Virium and has to be implemented by the city administration in cooperation with the other actors. Healthy Helsinki is governed by a Steering Board which is chaired by the Health Centre’s CEO – because it is officially a project of the health department – and comprises representatives of third-sector organisations, companies and the other municipal departments. This Steering Board comes together four times a year to take strategic decisions, for instance on whether or not a project can be continued. On a more regular basis – once every month – 15 representatives of the partner organisations meet each other in a meeting of the Healthy Helsinki Committee. Two persons – one on behalf of Forum Virium and one on behalf of the Health Centre – take care of the daily management. Their main job is to facilitate and smooth interaction between the various sectors and departments, acting as a ‘gearbox’ in the communication process. Herttoniemi, A Living Lab for New Concepts Initially the idea was to create an umbrella for all health promotion projects in Helsinki: promoting synergies and avoiding overlap. However, because this ambition turned out to be unrealistic, it was decided to focus on one district only: Herttoniemi. The Herttoniemi district, located in the southeastern major district of Helsinki (in East Helsinki), has been selected because its population (26,000 people) is a good representation of the city: most indicators are close to the city’s average. Only the population density is significantly lower. The district, one of the 34 in which Helsinki is divided, consists of three areas (Herttoniemi, Roihuvuori and Tammisalo) with their own specific profile. Herttoniemi used to be a village but developed into one of Helsinki’s first suburbs in the 1950s. Other parts of this area have been developed more recently such as Herttoniemenranta (the beach area), also attracting higher-income groups. The service level is relatively good, with a concentration of retail functions near the metro station. The primary objective of Healthy Helsinki is not to improve the health situation in Herttoniemi but rather to develop concepts and products that can be implemented in other parts of the city, the region, the country and other parts of the world. That is why the initiators selected a district that is statistically average but with considerable internal differences. For sure, Herttoniemi is not a ‘problem area’ and the quality of housing and the physical environment is as good as for the rest of the city. The initiators only use the district as a living lab to test and improve new concepts in health promotion. This implies that also residents, businesses and associations in the district participate in the programme: as users but also as

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Towards Healthy Cities

communication channels, for instance in the case of shops and schools. A more practical reason to select Herttoniemi as a living lab was the fact that citizens were already relatively well organised. Moreover the initiators expect that a concept implemented in the complex institutional context of Helsinki – no matter in what district – can be easily exported to other parts of the country. The broader geographic scope explains the involvement of city departments, businesses (through Forum Virium), research institutions, third-sector organisations (NGOs, in most cases funded by the government) such as the Young Finland Association, and national organisations such as the Finnish Centre for Health Promotion. The Finnish Centre for Health Promotion is a national platform with more than 120 member organisations, mostly from the healthcare and social sectors. The Centre stimulates cooperation and knowledge exchange between its members, for instance by organising thematic expert groups. Furthermore the platform participates in projects in the field of health promotion. Most of these projects have a national scope. The Centre is involved in Healthy Helsinki because it may result in concepts that can be applied throughout the nation. Among the companies that participate in Healthy Helsinki are members of Forum Virium (Nokia, Elisa, Logica, TietoEnator, VTT) but also experts in e-health such as Medixine. In January 2009 Healthy Helsinki was still in the stage of development. In this stage the companies and third-sector organisations (NGOs) are invited to come up with proposals for projects in which they do not necessarily have to participate. Apart from several Forum Virium members, three other types of companies showed their interest: healthcare companies, media companies and local firms in Herttoniemi (mainly retail). The main driver for companies to get involved in the programme are the business opportunities it generates: many firms were eager to hand in proposals for projects they could earn money with. The second reason is ‘free publicity’ as the programme gets quite some media attention. Corporate social responsibility (concern about health) is a less important motive, although some discussion partners expect it to become more relevant in the near future as health co-determines productivity. It is also relatively easy to get NGOs on board: they are funded by the government and provide free advice and contacts. The challenge, however, is to bring together partners with different time horizons: particularly SMEs are not used to think one year ahead, in contrast with public actors. And then there are also financial issues to be tackled: different municipal departments have to invest, and while they all agree on the main aims of the programme, they often disagree in practice on the priorities as Healthy Helsinki competes for public funding with other municipal policies. Organising capacity is required to make the programme work: the challenge is to gain broad support. Local retailers are expected to play a key role in the delivery channel with permanent information stands and participation in events. The idea is to have several projects running, accepting some to be more successful than others. The initiators do not want to become too dependent on the success of a limited number of projects. They need at least one successful showcase to secure political and social support. The

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following projects have been accepted so far and are in the stage of implementation: Mobile Health, Personal Health Records, Closeby Sports Places, a Study on the Everday Life of Children, and several so-called horizontal projects. Mobile Health One of the first Healthy Helsinki projects that has been set up, is Mobile Health. This is a joint initiative of Elisa (telecom operator), MIT’s House N (a research group within the department of architecture), Forum Virium and the Future Home Institute (University of Art and Design, Helsinki). Elisa is a leading Finnish communication services company that provides services to private, corporate and institutional customers in the Nordic Countries, the Baltics and Russia. The company is the result of a merger in 2000 between the Helsinki Telephone Corporation and HPY Holding Corporation. HPY was founded in 1882 as a telephone cooperative for Helsinki, owned by the City. In the mid-1990s, with the liberalisation of the telecom market, HPY took over Radiolinja, the first competitor of Telecom Finland (today known as TeliaSonera) in the Finnish mobile telecom market. Elisa’s core values in all business operations are customer-orientation, responsibility, renewal and profitability. These values are also reflected in the company’s involvement in research. The research department aims to identify new, easily exploitable business opportunities by participating in research projects. Elisa is one of the initiators of Forum Virium, and a key actor in the first project: Finnish Mobile TV Forum. Apart from Mobile Health, Elisa has developed several other products that are related to health such as Traxmeet (a virtual training world for sports fanatics) and integrated personal occupational health services to companies. Elisa’s main reason to be involved in Healthy Helsinki is to develop a new service of which the user interface has proven to be effective. The Mobile Health project aims to promote a more active lifestyle by using the mobile telephone to analyse and influence human behaviour. MIT has approached Elisa to test the software they developed because operators in the US were not interested. Together with Herttoniemi’s health station and the local library the operator has invited people to participate in the experiment. Candidates had to fill in a form – set up by MIT – with questions about their age, sex, weight, length, health, address, use of technology, use of telephones, mode of transport, amount of leisure time, etc. In the end 100 people were selected to participate, creating a representative sample of the population. Interestingly, it appeared to be difficult to find participants with a relatively unhealthy lifestyle. For that reason some additional participants had to be found elsewhere in the city. The participants receive a free Nokia 5500 which includes a pedometer and software which keeps track of their behaviour and automatically sends the results to the research team. The objective of the experiment is to test and refine the user interface: the ultimate aim is to develop software that is device and operator independent, possibly using other technologies such as GPS. Mobile Health encourages the participants to increase their daily exercise by positive motivation: ‘Exercise is rewarded with

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positive feedback. By receiving feedback, the participant becomes more aware of his or her daily level of activity. The aim is that continuous positive feedback motivates people to change their behaviour and way of life permanently and adds a spark of enjoyment to exercise’. The role of municipal departments in this project is limited. The health centre and the social services department have helped with the selection of participants. Personal Health Records Another Healthy Helsinki project concerns the development of Personal Health Records. This is a personal web-based service which enables collecting and monitoring individual health information. The leading partner in this project is Medixine, a company that specialises in multimodal communication software for healthcare and wellness. The company has its headquarters in Espoo, and sales offices in France, the UK and the US. Medixine develops the software in consultation with the customers; many of them are local authorities. Through Culminatum the company has been able to build strategic relations with the City of Helsinki and other municipalities in the region. For the City of Helsinki the firm developed a Mobile Nurse application which uses a mobile phone and radio-frequency identification (RFID) to reduce the amount of time spent on administration. Another product was developed for the City of Espoo: a central database with the growth statistics of 60,000 children enabling healthcare professionals to recognise abnormalities in growth at the earliest age possible. Together with the Met Office of Cornwall (UK) and funded by Cornwall Adult Social Care Medixine developed an interactive, mobile-phone weather service for COPD patients. This service does not prevent people from becoming ill, but prevents diseases from becoming more severe, thus saving costs for society. Already before the start of Healthy Helsinki, Medixine developed a healthcare communication portal which enables users to store their health information. The company was approached by Forum Virium and the City to participate in the Healthy Helsinki programme. The aim of Personal Health Records is to reach specific target groups in Herttoniemi and to test new features. New scripts will be developed to give users advise on their lifestyle (‘flags and warnings’), creating a virtual personal trainer (as in Nintendo’s Wii Fit). It is even considered to connect the PHR system to a customer card system of a supermarket chain in order to provide feedback on purchases. Privacy can be secured, to some extent, by anonymous data recording. To avoid associations with Big Brother the initiators are looking for solutions that people trust (e.g. enabling people to record a reminder for themselves). Municipal departments are not yet actively involved in this project.

  www.forumvirium.fi.

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Closeby Sports Places The Young Finland Association (Nuori Suomi in Finnish) is one of the leading actors in a project called ‘Closeby Sports Places’. This no is a membership platform of 55 national sports federations that ‘want to promote children’s and young peoples’ well-being and joy of life by means of physical activity’. Its activities are mainly funded by state aid (allocated by the Ministry of Education) but also by selling services and through cooperation with companies (e.g. retailer Kesko and Veikkaus lottery). The project Closeby Sports Places aims to improve the supply of sports facilities in the immediate environment of the home. It builds on the assumption that children, but presumably also older people, have a ‘radius of action’ of less than 500 metres. As part of the project, the Young Finland Association has developed a tool to evaluate the offer of recreational and sports amenities at short distance. This tool will be tested in Herttoniemi. The present offer will be mapped, and after that citizens will be consulted to find out what additional facilities they need, possibly resulting in investments. As such investments not only relate to sports, but also to education, social services and health, several municipal departments have to be involved in this project. Particularly, the involvement of the educational department is important since part of the solution may be found in a more efficient use of school buildings and gyms, not only for sports activities but also for social events. The problem, however, is that several laws restrict the after-school use of these facilities. It is now considered to extend the afternoon break (between the morning and afternoon session) giving young people the opportunity to exercise, but also for this change cooperation with other departments is needed. Study on the Everyday Life of Children Another project has been set up to find out what 3rd to 6th graders do with their spare time and what kind of hobbies they have. This study has been carried out on behalf of seven different departments of the City of Helsinki jointly, including the departments of health services, social services and education. One central finding of the study is that nine to 13-year-olds in Helsinki are satisfied with their everyday life, which consists of three basic elements: home, friends and hobbies. According to the children themselves, they have enough hobbies, friends and meaningful activities. As many as 82 per cent of the respondents have hobbies. Many of them have a sporting hobby or combine sports and arts activities. The majority of the children (37 per cent) have one hobby, which they practise twice a week, on average. The most common form of sport was football and the most common artistic hobby was playing the piano. Of the other hobbies listed, scouting was the most frequent to occur.

 Source: www.aktivungdom.eu/element_db/81/817_EYSF2006_invitation.pdf.

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Towards Healthy Cities

The study also found that the everyday life of children changes with age. The older they are, the more social their life becomes. Friends meet up in specific places, the most popular being swimming pools and shopping centres. Drawing on the results of this study, it is possible to present various options that could improve the quality of third to sixth graders’ daily lives. When services for this age group are planned, the children’s opinions should be taken into account. Children are of the opinion that the city should provide both guided activities and facilities where children can act on their own initiative. The differences between the pastimes and interest of girls and boys should also be taken into account. Currently, more support is given to the sports activities that more typically interest boys than girls; at the same time, arts-oriented hobbies for boys are less common. Overall impression from the study is that children are content with their everyday life. Horizontal Projects Horizontal projects deal with issues that are relevant for nearly all projects such as a joint database of knowledge and experiences, the development of user interfaces, the adoption of change and evaluation methods. For instance, all projects use a questionnaire to measure the status of change and the attitude towards change, in which change refers to the adoption of a healthier lifestyle. This horizontal project helps other projects such as Mobile Health to identify specific target groups according to their status of change. A leading actor in the development of evaluation tools is the research institute VTT (Technical Research Institute of Finland), but the ambition is to involve other research centres as well. Healthy Helsinki will also be evaluated as a programme, looking at the impact on health and wellbeing in Herttoniemi. Obviously the evaluation of the programme is relevant for all partners, but in particular for the Helsinki health centre because it might change the municipal health policy.

Conclusions At the time of writing this case study Healthy Helsinki was in the preparation and development stage, making it difficult to draw conclusions on the effectiveness of the programme and the individual projects. Nevertheless we have been able to gain some insight in the relevance of the three conditions for investments in healthy cities and the strategies that have been developed to meet these conditions. Citizen Empowerment Healthy Helsinki empowers citizens by involving them in the development of new digital services that enable and promote a healthier lifestyle. This is done by applying the concept of living labs to innovations in health promotion. The

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Herttoniemi district functions as a real-life laboratory to test new concepts. The aim of the programme is not to promote the health of the citizens that live in Herttoniemi, but rather to develop instruments and concepts that can help to improve the health of all citizens, in the city, the region, the country and even beyond. A priori, the initiators do not claim to know what is needed to make people healthier; instead they experiment with interventions to find out what incentives are most effective expecting factors such as competition and influence by peer groups to play a role. Although the aim is to improve the health for all (in line with the WHO philosophy), Healthy Helsinki clearly tries to develop adequate, tailor-made tools to reach particular target groups, with age, gender and the current health status (‘status of change’) as main segmentation criteria. The Healthy Helsinki programme builds on user-driven technological innovations which imply that citizens become co-producers of digital services that can help cities, NGOs and companies to promote a healthier lifestyle. By involving users in the development stage, user interfaces can be developed that take into account the needs, competences and fears of the users. For instance, the Mobile Health project may reveal what kind of rewards make people move (needs), while the Personal Health Records project is expected to provide insight on how to avoid privacy concerns (fears). In the case of Closeby Sports Places the limited radius of action of children (competences) is taken into account in the development of an environment that facilitates an active lifestyle. Citizens are not only asked to test new services (in Mobile Health and Personal Health Records), but they are also asked to express their needs and wants (in Closeby Sports Places and Study on the Everyday Life of Children). Corporate Responsibility The Healthy Helsinki programme has the ambition to develop partnerships: between various municipal departments, but also between the municipality, NGOs, the business sector and knowledge institutions. These organisations are represented in two governing bodies: a Committee and a Steering Board. The Healthy Helsinki office – managed by two persons only – has the task to accelerate the coalition forming process on project level. This appears not to be easy: while the partners all agree on the strategic objectives of the programme, they find it difficult to reach consensus on concrete projects. The impression is that top-level support is not complemented by support from managers at the intermediate level. Most problematic is the cooperation between the municipal departments: large, bureaucratic bastions with their own priorities and pat projects. We observed that many people are not yet (fully) acquainted with the programme: the general feeling is that concrete, visible projects are now needed to put the programme on the mental map of policy makers and citizens. The involvement of the business sector is a potentially strong element of the programme. Companies see their participation in the programme as a way to gain access to new business opportunities. Moreover, several discussion partners foresee

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Towards Healthy Cities

a stronger involvement of business in health promotion in the future, in view of the increasing attention to corporate social responsibility. Interestingly, large firms such as Elisa appear to be very patient, accepting return on investment on the long run. SMEs (e.g. Medixine) tend to work with shorter time horizons, which is an issue to take into account when developing coalitions with the public and NGO sectors. In the delivery of the projects the initiators count on the willingness to cooperate of local retailers, but it remains to be seen if they actually succeed to get them on board. Presumably, local shop owners are relatively well embedded in communities, thus showing interest in promoting the health of the communities in which they operate. Another strength of the Healthy Helsinki programme is the involvement of organisations that work on a national level. Because expectations are that the experiments in Herttoniemi will result in products and services that can be provided everywhere, actors with a national or even international work area (e.g. the Finnish Centre for Health Promotion and the Young Finland Association, but also Elisa and Medixine) are interested in participation. The programme aims to produce benefits for all participants by developing and implementing projects that combine private-sector interests with public-sector and non-profit-sector interests. The projects that have been initiated so far all seem to be in line with this ambition. Companies are willing to join the projects because they 1) help them to develop new products and services, 2) provide them access to the public and non-profit sector (as customers), and 3) generate positive publicity. Direct business benefits are obviously more important than the indirect benefits that accrue to the business sector via improvements in the urban environment (health, safety, social cohesion, etc.). Knowledge institutions are positive about the programme because it can generate interesting data to be published in international journals. NGOs can use these results to reach their specific objectives in the field of health promotion. The main bottleneck of the programme is the involvement of the municipal departments. They have to invest in risky projects for which the public benefits in terms of health promotion are uncertain. One of the discussion partners explained that civil servants tends to be risk adverse because they are not rewarded for success, while they have to bear the responsibility for failures. This problem can be partly tackled through project funding of national organisations such as TEKES and SITRA. It is, however, not only a matter of money: the support of municipal departments is also needed to take away political-administrative barriers; for instance the restrictions that apply to the use of schools for after-school activities. One of the reasons that explains the lack of support on the side of the municipality, is exactly the strong business orientation of the projects. Although the programme promotes a new form of cooperation between the various sectors, it runs the risk of becoming a tendering programme. The general impression is that the support of the public sector is negatively influenced by the strong focus on direct benefits for the business sector. Possibly the increasing awareness that companies should take their responsibility in promoting the health of communities enables the

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development of coalitions with a less traditional division of roles between the public and private sectors. Coordinated Improvement of Urban Health Conditions Although Helsinki is not a member of the European healthy cities network, the city has adopted a coordinated approach to health improvement. Both the Healthy and Safe City advisory committee and the Healthy Helsinki office promote the development of an environment that stimulates people to live a healthy life. Safety and social contacts are obviously important ingredients of such an environment, with the development of neighbourhood houses as weapon in the battle against drugs, and e-genitors as instruments against loneliness. In the Healthy Helsinki programme, horizontal projects have been defined to exchange experiences between the various ‘vertical projects’. Three of the four vertical projects aim to improve a specific aspect of the environment such as the supply of sports facilities (Closeby Sports Places) or the incentives to promote exercise (Mobile Health). The most comprehensive project defined so far is Personal Health Records because it can – in theory – provide users advise on how to improve their lifestyle: nutrition, exercise, social and economic participation, etc. Healthy Helsinki is clearly a technology-driven programme. Its aim is to develop new services that can help to empower citizens. Nevertheless, the experiments in Herttoniemi may also help to develop more comprehensive methods in which technological innovations are combined with social innovations (e.g. peer group pressure and activating parents via the children) and investments in the physical environment (e.g. sports facilities). The physical component is,

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Vertical and horizontal projects in the Healthy Helsinki programme

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Towards Healthy Cities

however, weakly represented in the programme, mainly because the quality of the living environment is equally high in all districts of the city. Opportunities to exercise are omnipresent; the question is how to get people moving and how to improve the legibility of these opportunities. As one would expect the Healthy Helsinki programme mainly looks at ways to improve the virtual accessibility (websites), while in some cases also improvements in the real accessibility could be useful. The link between the programme and the physical environment (also in terms of land planning) is weak. Finally we conclude that Healthy Helsinki is not only a social programme, but also helps to improve the competitiveness of the city. The city has discovered living labs – of which Healthy Helsinki is just one example – as a possibility to strengthen its position in the global knowledge economy. By providing an attractive environment for innovations, Helsinki expects to enhance its appeal to R&D departments of companies and research institutions. In addition, the programme helps to improve the quality of public services which makes the city more attractive as a place to live and work.

References City Office of Helsinki (2002), Urban Programme for the Helsinki Metropolitan Area Competence and Cohesion, Implementation Programme 2002, 4. (In Finnish, English summary). City of Helsinki Urban Facts (2007a), Statistical Yearbook of the City of Helsinki. City of Helsinki Urban Facts (2007b), Facts about Helsinki. City of Helsinki Urban Facts (2008a), Helsinki Region Trends. City of Helsinki Urban Facts (2008b), Helsinki Quarterly 2008, 2. City of Helsinki Urban Facts (2008c), Helsinki Population Forecast 2009–2040. Statistics 2008, 39. Culminatum (2005), Innovation Strategy Helsinki Metropolitan Area. Forum Virium (2005), No More Bullshit!, Point of View, 6.11.2008, (English summary available at: http://news.forumvirium.com/node/208). Health Centre (2007), Annual Report 2007: Health for the Residents of Helsinki. Holstila, E. (2008), Trends in innovation policy: Helsinki towards a Living Lab, in Conference on Metropolitan Challenges and Innovation, edited by M. Gräsbeck. Finnland-Institut, Berlin, April 2008, City of Helsinki Urban Facts, Discussion Papers 2008, 1. Laakso, S. and Kostiainen, E. (2007), The Economic Map of Urban Europe; A Comparative Study of 45 European Metropolises, City of Helsinki Urban Facts, Statistics 2007, 42. Lafond, L.J., Heritage, Z., Farrington, J.L. and Tsouros, A.D. (2003), National Healthy Cities Networks: A Powerful Force for Health and Sustainable Development in Europe, WHO.

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OECD (2005), Territorial Reviews: Finland. Susiluoto, I. and Loikkanen, H. (2001), Efficiency of Regional Economies in Finland 1988–1999. (In Finnish, English summary) Tukiainen, J. (2003), ICT Cluster Study Helsinki Region, City of Helsinki Urban Facts, Web Publications 2003, 2, MUTEIS. Vaattovaara, M. (2002), Future Developments of Residential Differentiation in the Helsinki Metropolitan Area: Are We Following the European Model? Yearbook of Population Research in Finland.

Discussion Partners Marianne Dannbom, Forum Virium Helsinki, Healthy Helsinki Kirsti-Marja Elisasson, Social Services Department, City of Helsinki Jarmo Eskelinen, Director of Forum Virium Helsinki Annakaisa Häyrynen, Research Area Manager, Elisa Hilkka Heikkilä, Laakson Health Centre Eero Holstila, Director of Economic Development, City of Helsinki Rauno Jarnila, Head of Educational Department, City of Helsinki Tapio Jokinen, CEO, Medixine Pirjo Koskinen-Ollonqvist, Development Manager, Finnish Centre for Health Promotion Asta Manninen, Urban Facts, City of Helsinki Jussi Olkkonen, Herttoniemi resident Helena Tukia, Project Manager, Health Centre, City of Helsinki

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Chapter 3

Liverpool

1  Introduction In the present chapter we analyse the applicability of our research framework to the case of Liverpool. First we provide a general profile of the city in order to gain some understanding of the relevant context. After that we assess various strategies and initiatives that have been developed to improve the health situation: the city’s participation in the WHO Healthy Cities Programme, a local strategic partnership, the city’s strategy for healthcare facilities and the redevelopment of the Alder Hey children’s hospital. 2  General Profile With approximately 440,000 inhabitants Liverpool is the eighth largest city of the UK. The city is located in the North-West of the country, on the Irish Sea and within the County Merseyside. The Liverpool City Region has a total population of around 2 million (Liverpool City Region, 2005). Economic Development Liverpool used to be one of the most important ports of the world. By the start of the 19th century 40 per cent of all trade was passing through the city’s port, which facilitated a fast growth of the population. This growth continued during the industrial revolution. The city became one the powerhouses of the UK economy, with the textile industry as the most important driver. From the 1970s onwards, however, the city faced a period of strong economic decline. The port could not accommodate the large container ships that increasingly dominated transport by sea. As a result many port-related factories had to close their doors. Liverpool lost more than 18 per cent of all jobs and 22 per cent of the population. This development had a severe impact on the Liverpool and the Merseyside region: high unemployment figures and social deprivation turned the region into one of the most troublesome areas of Western Europe. Policy makers realised that large-scale regeneration efforts – requiring substantial investments – were needed to get the region out of the negative spiral. In the 1990s the region successfully applied for the status of an Objective 1 region, one of the subsidy programmes of   This case study is based on interviews with various stakeholders in July 2008.

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the European Union to assist regions that are lagging behind. The EU awarded ₤605 million to the region for the first phase (1994–2000) and another ₤950 million for the second phase (2000–2006), both amounts to be matched with funding from the local governments. The funds were used to invest in infrastructure (e.g. John Lennon Airport, Merseytram, Sourth Liverpool Parkway, and several bus and train stations), support to small- and medium-sized enterprises and would-be entrepreneurs, workforce development projects and the renovation of historical buildings (e.g. Liverpool Museum, Liverpool Metropolitan Cathedral and St. Georges Hall) (Hayes, 1999; McIntyre-Brown, 1998). Since the mid-1990s the investments in the region seem to pay off: in this period the economy of Liverpool outperformed the economy of North West England in terms of Gross Value Added (GVA), GVA per capita and job growth. For two of these indicators – GVA per capita and job growth – the city had a better score than the UK average.

Table 3.1

The relative performance of the Liverpool economy

GVA growth (1995–2005) GVA per capita growth (1995–2005) Job growth (1998–2006)

Liverpool +5.1% +5.8% +1.4%

North West +4.7% +4.6% +1.0%

UK +5.5% +5.1% +1.0%

Source: Key Statistics (City of Liverpool, 2008a)

In 2008 Liverpool demonstrated the world its regained self-confidence using its status as Europe’s Capital of Culture. In the years before this event the city seized the opportunity to invest in museums, historical buildings and tourist attractions. One of the aims of the city was to show Europe that Liverpool is not only an area with problems (Liverpool First, 2007). Health and Deprivation Liverpool is one of the most deprived cities in England: almost 56 per cent of the population is living in neighbourhoods that belong to the 10 per cent most deprived areas of England. The social-economic problems in these areas are also reflected in health statistics: male inhabitants of Liverpool live more than three years shorter than the average Englishman. Although life expectancy increased   To become an Objective 1 region the Gross Domestic Product per capita has to be less than 75 per cent of the EU average.   Based on Indices of Multiple Deprivation (income, employment, education, skills and training, health, crime, living environment, access to housing and services) for the 32,482 Super Output Areas in England.

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between 1995 and 2005 the health penalty for Liverpool has remained equal (NHS, 2007). In addition it appears that people who live in other large UK cities such as Birmingham, Bradford, Leeds, Bristol, Sheffield and Edinburgh are better off. Only in Glasgow and Manchester people expect to live shorter, as depicted in Figure 3.1. In Liverpool short life expectancy rates go hand in hand with socio-economic deprivation and unhealthy lifestyles. The city’s Health Profile makes clear that Liverpool scores significantly worse than the England average on socio-economic indicators such as income deprivation, homelessness, children in poverty and crime. The statistics also demonstrate that people from Liverpool tend to smoke and drink more often while they are less physically active; remarkably, the score for obesity is significantly better than the UK average (NHS, 2007). Health inequality also manifests itself within the borders of the municipality; the most deprived areas – the neighbourhoods near the city centre and some neighbourhoods in the southern and eastern part of the city – also score low on health (City of Liverpool, 2008b). The Liverpool Primary Care Trust The organisation that is responsible for organising and delivering healthcare is the Liverpool Primary Care Trust (PCT). This organisation, with an annual budget of over ₤800 million and more than 3,200 staff members, belong to 

  

























 

Life expectancy at birth in large UK cities

Sources: UK National Statistics and General Register Office for Scotland

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Towards Healthy Cities

the National Health Services (NHS) which falls under the responsibility of the National Department of Health (Liverpool Primary Care Trust, 2007, 2008c). The core task of the NHS is providing primary care to local communities. The leading principle is that good care has to be freely available for everyone. This implies that care is free of charge at the point of delivery and delivered to everyone who needs care. In each region of England, a Primary Care Trust is responsible for commissioning primary healthcare services to independent contractors such as general practioners, dentists, pharmacists and optometrists. There are in total 153 Primary Care Trusts that spend all together 80 per cent of the NHS budget. Besides providing primary care, the NHS is also responsible for secondary care. Secondary care is acute healthcare that can be either elective or emergency and is commissioned and/or provided by specialist Trusts such as Hospital Trusts, Ambulance Trusts and Mental Health Trusts. The NHS also undertakes prevention programmes, for example promotional campaigns that stimulate people to adopt a healthy lifestyle. In 2008 the Department of Health recommended to better adjust the healthcare provision to the specific needs and wants of local communities. In response to this advice the NHS has decided to delegate more responsibilities and tasks to Primary Care Trusts, since they are working closest to the communities. An important tool to facilitate cooperation between Primary Care Trusts and cities is a local strategic partnership, to be discussed in the next section.

3  Initiatives to Improve Urban Health Conditions Healthy Cities After the World Health Organization launched the Healthy Cities Programme Liverpool was one of the European cities that took the lead in developing a European network and implementing the programme. As an active member of the network Liverpool started to incorporate the philosophy of Healthy Cities in its vision, strategy and actions. In the first phase (1988–1994) a committee was created to raise awareness of the Healthy City Programme. Its main task was to promote a more integral approach to health among members of the City Council and other stakeholders in the city. This committee also commissioned a survey to gain insight in the needs and wants of the population. From the results of the survey the conclusion was drawn that many people are not able to keep control of their own lives. They lack the power to influence their own health and well-being and the capacity to cope with their own everyday problems. As it became clear that the committee did not have enough political power to make a real difference (Costongs and Springett, 1997; Strobl and Bruce, 2000), a new institution was created in the second phase of the programme (1994–1998): the Healthy City Team. This team became part of the ‘central policy unit’ of the

Liverpool

45

City Council, and in this way it got more influence on the development of policies. One of its tasks was to write a comprehensive city health plan: an integrated and extensive strategy and action plan for improving health. It sets out the city’s vision and the steps it intends to take to achieve these goals. All cities participating in the European Healthy Cities Programme are obliged to produce such a Plan (WHO Organization, 1997). The plan for Liverpool (1996–2000) has been written in consultation with a broad range of organisations such as the Primary Care Trust and universities, as well as voluntary and community groups. It incorporates insights from professionals (supply) as well as citizens (demand). The main ambition is ‘to create a future for Liverpool in which economic prosperity, social justice and protection of the natural environment are pursued simultaneously to secure good health and enhance wellbeing for all people, now and for generations to come’. With this plan the Healthy City Team sought to influence, coordinate and integrate the activities of the key organisations in the city, based on a broad view of health and its determinants (Costongs and Springett, 1997; Strobl and Bruce, 2000). The third phase (1998–2002) was jump-started by the election of a new national government which actively supported the Healthy Cities philosophy. In the 2004 White Paper ‘Choosing Health’ the government recognised the importance of the Healthy City Programme: incorporating its philosophy into all decision related to urban management and planning on the local level (thereby taking into account the specific local circumstances) was seen as an important and effective way to create an environment that makes ‘the healthy choice the easy choice’ (Department of Health, 2004). Until the year 2000 the Healthy City Team coordinated the implementation of the comprehensive plan. In that year the plan expired without a follow-up, resulting in the dismantling of the Healthy City Team. Although the Healthy City Team is no longer active, the Healthy Cities philosophy is still being used in Liverpool. The former coordinator of the team joined the Primary Care Trust, but never stopped advocating a coordinated approach to health promotion in close cooperation with the city and other stakeholders. Still today many strategies for health promotion can be related to the principles of Healthy Cities. One of the examples is Liverpool First. Liverpool First The City Council of Liverpool and the Primary Care Trust are jointly responsible for promoting health. They work together intensively, while some people are even employed at both organisations. They also understand that cooperation is needed with other key partners and stakeholders from the city. An important platform for cooperation and coordination is Liverpool First: a local strategic partnership which brings together representatives of the private sector, the public sector, the government and community organisations. All public authorities in England and Wales are obliged to set up such a platform. They are free to choose the organisational structure, priorities and strategies that fit in the

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Towards Healthy Cities

local circumstances (e.g. political history and existing tradition to cooperate), but most of them focus on regeneration and renewal. The main ambition of Liverpool First is to create equal opportunities for all people living in the city. The platform gives special attention to people and areas that struggle with a combination of interlinked problems such as unemployment, poor skills, low incomes, poor housing, high crime, poor health and family breakdowns (Liverpool First, 2005). Liverpool First brings together key public, private, voluntary, community and faith sector organisations, including the Primary Care Trust and the City Council. The platform is in fact a collection of partnerships led by the Liverpool First Board which is responsible for writing the two main policy documents in Liverpool: the Liverpool Sustainable Community Strategy and the Liverpool Local Area Agreement (Liverpool Primary Care Trust, 2008b). The Sustainable Community Strategy enforces the joint vision of the partners to become a ‘premier European City by building a more competitive economy, creating sustainable communities and enhancing individual life chances’ (Liverpool First, 2005, 2007). The strategy sets five targets, which were to be achieved by (joined) actions of all stakeholders. One of the goals is ‘to reduce poor health and preventable death towards the national average by 2010’. Other strategic aims are to improve the business climate and to meet national targets for schools, qualifications and employment by 2008. For each target the strategy describes the current (2005) position, possible barriers, relevant stakeholders (partners of Liverpool First as well as other organisations), the organisation with the lead responsibility and relevant existing plans and strategies. A Local Area Agreement is a three-year contract between the national government and the local government. It specifies local priorities and responsibilities and the allocation of national budgets to local strategic partnerships. In this way the national government tries to solve local problems on a local level (subsidiary). In the case of Liverpool the Local Area Agreement can be seen as the implementation plan of the city’s Sustainable Community Strategy (Liverpool Primary Care Trust, 2007). It specifies the actions that are needed to reach the targets and the contributions that are expected from various public and private actors (Liverpool First, 2007). The Big Health Debate In order to improve the health situation in Liverpool the Primary Care Trust took the initiative in 2006 to develop a new strategy for healthcare services. They organised a Big Health Debate which resulted in the Outside of Hospital Strategy. The Big Health Debate took place in 2006 and 2007 and comprised three phases. In the first phase representatives of more than 40 community groups were asked to fill in a questionnaire with the aim to identify health-related topics for further study (Liverpool PCT, 2007b, 2007d). In the second phase the Primary Care Trust discussed these topics during a workshop – The Big Health

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47

Debate Live! – with 150 participants: 100 citizens (a representative sample of the population) and 50 healthcare professionals. Moreover 13 focus groups were organised to gain knowledge about the specific needs and wants of ‘hard-to-reach groups’ such as members of the Chinese, Arabic, Somali and Sikh communities and people with hearing and visual impairments. In the third phase the initiators analysed the use of primary care facilities by a representative sample of 600 frequent users. The debate has provided insight in the priorities and preferences of users. For instance it turned out that users appreciate good access to healthcare facilities but they also value the combination of healthcare and social services. Moreover the workshop also helped to identify so-called trade-offs: for instance it became clear that people are willing to accept a higher concentration of higher-level facilities if lower-level facilities are well accessible. The empirical analysis of actual behaviour has shown that the maximum travel time people are willing to accept for visiting a basic healthcare facility is 15 minutes (Liverpool Primary Care Trust, 2007). One year after after the first workshop the Primary Care Trust organised another workshop to evaluate the consultation process. In general people were positive about the way they had been involved in the development of a new strategy for healthcare facilities. They felt their input had influenced the strategy to some extent. Apart from the output of the strategy (an improved access to healthcare, improved health), participants indicated they felt more empowered than they did before taking part in the consultation process. The Outside of Hospital Strategy After the Big Health Debate, the Primary Care Trust came to the conclusion that more healthcare services could be provided outside of hospitals in communitybased centres (Liverpool Primary Care Trust, 2007, 2008a). This so-called Outside of Hospital Strategy recognises three types of healthcare facilities. On the first level 20 to 25 neighbourhood health centres serve relatively small communities with 20,000 to 25,000 inhabitants. They can be reached by public transport within 15 minutes. On the second level, NHS Treatment Centres serve a community of 100,000 to 150,000 people. They provide a range of extended primary and secondary care services including diagnostic tests, minor surgical procedures, counselling and other mental health therapies and outpatient clinics. The Treatment Centres will be developed in locations that are accessibly for all community members within a public transport journey of 30 minutes. Third level facilities are the hospitals. The Primary Care Trust will invest a substantial amount (about ₤80 million) to develop new facilities and adapt existing ones (Liverpool PCT, 2007).   The aim is to have the first Treatment Centre up and running in 2009, the second by 2010 and the third by 2011 (Liverpool Primary Care Trust, 2008a).

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Towards Healthy Cities

One of the aims of the Outside of Hospital Strategy is to improve the fit between healthcare facilities and the specific needs of local communities. Local healthcare professionals will be consulted regularly in order to develop neighbourhood health centres that meet the demands of the intended users. The health centres are designed in such a way that changes in services – in response to changing needs – can be realised easily (Liverpool Primary Care Trust, 2007). The idea is that these centres bring together providers of healthcare and provides of community services. In this way the centres are expected to promote coordination between professionals enabling them to deal with health-related problems in a coherent way. For each health centre possibilities for the co-location of health and community services are to be considered (Liverpool Primary Care Trust, 2007, 2008c). The expectation is that multifunctional neighbourhood centres make it easier to tackle the accumulation of interrelated problems – medical and nonmedical – of community members. It is envisioned that the neighbourhood centres will play an important role in improving local health conditions; they will not only supply healthcare but also promote changes in lifestyle (for example, health centres are developed at locations that encourage people to walk or to use public transport). In addition the development and maintenance of health centres will create and secure local jobs as local procurement is strongly recommended (Liverpool Primary Care Trust, 2007). The health centres will presumably also add to the attractiveness of the immediate surrounding: the Primary Care Trust pays considerable attention to the design of buildings with health, safety, sustainability and a good fit in the surrounding as guiding principles (Liverpool Primary Care Trust, 2007, 2008a). One of the first neighbourhood health centres was opened in the neighbourhood of Picton in March 2008. Picton, located close to the city centre, is one of the most deprived parts of Liverpool. The Picton health centre accommodates two general practioners, a pharmacist and a dentist, but also a day care centre and several rooms for health education. It has been nominated for the Community Benefit award which honours achievements in providing community facilities, to be demonstrated by positive local community feedback, improvements to local landscape and a high level of public access.

4  The Redevelopment of Alder Hey One of the third level facilities in Liverpool is the Alder Hey children’s hospital: one of the largest children’s hospitals in Europe. The central facilities of Alder Hey are located in West Derby, a suburb in the north of Liverpool. The facility has a catchment area with a population of 7.6 million and treats more than 200,000 children annually. These children come in for standard procedures as well as for more specialist services, including bone marrow transplant, burns, cleft lip  Source: http://www.communityhealthpartnerships.co.uk/?id=127&ob=2.

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49

and palate, cancer, renal replacement and spinal injuries. Alder Hey is also a teaching hospital for medical students. It has an annual turnover of approximately ₤130 million and a workforce of 2,600 people. The hospital falls under the responsibility of the Royal Liverpool Children’s NHS Trust. This trust also operates 38 community sites across Merseyside. From these sites a wide range of child health services are offered in close cooperation with the specialists from Alder Hey Hospital, Primary Care Trusts and local authorities. In 2001 the decision was taken to build a new hospital replacing the incoherent mix of mostly outdated buildings that had been developed in the past. Inefficient use of space, a lack of land for expansion and difficulties to meet the strict requirements for hospitals were the main arguments for this decision (Royal Liverpool Children’s NHS Trust, 2007a). In the process towards the redevelopment of the hospital Alder Hey paid much attention to consultation. The hospital invited users (patients and their families) as well as neighbouring citizens to gain insight in their view on the interior and exterior design of the hospital as well as the layout of the surrounding environment. This so-called inquiry-by-design method was used to ensure a better match between supply and demand, but also to win the sympathy of important stakeholders. It was particularly important to take away the fear that the redevelopment of Alder Hey would reduce the size of the adjacent community park: Springfield Park. During these so-called design events relevant stakeholders shared their ideas and drew sketches that helped to inspire professional designers. Another strategy used by Alder Hey was to cooperate with so-called ‘sustainability partners’ who played a key role in communicating the trustworthiness of Alder Hey creating enthusiasm for the project. These ‘honest brokers’ were also asked to give advice on how to make the project more sustainable.

Table 3.2

Sustainability partners of Alder Hey

Aspect of sustainability Waste and recycling Sustainable communities

Partner organisations Environment Agency The Prince’s Foundation for the Built Environment Renewable energy Liverpool John Moores University Sustainable health initiatives Sustainable development foundation, Shine: the Learning Network for Sustainable Healthcare Buildings Green transport TravelWise Merseyside Local labour and skills Construction for Merseyside Sustainable construction procurement WRAP (material change for a better environment) Source: Alder Hey

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50

In 2006 the Liverpool City Council granted an outline planning permission for the development of the Alder Hey Children’s Health Park: a hospital surrounded by parkland (Royal Liverpool Children’s NHS Trust, 2007b, 2008). It is envisaged that the setting of the hospital in the park contributes to the recovery process of the patients (Royal Liverpool Children’s NHS Trust, 2007b). Through the design the natural landscape will be connected to the internal environments, creating a strong relationship between the hospital and the parks. The attractiveness of both the internal and external environment will thereby be further stimulated by the use of colour, water, natural illumination and artwork. In the design of the new building considerable attention has been paid to sustainability (e.g. the use of renewable energy sources for heating). The total costs of the construction scheme – to be finished in 2014 – are approximately ₤200 million (Royal Liverpool Children’s NHS Trust, 2007a). The plan for the Alder Hey Children’s Health Park foresees the development of hospital buildings on the location of Springfield Park in the old situation (see Figure 3.2). In return, however, the developers will create new parkland at the location of the old hospital. In this way the surface of the park will remain equal. More importantly, however, the redevelopment of the hospital and its immediate environment facilitate more intensive use of the park. In the old situation the park is not well accessible while it suffers from a poor image (unsafe) and a lack of adequate facilities. The redevelopment of the hospital includes a quality upgrade for all parts of Springfield Park (old and new). Investments will be made in sport pitches, safety (more surveillance and the construction of buildings that overlook the park), and accessibility (among other things by introducing walking trails in cooperation with Liverpool’s Active City Programme). In the new setting the park provides an attractive and fast connection for pedestrians and cyclists between the ROGVLWXDWLRQ

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Liverpool

51

residential area to the north and the retail facilities to the south (Royal Liverpool Children’s NHS Trust, 2007b, 2008). The development of Alder Hey Children’s Health Park fits in the hospital’s view on health promotion. In its strategy ‘Why your health matters’ (Alder Hey, 2007) the hospital emphasises the importance of health promotion: prevention instead of cure and care. The hospital trains its health professionals to support patients and their families in adopting a healthier lifestyle and activities are undertaken to improve the health of the population in cooperation with other health-promoting agencies. They use the argument that many of their patients have preventable illnesses caused by lifestyle problems (of their parents) such as unhealthy eating habits, a lack of exercise, smoking and drinking too much alcohol. The World Health Organisation has even accredited Alder Hey the title of the first public health promoting paediatric health organisation in England.

5  Conclusions What are the main conclusions from the initiatives we analysed in Liverpool? Can we find evidence that supports the relevance of the three conditions for investments in healthy cities that we identified? And if yes, how the actors involved try to meet these conditions? Although most of the initiatives can not be fully evaluated yet, it is possible to draw some conclusions about the expected impact of citizen empowerment and corporate responsibility on the coordinated improvement of urban health conditions. Citizen Empowerment The experiences of Liverpool make clear that consultation is a first step towards the empowerment of citizens. The Big Health Debate, the Out of Hospital strategy (including the development of neighbourhood health centres) and the inquiry-bydesign method used by Alder Hey are good illustrations of how to involve citizens and other stakeholders in the development of effective interventions in health determinants. The interventions have in common that they combine input from citizens with the input from (professional) experts. Citizens are able to identify factors that influence their own health and the health of friends and relatives, but they often do not have an overview of all underlying determinants and the range of possible interventions. Experts can add to citizen empowerment by explaining what interventions are effective in other neighbourhoods or cities. Whether or not consultation actually empowers citizens depends on the degree to which people are actually able to influence the process. Often consultation is only an instrument to inform people and to take away resistance against change, as in the case of Alder Hey. By inviting people to design the new hospital they at least got the feeling they have an influence on the design even if their influence is marginal. In the case of the Big Health Debate, the Primary Care Trust even

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evaluated the impact of workshops on citizen empowerment, with a positive outcome. By asking people about their priorities and involving them in the tradeoffs made by governments and other institutions their perceived ability to take control of their own health and wellbeing seemed to grow. An important condition for citizen empowerment is to make sure that also ‘hard to reach’ groups are consulted somehow. Corporate Responsibility The City of Liverpool and the Primary Care Trust have jointly taken the lead in the improvement of urban health conditions. Private-sector involvement in the development of a healthy city is to some extent facilitated by Liverpool First, a local strategic partnership of a kind that can be observed in other UK cities as well. Although the Healthy Cities Team is no longer operational, the healthy cities philosophy still dominates the policies of the city and the healthcare sector. The way children’s hospital Alder Hey deals with its environment – involving stakeholders as honest brokers and playing an active role in promoting health – is illustrative. We found, however, little evidence of private actors in other sectors taking their responsibility in the development of a healthy city. The city and the Primary Care Trust expect that the co-location of health organisations and other (public or private) organisations in the neighbourhood health centres facilitates partnerships, but it is too early to draw conclusions about the effectiveness of this strategy. Coordinated Improvement of Urban Health Conditions The City Health Plan, the Liverpool Sustainable Communities Strategy and the Local Area Agreement are all examples of strategic documents that aim for a coordinated improvement of urban health conditions. At grassroots level the neighbourhood health centres are considered effective instruments to put a coordinated improvement of health conditions into practice. They can function as ‘one-stop-shops’ where various actors offer their services to improve the health and wellbeing of citizens. Moreover they create local jobs and make the surrounding more attractive. Another example is the redevelopment of Alder Hey which has been organised in such a way that it improves the health situation in many aspects: the Children’s Health Park will accelerate the recovery of patients but also stimulate families of patients and neighbouring citizens to make healthy choices.

References Alder Hey (2007), Why Your Health Matters, A Public Health Strategy for Alder Hey.

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City of Liverpool (2008a), Key Statistics, 4. City of Liverpool (2008b), The Indices of Deprivation 2007. Costongs, C. and Springett, J. (1997), Joint Working and the Production of a City Health Plan: The Liverpool Experience, Health Promotion International, 12(1). Oxford: Oxford University Press. Department of Health (2004), Choosing Health: Making Healthy Choices Easier. Hayes, C. (1999), A Century of Liverpool. Sutton Publishing. Liverpool City Region (2005), Transforming Our Economy. Liverpool First (2005), Liverpool First 2008–2008, Our Sustainable Community Strategy. Liverpool First (2007), Accelerating Delivery Changing Perceptions, Liverpool’s Area Agreement. Liverpool Primary Care Trust (2007), A New Health Service for Liverpool, Outside of Hospital Strategy. Liverpool Primary Care Trust (2008a), A New Health Service for Liverpool, Consultation on Improvements to Health Services in South Liverpool. Liverpool Primary Care Trust (2008b), Annual Report of the Joint Director of Public Health 2007. Liverpool Primary Care Trust (2008c), Strategic Plan 2008–2011, a discussion document. McIntyre-Brown, A. (1998), The Official Guide to Liverpool. NHS (2007), Liverpool Health Profile. Royal Liverpool Children’s NHS Trust (2007a), Annual Report and Account 2006–2007. Royal Liverpool Children’s NHS Trust (2007b), Presentation Alder Hey. Royal Liverpool Children’s NHS Trust (2008), Profile of the Trust, 2008. Strobl, J. and Bruce, N. (2000), Achieving wider participation in strategic health planning: experiences from the consultation phase of Liverpool’s ‘City Health Plan’, Health Promotion International, 15(3). Oxford: Oxford University Press.

Discussion Partners Mrs Jane Corbett, Chair of Education and Skills Select Committee, Councillor Liverpool City Council Mrs Betty Dunderdale, West Everton Community Council Mrs Noreen Fallon, CDS Housing Mr John Garrett, Director of a New Health Service for Liverpool Programme and NHS Lift Mr David Houghton, Estate Manager, Alder Hey Hospital Mr Graham Pink, Chief Executive, Liverpool and Sefton Health Partnership Mr Steve Ryan, Consultant Paediatrician and Medical Director, Alder Hey Hospital Mrs Julia Taylor, Director, Liverpool Healthy Cities, Liverpool PCT

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Mr Terry Windle, Director of Corporate Services/Deputy chief executive, Alder Hey Hospital

Chapter 4

London

1  Introduction This chapter analyses and discusses various health-related initiatives in one of the largest financial centres of the world: London. Our guide is the framework we made to test the relevance of three conditions in the development of healthy cities. After a general profile of the region we focus on some specific policies that aim to improve the health and wellbeing of Londoners: a local strategic partnership in the borough Croydon, the redevelopment of Thames Gateway and the Well London programme. 2  General Profile London is the capital (seat of the national government) and by far the largest city of the UK with a population of 7.5 million in the Greater London area (surface: 1600 km2). It is the focal point of an urban agglomeration that counts approximately 13 million inhabitants on a surface of 8,000 km2 (depending on the definition of this area). A key characteristic is the high ethnic diversity of the population: 29 per cent of all citizens belong to ethnic ‘minorities’ and for children this percentage is even higher (up to 40 per cent). London can be divided into Inner London (14 boroughs) and Outer London (19 boroughs). In economic terms London is still one of the most important cities in the world, competing in the league with cities such as Paris, New York and Tokyo. The city is an important motor of the UK economy generating 18.8 per cent of the Gross Domestic Product. After the 1980s the London region entered a period of steady growth resulting in above-average growth rates for indicators such as income and productivity. Increases in employment (27 per cent) explain the influx of people from other parts of the UK as well as from abroad, with higher housing prices as logical outcome (London School of Economics, 2008a). The big economic recession that started in 2008 has brought this period of growth to an end, resulting in severe problems for the financial sector, one of the pillars of the London economy, and serious consequences for the real estate market (housing prices went down) (Economic Development Office, 2008).

  This case study is based on interviews with various stakeholders in November 2008.

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Health Inequalities The difference between London’s health performance and the UK average is fairly small. Men live only 0.1 year shorter than the average UK citizen, while women live 0.2 years longer. The percentage of people who experience ‘good health’ is 70.8 per cent, compared to 68.7 per cent on a national level (London Health Commission, 2007). The problem, however, is that these aggregated statistics hide away the internal health inequalities between the prosperous and poor parts of the city. There are remarkable differences between the average life expectancy on borough level. These internal inequalities are also reflected in other health indicators (Mayor of London, 2008). Several discussion partners refer to the fact that life expectancy drops with almost one year for each station one travels eastward on the Jubilee Line. In Westminster people live seven years longer than in Canning Town. The average male life expectancy ranges from about 80 in Kensington and Chelsea, located to the west of the City of London, to approximately 74 in nine boroughs that are located to the north, south and east of the City of London (Mayor of London, 2008).

Table 4.1

Health indicators for Greater London and Great Britain Year

Average life expectancy at birth

2002–2004

Infant mortality per 1,000 live births Self-assessed health, reporting good health

2002–2004

Greater London Male: 76,5 Female: 81,1 5.4%

2001

70.8%

Great Britain

68.7%

Male: 76.6 Female: 80.9 5.2%

Source: ‘Health in London; Looking back – looking forward’ (London Health Commission, 2007), adapted by the authors

In many boroughs health inequalities manifest themselves on lower levels such as neighbourhoods and even streets. These health inequalities are strongly related to the internal socio-economic differences in terms of income, employment and opportunities for training and education as well as differences in the quality of the environment in terms of air quality, safety, accessibility and (recreational and social) facilities (London Health Commission, 2007). Indices of deprivation can be used to assess the accumulation of problems in particular areas (Greater London Authority, 2008). It is not a surprise that most of these areas can be found in boroughs with a relatively low life expectancy. The Greater London Authority seems to be aware of the complex interaction between health, economic conditions and the quality of the environment. Many Londoners can only afford a house in less prosperous parts of the city where the socio-economic and environmental

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conditions are suboptimal. These conditions not only affect their health but also restrict their ability to earn a higher income (Mayer of London, 2008). The London Health Commission has identified lifestyle as an important issue in this complex interplay between determinants: many people who live in problem areas exercise too little, for one thing because they consider their environment not sufficiently safe and attractive. Parents are reluctant to allow their children to walk or bike to school and many parks are hardly used. Another reason is that lower-income groups simply cannot afford a sports club membership or entrance to a leisure facility. Budget restrictions also explain why people choose unhealthy food, although the choice for unhealthy food is often also a matter of convenience, a lack of motivation or insufficient knowledge. An additional problem is the unavailability of healthy food (e.g. fruits and vegetables) in some parts of the city; particularly in East London so-called ‘food deserts’ make it difficult for citizens to adopt a healthy life style. Health inequalities are persistent because of mobility, a phenomenon that can be observed in many large cities: people who manage to acquire better skills and find their way to a better paying job also choose to move to a better place. This explains why it is extremely difficult to reduce the problems in particular areas (Mayor of London, 2008).

3  The London Health Commission London is governed by the Greater London Authority which consists of the mayor, an assembly and a permanent staff of public officers. The elected major is responsible for policies on transport, spatial planning, economic development, culture and the environment (e.g. air quality, biodiversity, energy, noise and waste). For the implementation of policies the Authority has to cooperate: not only with the 33 boroughs but also with various other institutions such as the Metropolitan Police Department, London Fire and Emergency Authority, Transport for London and the London Development Agency. Together these organisations constitute the Greater London Authority Group. The boroughs implement the strategies developed by the Greater London Authority and they deliver educational and social services. In 2000 the British government accepted a formal statement which compels all layers of government (national, regional and local) to contribute to a reduction of health inequalities. In London this legal obligation soon resulted in the creation of the London Health Commission (London Health Commission, 2008). This commission is composed of representatives from a broad range of organisations such as the National Health Service (NHS), the London Development Agency, Transport for London and various universities. As we explained in the previous chapter (the case of Liverpool) the NHS has the legal task to deliver healthcare: the actual delivery on a local level is the responsibility of Primary Care Trusts. Before 2000 the Greater London Authority and its boroughs hardly cooperated

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with the NHS. The Primary Care Trusts used to have insufficient insight in regional economic developments and plans. On the other hand regional and local authorities paid little attention to the health impact of their economic and spatial development plans. The legal obligation radically changed this situation. Cooperation and Coordination in Health Promotion In 2004, the decision was taken to set up an organisation that promotes and facilitates cooperation and coordination between health experts and urban developers: the Healthy Urban Development Unit. This intermediary organisation arranges meetings that bring together people from both sides, while they also provide information and practical instruments to make actors more aware of their common interests in the development of healthy and sustainable communities. As a result city developers now give more priority to healthcare facilities in their spatial and economic plans and they involve the healthcare sector in the design of these plans. In addition one can observe more examples of cooperation between local authorities and Primary Care Trusts, for instance in local strategic partnerships (Blackshaw, 2008). Such partnerships are active in all boroughs of London in line with the policies of the State as we discussed in the previous chapter on Liverpool. Essentially they bring together important and influential stakeholders to discuss the problems and opportunities of a specific area, encouraging these actors to take action, though without any legal tools to enforce action. Examples of stakeholders are (apart from the two we already mentioned) community organisations, businesses and NGOs. In section four we present an example of a local strategic partnership. Activities of the London Health Commission The main task of the London Health Commission is to make sure that health considerations are integrated in all policies and tasks of the Greater London Authority and the boroughs. One of the commission’s tasks has been to formulate a strategy for the mayor to reduce health inequalities in a proactive way through interventions in health determinants (Mayor of London, 2008). This strategy – Living Well in London – has resulted in investments in housing and public space in order to create an environment that promotes healthy choices. The strategy fits in the new, more active role of the London government in health promotion which was defined by the Greater London Authority Act, approved in 2007. The   The White Paper ‘Strong and Prosperous Communities’ obliges local governments to take the initiative for setting up a local strategic partnership in which it also has to participate (London Health Commission, 2007). It does not prescribe how the partnerships have to be organised nor what actors have to be involved, although it emphasis the importance of involving non-governmental actors.

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commission also initiates projects such as Well London (see Figure 4.1) and advises other actors (mostly public) on how to set up effective health interventions. One of the commission’s missions is to make organisations in the field of health and wellbeing more aware of their interdependence. To that end they developed a poster that identifies relevant stakeholders in health promotion and how they are related to another. This diagram has the same layout as the famous tube map of the London Underground. Each line has a different color and represents an important determinant of health: community safety and crime; education; environment; employment, skills and enterprise; health and social services; housing; transport; and urban planning. There is also one line that connects organisations with crosscutting influence. Other organisations are connected to two determinants such as the Greater London Alcohol and Drug Alliance (connected to health and social services, community safety and crime) and Homeless Link (health and social services as well as housing). Some actors are connected to even more lines which implies that they have a very broad scope. Examples are the Greater London Authority and the London Borough Councils. The poster includes a disclaimer which emphasises that the diagram is only indicative and not a complete overview of all organisations and their roles.

Figure 4.1

Making the links for health

Source: London and Londoners: Making the Links for Health (London Health Commission, 2006), adapted by the authors   In this simplified version of the map developed by the London Health Commission the names of some organisations have been shortened. The original version (poster size) includes information about the missions and contact details of all organisations. It also says that the poster ‘is indicative and not intended to give a comprehensive description of all organisations in London and their role in health. Information was correct at the time of going to print’.

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4  A Local Strategic Partnership in Croydon In the UK one of the tools for cooperation in the field of health promotion is a local strategic partnership. Also the borough of Croydon – located in the south of London – has been obliged by the State to set up such a partnership. Croydon is the largest borough of London in terms of both surface (87 km2) and population (340,000). Many of the relatively young inhabitants – 25 per cent are younger than 18 – belong to ethnic minorities: 63 per cent, including many refugees and asylum-seekers. There is a remarkable socio-economic divide between the poor northern and the relatively rich southern part of the borough, which is reflecting in housing prices, indices of deprivation and life expectancy rates. People who live in the north live on average seven years shorter. Typical problems for the north are crime, excess drinking and teenage pregnancies (Department of Health, 2008a; Healthy Croydon, 2008). The Partnership: A Strategic Board and Eight Thematic Groups The main objective of Croydon’s local strategic partnership is to improve the quality of life for its citizens. The partnership consists of a strategic board and eight thematic groups. The board is responsible for developing an overall strategy; it includes representatives from the public sector (borough, NHS and the police), the business sector and citizen groups. These three sectors are equally represented. The board has no formal power: the implementation of decisions and strategies is the responsibility of the partner organisations. Informally, however, the respected and highly committed members of the board are able to influence partner organisations considerably, using their individual networks. The thematic groups are made up of representatives of public, private and civic leaders who have a stake in the theme in question. Together they develop and implement strategies. Apart from their role in the board and thematic groups businesses and citizens are also involved through a business development partnership and a community network. The business development partnership acts as an intermediary between the local strategic partnership and the local business community. Companies play an active role in the implementation of projects. The community network is a similar platform for citizen groups (e.g. clubs, volunteers, etc.). Both platforms regularly organise thematic meetings in order to inform and activate their members. Healthy Croydon One of the thematic groups is Healthy Croydon. Its main mission is to enable citizens to take better informed decisions that improve their health (Healthy Croydon, 2008). Among the actors involved are the Primary Care Trust, members of the borough council and representatives of volunteer groups. The role of the business sector in Healthy Croydon is rather small. The meetings organised by the thematic group are well evaluated and they have resulted in joint projects,

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such as a successful application for subsidies. One of the projects initiated by Healthy Croydon is Health Champions which enables volunteers to attend a course that teaches them how to identify and tackle health-related problems in their community. In addition they may apply for a small subsidy (₤500) to develop and implement a project in response to these problems: stimulating citizens to adopt a healthier lifestyle in terms of eating, drinking and exercising or to improve other more indirect health determinants such as the access to social networks and skills.

5  The Thames Gateway Redevelopment Another health-related initiative we analysed in the case of London is the redevelopment of the Thames Gateway: a very large area, a 60 km stretch from the east of London to the North Sea coast, along both sides of the Thames. The area provides homes to about 1.6 million people. The part that falls within the borders of the Greater London Authority is densely populated in contrast to some other parts with hardly any buildings and, hence, a lot of development potential for residential and commercial use. To utilise this potential, however, actors involved agree that some of the current problems in the Thames Gateway need to be tackled somehow. The area comprises some of the most deprived neighbourhoods of the UK, notably in the London part of this area. Many industrial activities have disappeared since 1960s while others generate fewer jobs, with high unemployment figures as logical consequence. Also the built environment needs improvement: many houses do not meet modern standards and derelict industrial sites spoil the landscape. In many parts of the Thames Gateway the health conditions are unfavourable (London School of Economics, 2008b). A good illustration is Newham, a borough in the east of London. This borough is the sixth most deprived area in the UK, with a poor performance on income, access to services, quality of life and health. The level of inactivity is higher than 40 per cent and life expectancies are among the lowest in London (Newham Primary Care Trust, 2007; Department of Health, 2008b). Objectives The combination of development potential and severe problems has made public and private actors aware of the urgency to redevelop the area. In the Thames Gateway Delivery Plan (2007), the National Government’s Department for Communities and Local Government has identified three main objectives for the redevelopment of this area. The first objective is to strengthen the economy creating 225,000 new jobs. The second ambition is to improve the living environment for current and future citizens through the construction of new houses and renovation of existing houses. In this way the area has to become more attractive for a range of target groups with different needs and different incomes, thus creating more balanced and sustainable communities. The third goal is to develop the area

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into an ‘eco region’ anticipating themes such as climate change, bio diversity, landscape, environmental quality, energy and water efficiency, waste management and sustainable transport. To meet the goals formulate above the government intends to invest in housing (for different target groups, including affordable housing), facilities (e.g. daycare centers, healthcare centers, cultural and community centers), transport infrastructure (public transport, roads, bridges, ports, etc.), and a network of accessible and sustainable parks and leisure areas. In total the public sector will invest more than ₤9 billion in the Thames Gateway The revitalisation of the Thames Gateway is, however, not only a public affair. The government hopes that public investments make it more attractive for private actors to invest as well. Developers will invest in residential and commercial areas while entrepreneurs will settle themselves in these areas to generate employment. For the London Thames Gateway Area expectations are that public investments worth ₤237 million will generate ₤1.8 billion private investments. Various projects have already been set up to improve the socio-economic and environmental conditions in the Thames Gateway. Below we discuss some of these projects, focussing on the role of the private sector and citizen empowerment. Olympic Legacies Programme One of the most promising projects in the Thames Gateway is the Olympic Legacies Programme. Many events of the 2012 Olympic Summer Games will take place in a newly built sporting complex in Stratford, East London. Apart from different sporting venues this so-called Olympic Park will also comprehend the Olympic Village. The construction of this complex will generate employment, but more importantly the Park will be transformed into a large and accessible urban park with 9,000 dwellings (including affordable houses) and a range of facilities improving the access to sports, healthcare, education, community centres, shops and restaurants. In this way the government wants to ensure that local communities also benefit from the mega-event. In the design and development of the Olympic Park future functions are taken into account as much as possible (Olympic Development Authority, 2008). Before the global crisis private developers showed willingness to make additional investments to make the Park more sustainable and ready for use after the event. The Olympic Games are an event many developers want to be associated with. As in many other places, however, the economic depression reduced the financial means of private actors to make such ‘additional investments’.

 Source: http://www.communities.gov.uk/thamesgateway/crossgovernmentpriorities/.

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Skills Plan Another relevant project is the Thames Gateway Skills Plan: various authorities have agreed to invest in educational facilities arguing that skills are crucial for regeneration and the development of healthy communities. An example is the development of Universities at Medway (also referred to as Medway Campus), located in Chatham Maritime in the western part of the Thames Gateway. This shared campus brings together the University of Greenwich, the University of Kent, Canterbury Christ Church University and Mid-Kent College. This so-called ‘multiversity’ not only offers courses on university level but also on more practical and lower-level courses. The aim is to enable all citizens to benefit from the concentration of knowledge (institutions) and the interaction with other students. Another example can be found in Essex (in the northwestern part of the area) where various educational institutions offer practical courses – for instance in construction – that respond to the needs and competences of surrounding citizens as well as to regional employment opportunities. The campus is located right in the middle of the community. Two other educational facilities worth mentioning are the National Skills Academy for Financial Services in the London borough of Tower Hamlets and the National Skills Academy for Construction in Stratford (near the Olympic Park). These educational centers have been developed by coalitions that involve governments, the private sector and educational institutions. Local businesses do not only co-finance courses but they are also involved in the design of courses to ensure a good fit between supply and demand. Community Initiatives In various ways citizens in the Thames Gateway Area are stimulated to take initiatives themselves to improve their environment. The national government’s Community Initiative Fund provides subsidies up to ₤1,000 for individuals and groups with ideas to regenerate their own neighbourhood. With the relatively modest financial support of this fund citizens get the opportunity to organise (cultural and sports) events and meetings, and to improve communication (e.g. newsletters). In this way the initiators – often unemployed people – also acquire essential competences that improve their employability substantially. Another project that stimulates citizen empowerment is the Community Champions programme, which has been developed by East Potential: a social and economic regeneration charity which works across East London and Essex ‘to empower local people to create a brighter future for themselves and make a contribution within their communities’. The Community Champions programme provides free  South Essex College, Anglia Ruskin University, The University of East London, The University of Essex, Barking College, The National Construction College and Palmers College.  Source: http://www.east-potential.org.uk/.

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courses to volunteers turning them into professional neighbourhood consultants. During this 12-week programme (three days a week) they acquire communication and administrative skills as well as basic skills in health promotion (East Potential, 2008). The consultants are trained to collect knowledge about health-related problems and the effectiveness of interventions, to tackle these problems and to activate citizens (stimulating them to do volunteer work or to find a job). The Community Champions programme has helped many volunteers who participated to find another job or to apply for another course. Neighbourhood Centre THE Hub An example of a new facility in the Thames Gateway is neighbourhood centre THE Hub, which has been developed in Canning Town, one of the most deprived areas in the East of London. This centre provides access to a range of health-related services (a health centre and a pharmacy), but also to other types of services with a more indirect impact on health: an internet café, a multifunctional room for community meetings, a training and employment centre, a safety and security team and a support desk for entrepreneurs. The initiators and actors involved are convinced that this centre will become ‘THE Hub’ for the entire area. The centre is located in a very prominent building making it easy to find for everyone (Trott, 2005). Contributions of the Private Sector The government expects that the private sector will make the largest contribution to regeneration through their primary process (generating income and employment, developing services and products). In addition the national government is preparing plans to introduce so-called Community Infrastructure Levies: taxes to be paid by developers – depending on the size and qualities of the development – to be spent on social infrastructure. Furthermore companies also add to regeneration through voluntary contributions. A good example is the East London Business Alliance which connects businesses in the east of London to the regeneration challenge in the neighbouring communities. Participating firms – such as banks and insurance companies located in Canary Wharf – have demonstrated their commitment to concrete projects through sponsoring (financial contributions) but also through contributions in kind such as free financial advice. Employees of financial firms also get the opportunity to help neighbouring residents with acquiring skills and finding a job.

 Source: http://www.communities.gov.uk/documents/planningandbuilding/ doc/931197.doc.

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6  Well London The Programme Well London is a five-year programme (2007–2012) with 14 projects to be implemented in 20 small areas in 20 different London boroughs. All target areas belong to the most deprived parts of London (Well London Alliance, 2007). The projects focus on the three most essential aspects of health: nutrition, exercise and mental wellbeing. The primary aim of the Well London programme is to enable the inhabitants of the 20 target areas to live a healthier life through these three pillars. The projects are adapted as much as possible to the local circumstances by giving citizens and community organisations an active role in all phases of development. In this way the programme stimulates community development and the accumulation of knowledge, skills and self-confidence on a local level: it thus aims to empower the citizens to solve their own problems in the future. Another objective of the programme is gain knowledge about the conditions under which health interventions are effective. To that end all projects are evaluated carefully. The Well London programme is a joint initiative of six organisations united in the Well London Alliance: • • • • • •

•

Central YMCA – The UK’s leading activity for health charity. Groundwork London – A charity that promotes the wellbeing of communities through investments in the natural and built environment London Sustainability Exchange (LSx) – A charity that aims to accelerate the transition to a sustainable London by connecting and motivating people. Support for innovative activities – This pillar concerns the traditional role of the government: stimulating technology transfer. Arts Council England – National development agency for the arts, financed by the state and National Lottery funds. University of East London – Represented by the Institute for Health and Human Development which carries out studies into health and wellbeing and their socio-economic determinants. South London and Maudsley (SlaM) – An NHS foundation trust that provides mental health and substance misuse services to people from Croydon, Lambeth, Southwark and Lewisham, and substance misuse services in Bexley, Greenwich and Bromley.

The programme is fully funded by the National Lottery funds. In the application procedure for this subsidy, the London Health Commission managed to convince the six organisations that they had to cooperate. In this way they could submit a larger and more coherent programme, and they could take advantage of the complementary competences of the partner organisations: Groundwork, London Sustainability Exchange and Central YMCA have much experience with working at grassroots level, while the University of East London, SlaM and also

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Groundwork are strong in process and performance evaluation. The total budget is ₤9.46 million, which implies that each small target area receives almost ₤100,000 a year. The Well London Programme is governed by a small project team that operates within the London Health Commission at the City Hall. This project team is kept relatively small in order to save management costs. The initiators hope that the project team can be further reduced when the partners take over some of the coordination. Target Areas The programme targets 20 Lower Social Output Areas (LSOAs) in 20 different London boroughs; each with a population of 1,500 to 2,000. The partner organisations have selected these areas in consultation with the Primary Care Trusts and the local authorities. All 20 areas belong to the most deprived areas in Great Britain with an accumulation of serious health problems. The partners have selected the 20 areas as follows. First, they identified boroughs in London with at least four LSOAs that belong to the eleven per cent most deprived areas of Great Britain. Second they collected and discussed information about four LSOAs in 20 different boroughs. Third they selected two of the four areas in consultation with local governments and Primary Care Trusts. Fourth they randomly selected one of the two areas as intervention LSOA and one as control LSOA. After the subsidies were granted by the Lottery Fund the partners entered the stage of consultation in the autumn of 2007. Numerous organisations in the field of health and wellbeing were consulted, including members of the London Health Commission. Through intensive interaction with the inhabitants – using tools such as community cafés, community action workshops and site visits – the initiators got insight in what aspects of their environment people appreciate and what aspects they dislike. This analysis made very clear what problems the inhabitants are struggling with, such as: • • • • • •

There is a lack of hope and aspiration. Disintegrating communities cause loneliness among vulnerable groups such as the elderly and ethnic minorities. People lack the motivation and knowledge to change their unhealthy lifestyles. Unemployment, poverty and a low quality of the living environment make it difficult to live a healthy life. People complain about a lack of coordination between providers of health care and social services. Etc.

The 14 programmes of Well London – that were already defined before consultation started – aim to tackle these and other problems in the 20 selected areas. Since the Lottery Fund does not allow any major changes in the projects they subsidise, the

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consultation process could only result in small, but not unimportant adjustments. Furthermore the interaction with local people and organisations helped the partners of Well London to decide what projects had to be carried out in each of the 20 areas. They stuck to their own rule that projects were only implemented in a particular area if the existing supply of projects and initiatives was insufficient to meet the demand. Cohosts Another principle of the Well London Alliance concerns the role of local partners in the implementation. The members of the alliance try to hand over tasks to these so-called ‘co-host’ as much as possible. In order to enable communities to take care of their own problems, the Alliance cooperates with Primary Care Trusts, local authorities, housing corporations, volunteering organisations, schools, churches, citizen groups, etc. The idea behind this strategy is that citizens as well as employees and volunteers of local organisations acquire skills, knowledge and self-confidence by implementing the projects. Clearly the argument is that the effects of the five-year programme have to be durable. Cooperation with business is less common, with the project Buywell (to be introduced hereunder) as the exception that confirms the rule. Projects The core of the Well London programme consists of six so-called ‘heart of the community’ projects which aim to increase the knowledge, skills and aspirations among the members of the targeted communities. These general projects facilitate the implementation of more thematic projects to be discussed hereunder. The six ‘heart of the community projects’ are: •

•

•

•

CADBE is short for Community engagement, Assessment, Design, Brokerage and Enterprise. This project, under supervision of the University, evaluates the Well London programme through the collection of information by citizens and local organisations, for instance via community cafés and Mental Wellbeing Impact Assessments (see below). Youth.comUnity – run by YMCA – tries to involve young people (well represented in the selected areas) in the design and implementation of other projects. Well London Delivery Teams is a joint project of the LSx and YMCA. It brings together five of more volunteers who live in the selected areas and have the task to help their neighbouring residents with making healthy choices. Training Communities is a project managed by SlaM that provides citizens a variety of training sessions to give them the knowledge and skills needed to carry out the projects of Well London.

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•

•

Wellnet makes it possible for citizens and professionals to exchange experiences with the promotion of health and wellbeing – within Well London, but also in other initiatives – through events, newsletters, publications, a website and a toolkit. This project is carried out by LSx. Active Living Maps are GIS-based maps that help people to find ‘healthy choices’ in their immediate environment (e.g. shops where they can buy healthy food, sports facilities and walking routes). Printed versions of these maps are distributed by the Delivery Teams. The development of these maps is organised by Groundwork.

The eight thematic projects are structured along five thematic lines: culture and tradition, food, mental health and wellbeing, open spaces and physical activity: •

•

• •

•

•

•

Be Creative, Be Well – a project in the theme culture and tradition – uses arts and culture to involve communities and individuals in the process of change, making them think about health and a healthy lifestyle. The leading partner is Arts Council London. Buywell ­– in the category food – aims to make it easier for people to buy affordable, healthy products by influencing suppliers (e.g. restaurants and supermarkets) and introducing new retail and catering concepts. This project is run by LSx. Eatwell ­­– a project of LSx – stimulates people to eat healthy food by organising events and facilitating the organisation of cook and eat clubs. Do It Yourself Happiness – carried out by SlaM – teaches people how they can improve their own mental wellbeing using humour, creativity and positive psychology. The project challenges citizens to come up with ideas for interventions that improve their own happiness and the happiness of their neighbours. The best ideas are rewarded with a small subsidy (up to ₤500) and a group training to turn the ideas into concrete project proposals. The project has resulted in so-called ‘happiness kits’ for each target area containing products that make citizens feel happy. Mental Well-being Impact Assessment is an instrument to measure the impact of projects and programmes on well-being, using a range of indicators such as control, resilience, participation and inclusiveness. These qualitative indicators are assessed by consulting local stakeholders. The assessments are carried out by citizens who have been instructed by SLaM, the organisation that manages this project. Changing Minds recruits and trains local people who have experienced mental health problems to share their experiences with other members of the community. This project is run by SLaM. Healthy Spaces – a project in the theme ‘open spaces’, managed by Groundwork – aims to improve the quality and use of the physical environment; for example by using ‘temporary public space’ (e.g. construction sites) as kitchen gardens, developing walking and biking

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routes that connect places of residence to public space, improving the design of parks and playgrounds (‘design out crime’) and organising events and activities (e.g. community gardening) to create a sense of ownership and stimulate the use of public space. Activate London has the ambition to increase physical activity by signposting existing sports and recreation facilities and delivering new ones. This project is carried out by YMCA.

The programme Well London not only aims to improve the health situation in the 20 areas, but also to identify the conditions under which interventions are most effective. To that end local organisations and citizens collect information. This performance evaluation results in the development of ‘models’ and the recognition of ‘best experiences’ that enable partners and co-host to adjust their interventions directly. The impact of Well London projects can be measured by comparing indicators (e.g. changes in unemployment and crime rates) in the intervention LSOAs with the control LSOAs. In this way the University of East London gains useful insights that become available to the other partners, co-host, the Health Commission and other organisations (Renton, 2007).

7 Conclusions In the previous sections we described and analysed various initiatives in London that aim to improve the health conditions. We discussed policies and projects on various spatial levels – ranging from Lower Social Output Areas to the entire Thames Gateway. Now, what are the main conclusions? Can we indeed conclude that citizen empowerment, corporate responsibility and a coordinated improvement of urban health conditions are key factors in the development of healthy cities? And what are governments, institutions and businesses doing to meet these conditions? Citizen Empowerment The empowerment of citizens is an important objective in all interventions we analysed, but some projects clearly pay more attention to this aspect than other projects. The redevelopment of the Thames Gateway is a large-scale project at a considerable distance of the community level. Nevertheless we have identified various attempts to promote the involvement of local actors, such as the Community Initiatives Fund and Community Champions. Particularly the Champions programme is innovative because it serves two goals at the same time: 1) local citizens help to identify the health-related problems of their neighbours which enables organisations to take away barriers and offer tailor-made solutions; 2) local citizens acquire useful skills and knowledge that help them to improve

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their employability. As we saw in Croydon – where we analysed the local strategic partnership Healthy Croydon – local citizens get a training first preparing them to become Health Champions. An important feature of the Champions programmes as well as the Community Initiative Fund is that they do not prescribe the projects or health determinants to be improved. Organisations and authorities are willing to agree with a high level of self-control for the population, assuming them to be able to identify the problems and to invent solutions themselves. Also the programme Well London – implemented in 20 small areas – attaches much value to citizen empowerment. The six partner organisations have done their best to reach and consult the targeted population, for instance by organising attractive and accessible participation sessions. These events have helped to gain insight in the specific problems in the different areas: the organisations used this valuable information to fine tune their projects that had, admittedly, already been defined before consultation started. As we explained, the sponsor of this programme – the National Lottery Fund – did not allow any major changes in the set-up. While the involvement of citizens in the design of the Well London programme is limited, citizens are truly activated in the implementation phase. Various projects (e.g. Well London Delivery Teams, Changing Minds, CADBE) give citizens an active role and also help them to fulfill their role by providing the training and courses needed. Furthermore nearly all projects have in common that they stimulate citizens to take control of their own lives, making them aware of their own responsibility and ability to influence their health and (mental) wellbeing. The name of one of the projects is most illustrative: Do It Yourself Happiness! Corporate Responsibility In line with national policies health promotion in London is the joint responsibility of the local government and the Primary Care Trusts, which implies that it is mainly a public affair. Nevertheless we do observe increasing awareness that the private sector also has to play a role in health promotion. For one thing, employment, skills and enterprise are considered key determinants of health, which is reflected in the involvement of the business platform London First in the London Health Commission. In addition private-sector organisations are expected to take their responsibility in the implementation of community strategies under the umbrella of local strategic partnerships. Businesses are, however, first and foremost seen as employers who provide jobs, skills and work experience to local citizens, also in the more deprived areas of London. In our empirical analysis of how a local strategic partnership operates on a local level – the case of Croydon – we could see that private actors are strongly involved in many issues, but not so much in health promotion. The public sector is also leading in the redevelopment of the Thames Gateway. The private sector is expected to take its responsibility as employer and developer of land, infrastructure and buildings. In this way businesses contribute to the development of a healthy urban environment. Our analysis makes clear that the public sector assumes that the business sector will optimise returns on investments

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within a relatively short period of time. Through tax legislation (such as Community Infrastructure Levies) the government enforces private contributions to social infrastructure in large-scale urban development projects. Private-sector developers consider these taxes as an extra burden to be taken into consideration in their investment decisions. The possibility that in the long run an urban area is better off if social infrastructure is developed right from the beginning, is apparently not a convincing argument for most developers. Our empirical analysis does not provide any evidence that companies in London recognise their self-interest in the development of healthy communities. The activities of the East London Business Alliance, for example, are not primarily driven by strategic interests in the local environment, but mostly by pressure on the license to operate and the call for corporate social responsibility. More promising, in our view, are initiatives to involve local supermarkets in the supply of healthy foodstuffs in the most deprived areas of London: potential oases in the food deserts. Coordinated Improvement of Urban Health Conditions The initiatives we analysed in London aim for a coordinated improvement of urban health conditions: 1) the Greater London Authority seems increasingly aware of the need to monitor the health impacts of urban policies; 2) the Living Well in London strategy makes clear that the Authority attaches much importance to the improvement of the socio-economic and physical determinants of health, in line with national policies; 3) the London Health Commission took the initiative to bring various actors together in view of a more coherent approach to health promotion in the programme Well London; 4) the redevelopment of the Thames Gateway has the objective to improve the physical and socio-economic conditions which presumably will improve the health situation in the area. The Well London programme mainly focuses on lifestyle (healthy food and physical activities), but also aims to improve the mental well-being. The partner organisations seem to recognise the interplay between lifestyle, mental well-being and the general urban health conditions (physically and socio-economically). A good example is the project Healthy Spaces which aims to stimulate people to make healthy choices through physical and social interventions such as the development of parks and playgrounds and the organisation of events. Another feature of Well London that illustrates the coordinated approach to health improvement concerns the ‘horizontal projects’ (comparable with Healthy Helsinki, see Chapter 2) that support, strengthen and connect the thematic ‘vertical’ projects. On a larger scale, the redevelopment of the Thames Gateway also aims for a coordinated improvement of urban health conditions, although the relation with health is not as explicit as in the case of Well London. Important elements of this comprehensive redevelopment strategy are: 1) the use of the Olympic Games 2012 as creator of jobs and catalyst for public and private investments; 2) investments

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in educational facilities that help citizens to acquire the practical skills that are needed to find a job; and 3) the development of multifunctional neighbourhood centers (e.g. The Hub) where various providers of health and social services are located under one roof.

References Blackshaw, N. (2008), Achieving health outcomes through spatial planning by building links between health and planning sectors, presented by Neil Blackshaw at the WHO International Healthy Cities Conferences in Zagreb. Communities and Local Government (2007), Thames Gateway Delivery Plan. Department of Health (2008a), Croydon Health Profile 2008. Department of Health (2008b), Newham Health Profile 2007. East Potential (2008), Community Champions Course Outline. Economic Development Office (2008), City Economic Digest, 4. Greater London Authority (2008), Indices of Deprivation 2007, A London Perspective Groundwork (2008), Making Change Happen – Making Change Last, Groundwork Impact Report 2007/08. Healthy Croydon (2008), Our Plan for a Healthy Croydon. London Health Commission (2007), Health in London, Looking Back Looking Forward, 2006/07 Review of Trends, Progress and Opportunities. London Health Commission (2008), London and Londoners: Making the Links for Health. London School of Economics (2008a), London’s Place in the UK Economy, 2008– 09. London School of Economics (2008b), The Thames Gateway: Building a City Within an Old One? Mayor of London (2008), Living Well in London, The Mayor’s Draft Health Inequalities Strategy for London, Draft for consultation with the London Assembly and functional bodies. Newham Primary Care Trust (2007), Saving Lives 2007, Annual report of the director of public health for Newham. Olympic Development Authority (2008), Investing in the Future. Renton, A. (2007), Selection of Communities. Research and Evaluation Framework (Presentation). Trott, C. (2005), ‘The Hub’, Community, Resource Centre, London, The Arup Journal, 2. Well London Alliance (2007), Well London Strategy, Delivering Well London.

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Discussion Partners Luke van der Beeke, Strategic Marketing Manager, National Social Marketing Centre Neil Blackshaw, Head of Unit, London Healthy Urban Development Unit Anita Blow, Community involvement worker, West Ham and Plaistow NDC Alison Bowerbank, Head of Planning, Office of the Deputy Prime Minister Hament Chabdar, Jetsol pharmacy, THE Hub Mary Clegg, Assistant Director, Strategy and Regeneration, Newham Primary Care Trust James Cleverly, Member of the London Assembly, Mayor of London’s Ambassador for Youth, Member of the Greater London Authority Tony Coggins, Head of Mental Health Promotion, South London and Maudsley NHS Nerys Edmonds, Leader of the MWIA project, South London and Maudsley NHS Gail Findlay, Coordinator, London Health Commission Jeff French, Director, National Social Marketing Centre Clive Furness, Executive member for Health, Newham Council Lee Johnson, Community Sport Coach, West Ham and Plaistow NDC Rachel Kirk, Programmes Officer, Groundwork London Steve Morton, Healthy Croydon Partnership Manager, Healthy Croydon Alison Pearce, Well London Programme Manager, London Health Commission Richard Sharp, Neighbourhood Coordinator, West Ham and Plaistow NDC Ian Short, Deputy Chief Executive, London Thames Gateway Development Corporation Malcolm Souch, Principal Planner, London Healthy Urban Development Unit Susan Withers, Community Programmes Coordinator, East Potential

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Chapter 5

Udine

1  Introduction This chapter discusses the experiences of Udine – a medium-sized city in the northeast of Italy – with the development of healthy communities. We mainly focus on the region’s participation in the Healthy Cities programme of the World Health Organization analysing several projects that have been implemented under this flag. First, however, we introduce the city and its region. 2  General Profile Udine is located in the northeastern part of Italy, at less than 40 km from the Slovenian border. With approximately 99,000 inhabitants (2008), it is the second city of the Friuli-Venezia Giulia region, one of the twenty regions in which Italy is divided, and one of the five ‘autonomous regions with special statute’. The region, of which Trieste is the capital, has its own language: Friulian, a Neo-Latin language with almost 800,000 speakers. The special status implies that the region can keep 60 per cent of all levied taxes on the condition that the region takes care of providing health care, education and (most) public infrastructure. The FriuliVenezia Giulia region is divided into four provinces; the Province of Udine is one them. Capitale della Guerra Udine is the historical capital of Friuli. Its foundation as a marketplace dates back to the 13th century. Before the city became part of the Kingdom of Italy in 1866, it had been under the control of the Republic of Venice, the French empire and the Austrian empire. During World War I the city was the seat of the Italian high command which gave Udine its nickname ‘Capitale della Guerra’: the War Capital. Due to its strategic location near the Austrian and Slovenian border the city had been an important location for the Italian army quite some time. From the 1970s onwards, however, the army relocated many of its activities away from the city. Only the army’s Alpine Brigade Julia (a light infantry brigade) is still headquartered in the city.

  This case study is based on interviews with various stakeholders in March 2009.

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In 1976 the Friuli region was hit by an earthquake causing 989 deaths and 4,500 billion Italian liras of damage (at the 1976 value; Cavallin et al., 1990). In Udine more than half of all residential units were damaged (Barbina, 1979). Ironically, the earthquake appeared to be the beginning of a renaissance for the city: it was a crisis situation that helped to get actors together appealing to the sense of solidarity that is typical for Fruilians – the region is known for having the highest share of blood donors in Italy. With financial assistance of the State, channelled through the regional government, factories and dwellings were reconstructed with the latest seismic safety features. As part of the reconstruction programme the University of Udine was founded in 1978. Consequently the exodus of about 19,000 military people since the 1970s was largely compensated by the influx of approximately 17,000 students. Many military areas are now to be rehabilitated, providing opportunities for the development of new clusters, e.g. in the field of health. Strategic Position With the fall of the Iron Curtain the geographic position of Udine improved to a great extent: from a peripheral town in Italy to a strategic node in a cross-border region in central Europe (including parts of Italy, Austria and Slovenia). One example that illustrates the strategic position is the fact that Slovenian Railways selected Udine as the location for its representation office for the Italian market (the office was inaugurated in 2009). Although the city has no airport of its own, it can be reached easily via three airports: Venice Marco Polo (120 km), Treviso (136 km) and Trieste (43 km). In addition, there are direct train connections with Venice, Trieste and Vienna. Plans are underway to further enhance train connections, particularly with neighbouring Slovenia. Accessibility by car is excellent: the city is located just near the A23/A4 highway that connects Villach (Austria) with Trieste and Venice. The region is an important cargo hub with several intermodal terminals. The population of Udine increased from less than 30,000 in 1871 to more than 102,000 in 1981. In the same period, however, many people migrated away from the region to other countries such as France, Belgium, the US, Canada and Australia. It was often one professional group (carpenters, brick workers, etc.) that ‘suddenly’ decided to leave the region, resulting in an export of ‘basic skills’. Between 1981 and 2001 the population decreased to 95,000, and since 2001 the number of inhabitants is again increasingly gradually. Since 1997 the share of foreigners has increased considerably: from 2.4 per cent to 10.7 per cent in 2007. The share of foreigners in the province is significantly lower: approximately 5 per cent of the population (CCIAA di Udine, 2007). Since 2002, the number of nonItalian citizens in the Friuli Venezia Giulia region has almost doubled (Servizio Statistica Regione Autonoma Friuli Venezia Giulia, 2008). In Udine the most important countries of origin are Romania and Albania.

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Economic Structure The Province of Udine has a rural character which reveals itself in a relatively high share of agricultural activities in the economic structure: 20.1 per cent in 2007. In the City of Udine the primary sector is much less important with only 3.2 per cent of the active local units (‘unita locali attive’). The most important sector is the service industry with a share of 41.7 per cent, while commerce, hotels (tourism!) and public administration represent 36.7 per cent of the units. The remaining 9.8 per cent of the units can be found in the construction sector (CCIAA di Udine, 2007). The regional economic structure can be characterised as a ‘widespread mosaic of small- and medium-sized enterprises’, also known as the ‘north-east model’. Four industrial districts are clustered in cities near Udine: Manzano for chairs, Brugnera for furniture, Maniago for knives and San Daniele del Friuli for cured ham. One of the biggest companies located in the region is steel producer Danieli, headquartered 10 km southeast of Udine, in Buttrio. Another famous name from the region is Zanussi, which was founded in Pordenone. The importance of the home furnishing industry and other industries that are related to quality of life (food and wine) reflects the value that people in this region attach to their homes, with the fire place as central point. National Health Service In Italy, the National Health Service (Servizio Sanitario Nazionale) – public healthcare for all Italians and those who visit the country – is organised on three levels. On the national level the ministry of health is responsible for the general health plan. Regions take care of translating this plan into more specific strategies with considerable autonomy (particularly for autonomous regions) on budget allocation. In 2004 it was decided to abolish the National Health Fund, and to gradually decentralise decision-making power and budgets to the regions until they have all received full autonomy on health policies in 2013. Regional governments are responsible for drawing up regional health plans every three years. On a local level Local Health Authorities (Unità or Aziende Sanitarie Locali, abbreviated as USL or ASL) are responsible for the daily management of healthcare delivery. In the Fruili Venezia Giulia region there are six local health agencies (‘azienda per i servizi sanitari’), one of which deals with Medio Friuli (No. 4). The Medio Friuli agency covers five districts, of which Udine is one.

3  Healthy Cities In 1995 Udine joined the WHO Healthy Cities project and in 1999 the city took the lead in setting up a regional network for healthy cities with more than 50 municipalities being member. Since then several projects have also been implemented on a regional level. The WHO Healthy Cities project aims to reduce

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health inequalities and promotes ‘participation and accountability of individuals, groups, institutions and communities for continued health development’ (WHO Regional Office for Europe, 1998). Being a ‘healthy city’ does not say anything about the health situation but rather about the awareness in Udine that the health situation can be improved by joint initiatives of the city, the health sector, the business sector, NGOs and the citizens. From the very beginning there has been strong political support for the Healthy Cities project, notably from the successive Mayors, which has helped Udine to build ‘solid alliances’ not only in the region but also on an international level. The Project Office In the first four years (1995–1999) the City of Udine set up the Healthy Cities Project Office as part of the Department of Social, Cultural and Educational Policies. Initially the local health agency (A.S.S. No. 4 Medio Friuli) was not involved in the Healthy Cities Project. Until 2001 only few people in the city knew about the Project because it took until that year before some concrete projects actually started. An important decision was taken in 2004: the municipality and the local health agency created an ‘integrating office’ managed by a scientific coordinator and acting as a link between these two organisations. In comparison with other ‘healthy cities’ this is a special model because the scale and scope of both organisations are different. The health agency operates on a larger scale than the municipality and is more ‘health oriented’ (health in the narrow sense of the word) than Udine’s Healthy City initiative which concentrates on health promotion and education. The integrated and partnership-based approach to health promotion is guarded by two platforms: a Coordination Group formed by all city councillors and managers of the municipal administration, and a Steering Committee formed by representatives of the main agencies, authorities, institutions, trade unions, etc. In 2008 it was decided to merge the Healthy Cities Project Office with the Local Agenda 21 office which used to fall under the Department of Planning. In the new set-up the Healthy Cities project is managed by the Department for General Affairs headed by the Mayor of Udine. Health Development Plan In 2002 Udine presented a Health Profile of the city, followed by Health Development Plan which was published in 2003 together with the Local Health Authority. The Health Development Plan is the result of a participative planning process – using the focus group technique – that has provided insight in the needs perceived by citizens. A representative survey among more than 700 people identified the living conditions for the elderly, the access to health care services, the quality of the road network and pollution as the four top priorities. More specific information, however, was collected on the issues in seven

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districts (different communities), and the priorities according to different citizen groups such as young people, women and ethnic minorities. In response to these needs, strategies and actions in numerous areas related to health promotion have been formulated. Apart from policies for several target groups (children, family, immigrants, disabled, elderly) the Plan also comprehends strategies and actions related to mental health, social inclusion, the environment and transport. All Healthy City projects, including the ones we discussed during our case study visit, can be related to this strategic document.

4  Projects Originally the projects managed by Healthy Cities Project Office were categorised in six themes handled by as many task groups: the health of children aged 0–14 years, women’s health, health indicators, indoor and outdoor environment, alcohol and smoke and the prevention of cardiovascular disease. In 2009, however, the city identified only three categories: 1) the elderly; 2) young and adolescent people; 3) the environment. The Elderly There are three projects that specifically target senior citizens. The first is named Age Friendly Cities: this WHO project aims to identify the need for specific services in various districts by gaining insight in the spatial distribution of older people and their needs through so-called health maps. The second project for the elderly is Services of Proximity, also referred to as No alla Solit’Udine (which could be translated as ‘No to Loneliness’). It is the City of Udine’s response to an ageing population: as people get older they become more dependent on health and social services. Traditionally, families take care of them, but their capacity to provide care is eroding due to changes in family structure and the increasing participation of women in the work force. As a consequence the role of voluntary organisations and volunteers (who often combine care with a paid job) has become bigger. To support both the elderly and those who take care of them, the city’s Social Services department has set up the project Services of Proximity, together with voluntary associations, the police, the house building enterprise and a phone call help service. To improve the access to services, the department has opened three public counters (onestop shops) and a free public phone line. Target groups are not only the elderly but also disabled people. Via these counters citizens can get in contact with numerous suppliers of services in the field of health, transport, repair, library (books), shopping, legal advice, housing, etc. The project is not managed by the Healthy Cities Project Office but by the Social Services department, though in cooperation with the Local Health Agency and the Project Office. Since 2005, when the Services of Proximity started, the number of requests has increased from

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1,841 to 4,554 in 2008. The project has been evaluated by means of a customer satisfaction questionnaire (with only 81 people not being satisfied in 2008) and focus groups with representatives of the voluntary organisations. According to the focus groups, results of the project are a reduction of the demand for entering residential and nursing homes and an improved quality of life with enhanced social relations for the customers. In 2008, the project Adding Life to Old Age was implemented. This project targets senior citizens (50 years and older) in fifteen municipalities in the region, including Udine. It promotes a healthy lifestyle, in terms of both nutrition and exercise. To promote healthy eating, several films were produced making people more aware of their eating habits, and the social, psychological and cultural values connected with food. To get people moving, walking groups have been created enabling people to walk under the guidance of a professional trainer. The project is a joint initiative of the municipalities and the local health agencies, in cooperation with the regional office of the sports association UISP. The idea is that walking groups not only improve health directly, but also indirectly as it can help to tackle social isolation. The project turned out to be successful as many groups continued to walk together without supervision. Young and Adolescent People From the very beginning of Udine’s participation in the Healthy Cities programme, young and adolescent people have been recognised as an important target group. One of the key projects is called ‘The Bet’: it challenges schools and pupils to reduce energy use within one year. To that end the Healthy Cities Project Office has developed five projects in various fields: the control and management of heating systems in school buildings, selective waste collection, walking to school (see section six), bicycle use and gardening. Another project is ‘Comics Against Smoking’ which promotes a healthy lifestyle among primary school children by means of an animated tale, and the publication of book for children: ‘a smoke-free future’. The project ‘Road Safety’ aims to improve the (perceived) road safety around schools and on home-to-school routes – in Udine and two neighbouring municipalities: Sacile and Cormòns. One of the projects for young people we will discuss in more detail below (section five) is Contract for a Healthy Snack. This project is part of a larger project named Crescere Sani (‘growing up healthy’) aimed at six to eight year old school children. It is an example of a multi-institutional project, involving citizens, schools, health services, the local government and businesses. Udine’s healthy food policy mainly targets young children: another project – Melanch’io – involves all nursery schools in Udine and 15 other municipalities in the region and aims to make four- to six-year-old children more familiar with simple and natural tastes such as that of apples.

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The Environment Udine wants to create an age-friendly environment that promotes a healthy lifestyle. Essentially this implies that the city wants to invest in the accessibility and road safety for pedestrians and cyclists. These so-called slow transport modes are considered not only good for the health of citizens but also for a healthy environment (sustainable development). Another strategic aim is to create more functions at walking or cycling distance. The merger between the Healthy Cities Project Office and the Local Agenda 21 office is line with this vision on healthy urban planning. Furthermore, the city’s Land Planning and Environment Department is developing and applying planning tools that combine principles of sustainability (Agenda 21) with principles of health (WHO). Strategic aims of Udine’s Local Agenda 21 policy are to change the modal split in favour of environmental friendly transport modes and to reduce the ecological footprint. Udine takes in leading role in a regional network (including 10 other municipalities) that aims to implement the Agenda 21 objectives in cooperation with the higher-level authorities (the province, the region), community organisations and the private-sector. Proposals have been made for a new masterplan in order to transform environmental, residential and infrastructural systems: 1) To build an environmental network with greenways and green belts; 2) To regenerate or rehabilitate neglected urban areas and brown field, and 3) To create new public transport connections for regenerated and peripheral areas. In a first evaluation, a working group has assessed these proposals by looking at objectives in the field of sustainability (e.g. reducing emissions, securing diversity and heritage, promoting community health, and stimulating social, cultural and economic cohesion) and health (e.g. reducing energy consumption and traffic, reducing pollution, improving building quality, water saving and waste collection, improving cycling and pedestrian network, creating a sustainable public transport system and creating a friendly environment for older and disabled people as well as children). One of the concrete projects that has resulted from the collaboration between Agenda 21 and Healthy Cities Project Office is the project I Pilastri della Sostenibilità (‘The Pillars of Sustainability’). This project, set up in 2007, particularly targets older people. First the Project Office carried out a survey among senior citizens to gain insight in the age-friendliness of the city, according to the standards formulated by WHO (Age-Friendly Cities). This study revealed, among other things, that senior citizens are not satisfied with the accessibility and quality of parks and green areas. To improve the situation, the second step is to create a system of green and open areas. Public sports fields, recreational areas and playgrounds are to be linked with each other by bicycle and walking routes, creating a complete ring around the city. Also farms are involved in these routes, notably to promote healthy nutrition with biological products from the region. From an environmental point of view the consumption of so-called ‘zero kilometer

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food’ can help to reduce the ecological footprint. From an economic point of view it is efficient to use farms for different purposes: production, (nutrition) education, environmental monitoring and agricultural tourism. The Pilastri project has come to an end, but one its main achievements is the creation of a new regional platform involving fourteen municipalities, the farmer’s association and the Chamber of Commerce. This platform’s ambition is to further expand networks of sustainable mobility, counting on the involvement of the private sector via the Chamber of Commerce. In the next two sections we discuss two projects in more detail: Contract for a Healthy Snack and Children Walking to School.

5  Contract for a Healthy Snack The contract for a healthy snack was originally developed outside the Healthy Cities programme. In the school year 2002–2003, one of the school districts (so-called Circoli) in Udine took the initiative to implement a health education programme, promoting healthy eating and an active lifestyle. The district’s school principal – responsible for five primary schools with approximately 750 pupils – took the lead in developing the contract by getting several actors together. Key partners of the coalition are the university Pediatric Department, the health department’s Food Hygiene and Nutrition Unit, the School District, and the Municipality of Udine. The University of Udine got involved because the pediatric department considered the city as a laboratory for analysing the eating habits of children and the effectiveness of interventions to change these habits. From the very beginning the initiators agreed on the importance of involving schools, but more importantly the children and their parents. The results of the pilot project have been published in an Italian pediatric journal (Carlin et al., 2006), summarised below. Before the Contract was developed, the Pediatric Department first analysed the actual dietary habits of children. Teachers simply observed and registered the snacks consumed during the midmorning break, and parents were asked to fill in closed-answer questionnaires about their children’s nutritional habits and consumption of different food categories. The study revealed that 64 per cent of the children brought snacks with more than 200 Kcal, while a snack of 100 Kcal would be enough. The consumption of such ‘hypercaloric snacks’ has a negative effect on the consumption of healthy food during lunch and even dinner. Most of these commercially prepared snacks contain too many preservatives and artificial ingredients which are difficult to digest. The questionnaires filled in by parents made clear that the consumption of fruits and vegetables was too low for a healthy diet, while the consumption of sweetened beverages and soft drinks was too high. The results from the questionnaire were in line with similar studies carried out on a national level (ISTAT, 2000 cited by Carlin et al., 2006). The study demonstrated that the involvement of parents is critical

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for the success of interventions to promote healthy eating among young people. They are responsible for selecting the snacks they put in the school bags of their children like they are responsible for the eating habits at home. To secure support from the target group the initiators set up an Advisory Group formed by representatives of the teachers, health professionals and parents. An Agreement Between the School and the Parents In order to improve the nutrition habits of children the partners decided to introduce a Contract for a Healthy Snack. The idea of a contract builds on social learning theories but also on concepts such as social marketing. The contract is an agreement between the school and the parents. The school promises to provide a free midmorning snack during three days of the week on the condition that parents ensure to give their children fruit for the remaining three school days (Saturday is also a school day in Italy) while encouraging their children to acquire new nutrition habits. For the supply of free mid-morning snacks the initiators cooperated with a local supermarket chain (Prima). Schools could choose between yoghurt, a bread roll specially developed for the Contract, or fresh fruit juice with no added sugar. Each option contains no more than 100 Kcal. Apart from the provision of snacks schools also commit themselves through educational activities that encourage and support the acquisition of new nutritional habits. Some of the classes that were involved made field trips to become familiar with the production of food. Schools can only participate if at least 60 per cent of the parents sign the contract; the reason for this condition is that the initiators assume that a clear majority is needed to facilitate the change in behaviour (the importance of peer modelling). In absence of formal penalties the schools use the method of ‘gentle persuasion’ (e.g. sending a letter to parents who do not live up to the contract) to ensure compliance with the contract. The Contract for a Healthy Snack institutionalises the shared responsibility of schools, parents, health professionals and the municipality for the health of children. Although the morning snack provides only a very small percentage of the daily consumption it has considerable potential to change the eating habits of children, particularly if combined with a supportive educational programme. With a participation rate of about 80 per cent the programme turned out to be very successful; some parents did not sign the contract, but in practice they complied with it. A survey among parents asking them about the reasons to sign or not to sign the contract revealed that the financial incentive was not as important as expected: 73 per cent of the parents were willing to continue their participation even if they had to bear part of the cost (Carlin et al., 2006, 226). Only for parents with a low socio-economic status the financial incentive appeared to be relevant. Most other parents responded that they signed the contract because they considered the school a reliable and trustworthy partner in nutrition education. Carlin et al. (2006) argue that the active involvement of representatives from teachers and parents played a key role in securing broad

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support of the target groups: it is a true partnership in which the target groups share a sense of ownership. The project has resulted in a change of nutrition patterns, not only at schools but also at home: the consumption of fruits and vegetables has gone up, while the consumption of soft drinks has declined. In the pilot stage of the project, the researchers also measured changes in overweight and obese, but no significant changes could be registered (yet). New Partners in the Project After the pilot stage of the project it became part of the Healthy Cities programme. The municipality joined as an active member of the project, enabling the expansion to other school districts. Another partner in the project is the Italian sports federation UISP (Unione Italiana Sport Per Tutti), in its role as organiser of sports and games events (yoga and gymnastics) to promote the Contract for a Healthy Snack initiative. Moreover, new sponsors were found to deliver the snacks: supermarket chain Spar, the regional baker’s association, and several agricultural corporations. Spar – a global, but highly decentralised company – considers its involvement in the project as a tool to distinguish itself from competitors. The company also introduced special health corners for its supermarkets in the city, with fruits, vegetables and yoghurts in an appealing setting. The baker’s association participates in the project because it is concerned about the declining consumption of bread and the preservation of agricultural and industrial heritage: the project promotes the consumption of healthy food from the region and educates children about the production process through agricultural tourism. The Contract for a Healthy Snack thus seems to fit in a broader strategy that combines health promotion with economic development, seizing regional opportunities. At the time of our case study visit plans were made to introduce a new contract that comprehends commitments concerning physical activities.

6  Children Walking to School Walking groups for children are the result of a project named ‘Children Walking to School’. This project aims to ‘reduce traffic and pollution around schools, to promote children’s autonomy, to encourage urban mobility and the use of the road by children and pedestrians, to create opportunities of socialization for children and to develop children’s social and emotional life’ (WHO, 2002). It is one of the first projects managed by the task group health of children aged 0–14 years, initially under the name ‘Going to school on my own’. As in the contract for a healthy snack, children are considered important target groups to change the behaviour of parents: children can educate their parents who are, in the end, responsible for taking decisions on the mode of transport. The project started as a private initiative of one parent at one school, and was soon adopted by the Healthy Cities Project Office.

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School mobility is also a key priority in Udine’s Urban Traffic Plan. This plan aims to improve safety and security in the urban environment (not only reducing the number of accidents, but also enhancing the perception) and to make the city more accessible and age-friendly. Traffic policies not only target children but also other weaker groups such as the elderly and the disabled. The city tries to improve road safety by changes in road infrastructure (e.g. investments in pedestrian crossings, sidewalks and bicycle lanes) but also by promoting the use of other modes of transportation in view of health and sustainability, with the project Children Walking to School as one of the examples. Another example is a pilot project called ‘safety measures in school areas in three municipalities of the region’ analysing the road safety problems from a technical point of view and from a social point of view. This initiative – targeting districts in Udine and two neighbouring municipalities – can be considered innovative because urban planners also took into account the perceptions and suggestions of citizens. A questionnaire was sent to the pupils and the parents, to be filled in by both. This survey demonstrated that parents and children have different views on road safety, for one thing because children are smaller which makes them afraid for not being noticed by others. In this pilot project urban planners worked together with medical doctors and psychologists to understand the different perceptions and needs of children and their parents. In the first phase (1996–2001) of the project the task group experimented with safe routes to four primary schools and carried out a survey which indicated that 60 per cent of the children and youngsters are taken to school by car. The results were the occasion to set up a school mobility project involving all schools in the city with the aim to create a wide network of safe routes to school. A working group was set up including representatives of parents and teachers of primary and secondary schools, the municipal administration, the local health authority and the Paediatric Clinic of the Udine University. In the second phase (2001–2002) the project was extended to almost all school in the city. The working group started to identify relatively safe routes from home to school. So-called ‘gathering points’ were created from where children could walk to school. In the third phase (2002–2004) safer home to school routes were singled out, with the assistance of teachers and parents who also watched over and assisted the children walking to school. Their joint analysis resulted in a feasibility study on school mobility identifying the necessary interventions in infrastructure. Children Walking to School became part of a larger project called ‘Going to school on foot, by bike, by bus’ which is part of the energy saving project The Bet. In the school year 2003–2004 the initiators started to organise a competition for school promoting sustainable transport, awarding a prize for the best-performing school. They also invited elderly people, students of the university (future P.E. teachers) and volunteers of the National Association of Alpines to accompany children on their way to school. In this way, the project indirectly also reached other age groups, with three generations walking together. In this phase communication became more intense, e.g. with the development of a board game.

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In 2009, the project was operational in seventeen municipalities across the region. About 50 per cent of the children participated in the project. Many parents decided to let their children walk to school or to bring them by car to one of the gathering points with parking facilities. The health impact of Children Walking to School has never been measured, but the fact that new task groups of parents and teachers have been set up at other schools can be considered an evidence of success too (WHO, 2002).

7  Conclusions In the previous sections we introduced Udine’s healthy cities policy and discussed some projects that fall under this heading. Although we have not a provided a full overview or evaluation, we can draw some conclusions in view of our research framework. The key question: can we find evidence that supports our hypotheses with respect to three conditions for investments in healthy cities? Citizen Empowerment The participation of citizens – which is not equal to citizen empowerment – is a key value of WHO Healthy Cities and hence, also a key value of Udine’s Healthy Cities programme. At closer inspection, however, we must conclude that the way citizens get involved is not very innovative. In various policy development processes and projects (e.g. Health Development Plan, Road Safety, Age Friendly Cities, Services of Proximity) the public sector takes the lead in consulting the city’s inhabitants, for instance through surveys. In this way policy makers gain insight in the needs of various segments of the population (children, families, immigrants, disabled people, the elderly, etc.) which enables them to develop tailor-made interventions for these groups. We do not consider this approach very innovative because the segmentation criteria (age, sex, disabled or not) are rather traditional. Analysing the various projects, the best examples of citizen empowerment are to be found in the projects Contract for a Healthy Snack and Walking Groups. Both projects were not initiated by the city or the health authority, but instead by one or two individuals. This makes clear that the Healthy Cities Project Office acts as a platform to facilitate bottom-up initiatives from citizens who take an active role in making their own community healthier. These community members have insider knowledge about the needs and wants of (specific groups of) citizens. So, we could state that in some way the Projects Office empowers citizens, although there is no clear strategy to stimulate civic action. Another way in which Udine’s healthy cities policy tries to empower citizens is by focussing on children. The argument is that children need support and education because they are vulnerable, but also because they can influence their parents. Experiences in Udine confirm that young and adolescent people can educate their

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parents when it comes to adopting a healthier and more environment-friendly lifestyle. Projects such as Children Walking to School, Contract for a Healthy Snack and Comics Against Smoking help to change the behaviour of parents, using their own children as fanatic ambassadors of change. It appears that children at primary schools are sensitive to campaigns in favour of health and sustainability, particularly if they include elements of competition (as in going to school on foot, by bike, by bus). To gain the support of parents, they participate in working groups together with other stakeholders such as teachers and health professionals. Also helpful in this respect is attractive educational material such as the book ‘a smokefree future’. Furthermore, we learnt that a formal contract – between schools and parents – can be helpful to make citizens more aware of their own responsibilities with regard to health. The project Contract for a Healthy Snack has also made clear that lower income groups can be triggered by financial incentives, in addition to the fact that parents – regardless of their social status – are concerned about the health of their children. Corporate Responsibility Although private-sector involvement is another key element of the Healthy Cities approach, the role of businesses in the development and implementation of the various projects is rather limited. The City of Udine has taken the lead in the development of various public-public partnerships connecting departments within the city or various authorities on a regional level. The development of this type of partnerships is facilitated by favourable context factors such as the high autonomy of the region and the strong sense of solidarity. Public-private partnerships in the field of health promotion are however less common, with some small exceptions: the participation of farms and a chain of supermarkets in the project Contract for a Healthy Snack; and the involvement of the Chamber of Commerce in healthy urban planning. Coordinated Improvement of Urban Health Conditions Following the WHO Healthy Cities guidelines the City of Udine aims at an improvement of all determinants that influence health in cities. By combining the principles of Healthy Cities with the principles of Agenda 21 the city has developed an even broader policy framework in which health, equity, diversity and sustainability are key values. Udine now has the challenging ambition to develop the city in such a way that these values are taken into account. It remains to be seen, however, if the city will actually succeed to translate a relatively abstract longterm vision into concrete measures on the short run. Nevertheless, it is already an achievement that urban planners take into consideration the impact of the physical environment on health and sustainability. Multi-criteria assessments or balanced score cards can be helpful in this respect. The pilot project Pilastri – creating a ring of bicycle and walking routes, connecting leisure and sports facilities – is a good

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example of how to aim for several interrelated objectives in the field of health, social cohesion, environmental preservation and sustainable economic growth simultaneously. The projects we analysed not only promote health in the narrow sense of the word – directly related to healthy nutrition and physical exercise – but also to other elements that are important for healthy cities. Road safety, for instance, is considered an important factor in promoting sustainable and healthy modes of transport. In addition, however, the improved perception of road safety also plays an important role in stimulating older people to participate in social networks (read: to enter the street). This brings us to another important determinant of health: loneliness, addressed by the project Services of Proximity with the tagline No to Loneliness, but also by Walking Groups and the participation of senior citizens in the project Children Walking to School. And also economic aspects are taken into account: healthy food projects such as the Contract for a Healthy Snack and My School has a Garden are combined with the promotion of local, organic food: good for the economy, good for people’s health, and good for the environment because it replaces imported goods with high transportation costs and the associated emissions.

References Autonomous Friuli Venezia Giuli Region (2007), La popolazione straniera residente in Friuli Venezia Giulia al 31 dicembre 2007 (Foreign population in Friuli Venezia Giula on 31 December 2007). Servizio Statistica. Barbina, G. (1979), The Friuli Earthquake as an Agent of Social Change in a Rural Area, Mass Emergencies, 4, 145–149. Carlin, E., Savonitto, C., Pilotto, L., Savoia, A., Vidal, E. and Tenore, A. (2006), The ‘Contract for a Healthy Snack’: A Winning Strategy for Nutritional Education in an Italian Primary School District, Italian Journal of Pediatrics, 32, 221–228. Cavallin, A., Broili, L., Carulli, G.B., Martinis, B., Mele, M., Siro, L. and Slejko, D. (1990), Case History: Friuli Earthquake, 1976, in Proceedings of the International Symposium on Engineering Geology Problems in Seismic Areas, Bari 13–19, April 1986, edited by V. Cotecchia. Bari: Geologia Applicata Ed Idrogeologia, 6, 1–82. CCIAA di Udine (2007), La situazione economica della Provincia di Udine – Comuni in cifre (The Economic Situation of the Udine Province – Communities in Numbers). ISTAT (2000), Indagine Multiscopo: Condizioni di salute e ricorso ai servizi sanitari 1999–2000. (Multi-Purpose Research: Conditions of Health and the Use of Health Services). WHO Regional Office for Europe (1998), Health 21.

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WHO (2002), A Physically Active Life Through Everyday Transport with a Special Focus on Children and Older People; Examples and Approaches from Europe, Regional Office for Europe.

Discussion Partners Raffaella Basana, Unione Italiana Sport Per Tutti (UISP) Luciano Calò, Associazione Nationale Dimagrire Insieme (ANDI) Susanna Cardinali, Social Services, City of Udine Luciano Ciccone, Local Health Authority, Ass.No.4 Maria Furgiuele, Associazione Insufficienti Respiratori (AIR) Bruno Grizzaffi, Local Agenda 21, City of Udine Furio Honsell, Mayor of Udine, General Affairs Maria Teresa Monsacchi, Associazione Insufficienti Respiratori (AIR) Stefania Pascut, Healthy Cities Project Office Francesco Passarino, Education and Sports Services, City of Udine Nives Peressini, Project Coordinator ‘No alla solit’Udine’ Maria Piani, School Director of the Third School District of Udine Orlandi Pierluigi, President of the Provincial Bakers’ Association Laura Pilotto, Health Promotion and Education Consultant, Local Health Authority Ass.No.4 Enrico Pizza, Alderman for Mobility and Social Services, City of Udine Alma Plai, Department of Land Planning and the Environment, City of Udine Agnese Presotto, Land Planning and Environment Department, City of Udine Mariagrazia Santoro, Alderwoman for Urban Planning, City of Udine Cecilia Savonitto, Local Health Authority Ass. No.4, Prevention Department Gianna Zamaro, Healthy Cities Project Office/Local Health Authority

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Chapter 6

Vancouver

1  Introduction In the present chapter we apply our research framework to one of the most ‘liveable cities’ of the world: Vancouver. After a general profile of the city we review the urban planning policy of the city – with special attention for the redevelopment of South East False Creek – and discuss this policy’s impact on health determinants. Next we analyse the revitalisation of Downtown Eastside, by far the most deprived area of the city. 2  General Profile With a population of 2.1 million, the Greater Vancouver area is the third largest agglomeration of Canada, following Toronto and Montreal. In 2006, the City of Vancouver counted 578,041 inhabitants (Canada Statistics, 2006). It is the largest municipality in the Province of British Columbia (capital city: Victoria), on the westerns shore of Canada. Population After Vancouver was founded in 1886 the city went through a period of rapid growth, spurred by the connection to the Canadian Pacific Railway (1886) and the Gold Rush (1890–1900). In contrast with many other cities in North America and Europe the City of Vancouver – the municipality – managed to grow, also in the decades after the Second World War. Only during the 1970s the city experienced a small decrease in population. Between 1981 and 1991 the population grew by more than 57,000, and between 1991 and 2001 more than 83,000 additional citizens were registered. In 2002, the local government expected that the average growth of 6,000 inhabitants would remain stable in the near future, resulting in an expected population of 635,000 in 2021 (City of Vancouver, 2002). With a population increase of 32,370 between 2001 and 2006, this seems to be a realistic expectation.

  This case study is based on interviews with various stakeholders in November 2008.

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With a history of immigration the population of Vancouver is highly diverse. In 2006, 51.0 per cent of the population was of ‘visible minority background’, while 45.6 per cent were registered as ‘immigrants’ (people not born in Canada). Important countries of origin among recent immigrants are China, Hong Kong and the Philippines. In the 2006 Census half of the population indicated that English is not their mother tongue. Similar to other Canadian cities Vancouver has been very successful in attracting higher-educated immigrants due to the national immigration policy which favours skilled migrants: more than half of all persons that arrived between 2001 and 2007 had a university degree. Several indicators confirm that Vancouver has a relatively healthy population. With a life expectancy of 81.1 years, the city ranks number one in a list of the 25 largest Canadian metropolitan areas, outperforming the Canadian average of 79.4 years (2000 data, Gilmore 2004). It can be demonstrated that the health performance of Vancouver (as well as other Canadian cities) depends on life style factors such as smoking, drinking and the involvement in physical activities. Statistics show, for instance, that Vancouver is the city with the lowest share of smokers: 15.5 per cent, compared to 24.0 per cent on a national level (data from the Canadian Community Health Survey 2000/2001). On nine of the 11 health indicators the performance of Vancouver is significantly better than the Canadian estimate (Gilmore, 2004). Also the percentage of people with un-met health needs is significantly lower than the national average. Downtown Eastside: Public Health Emergency Despite the outstanding health performance of the city, one of the downtown areas belongs to Canada’s most deprived districts: the Downtown Eastside. In the 20th century the Downtown Eastside gradually developed from the most important commercial centre of the town into an area with a concentration of environmental, socio-economic and health-related problems. Warehouses were relocated from the area to the edges of the city, streetcar services were cancelled (making the area the less attractive for pedestrians), public and commercial functions disappeared, and many people got unemployed. The area became ‘the last resort’ for people who could no longer afford to live somewhere else due to the rising housing prices in other parts of the city. In the 1970s the area received thousands of psychiatric patients after several institutions had to close their doors because of cuts in public funding. Prostitution entered the scene in the 1980s when the former red-light district West End was redeveloped. Alcohol and drugs usage increased dramatically and an extensive and deeply rooted criminal network developed. In the 1990s the area developed into the centre of a HIV/AIDS epidemic, which especially caused deaths among drug users.  Source: http://vancouver.ca/commsvcs/socialplanning/initiatives/multicult/index.htm.   In 2000, the life expectancy of 79.4 years placed Canada on the fifth position of all OECD countries (Gilmore, 2004).

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All these developments created an environment in which businesses could hardly survive. In 1993 Woodwards, the last remaining and most famous department store of the area, had to close its doors. This caused bankruptcies of other shops and restaurants in its surrounding area. The only businesses that managed to survive were pawnshops, second-hand shops, fast food restaurants, cafés and coffee shops, and in some cases these were no more than cover-ups for the illegal activities taking place behind the scenes. In the 1990s for many citizens the problems they experienced (unemployment, alcohol and drugs addictions, psychiatric problems) became so bad they could no longer continue to pay their rent. Many of them are now part of the large population of homeless people living in the streets of the Downtown Eastside. The people that are one step higher on the socio-economic ladder are not in a much better situation. They live in so called Single Room Occupancy (SRO) hotels. These ‘hotels’ have very small rooms with shared bathrooms: the cheapest type of market housing. Most of the SRO hotels in Vancouver, of which 80 per cent can be found in the Downtown Eastside, were built before the Second World War and are in urgent need of renovation. In response to the accumulation of problems in the Downtown Eastside, policy makers officially declared a ‘public health emergency’ for the area in 1997. In the years that followed the area became the focal point of a comprehensive regeneration programme, to be discussed in section four. Levels of Government In Canada the public administration acts on three levels: the national level, the province and the municipality. Governments on all three levels influence the health of citizens, directly or indirectly. The national government is, among many other tasks, responsible for the organisation of health care and the development of policies on sports. Provinces have substantial political power in the Canadian system: they develop and implement policies on highly relevant issues such as education, health, culture and social services. This implies that – in comparison with other countries – municipalities are relatively weak: their primary task is to provide specific services to citizens, businesses and visitors, such as cultural and leisure facilities, the police and education. Municipalities are not responsible for health-care delivery or health promotion. They do have, however, some influence on the development of a healthy environment through their transport and zoning policies. In comparison with other Canadian cities, Vancouver has relatively much freedom in developing and implementing urban planning and development policies. Already in 1953, the province of British Columbia accepted a law that gives the City of Vancouver more power than other municipalities: the Vancouver Charter. For example the city has the right to borrow and lend out money (to a certain amount), buy and sell real estate and levy particular taxes (Mason, 2007).

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Healthcare Delivery and Health Promotion As we explained above the province of British Columbia plays a key role in the delivery of healthcare and health promotion in Vancouver. More precisely, it is the Vancouver Coastal Health Authority: one of the six health authorities that fall under the control of the province’s Ministry of Health Services. The main task of this organisation is to deliver primary and secondary healthcare services at hospitals, health centres and in people’s homes. Besides cure and care, the Authority also invests in prevention through the development of campaigns that inform people about healthy lifestyle choices. To make sure that local healthcare needs are met the Vancouver Coastal Health Authority cooperates with Community Health Advisory Committees. These committees bring together groups of influential and well connected people from local communities. They inform the Health Authority about issues related to health and health care that are relevant on the level of communities. They also point out problems with socio-economic and environmental conditions that influence health. The Health Authority works with so-called ‘community developers’ to initiate and develop projects, policies and services in response to the advise of the local committees. These community developers work together with inhabitants as well as public and private organisations in the communities. Each developer serves a particular area focusing on the most relevant health-related problems (Vancouver Coastal Health, 2006, 2007).

3  Vancouver’s Urban Planning Policy and its Impact on Health The Vancouver charter gives Vancouver relatively much freedom in developing urban planning policies. While the province takes care of healthcare delivery and promotion, urban planning is the city’s main instrument to improve urban health conditions. In the present section we discuss two leading policies – Living First and EcoDensity – and their implementation in the redevelopment of South East False Creek. Living First As many other North American cities, Vancouver’s downtown was confronted with an increasing pressure from office development in the 1980s. Because the municipality feared that offices would push away citizens, they introduced the policy Living First. As the name of this policy indicates, it favours residential development in the downtown area: it literally puts living first. First of all the city adapted the city center’s zoning plan thus creating more space for dwellings. In addition, however, several other measures have been taken to make inner-city living more attractive (Beasley, 2000).

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Through adjustments in infrastructure and legislation the city centre has become less accessible for cars – in sharp contrast with policies of many other cities in the US and Canada. These interventions have made the downtown area more attractive as a place where people can combine living and working. Moreover the policy stimulates citizens to travel on foot or by bike. As a result the city centre has become more attractive: less traffic and a healthier environment, not only in terms of air quality but also because it stimulates people to be active. Walking and biking are clearly the preferred modes of transport. The city argues that also public transport facilitates commuting, explaining why they are somewhat reluctant to invest in the public transport system. Another strategy to put living first has been to develop relatively small and more or less independent ‘complete neighbourhoods’. In this way the city has managed to create well-balanced communities with a high degree of function mixing. The result is that job opportunities, shops, schools, recreational facilities, social services, etc. are all to be found within short distance of the places where people live. This policy has made inner-city living more attractive, while promoting walking and biking. To avoid spatial segregation – the development of slums or ghettos – the city has tried to secure a good housing mix in all neighbourhoods. In this way they created neighbourhoods with a mix of rental and owner-occupied houses, family houses and single-occupancy apartments, and houses with different price levels for various income groups. This policy could, however, not prevent the decline of Downtown Eastside: it is exactly the growing attractiveness of Vancouver which has resulted in increasing housing prices pushing the lowest income groups away from the neighbourhoods to this part of the downtown. Inner-city living has also been made more popular through public and private investments in the urban design. As part of the Living First strategy the municipality stimulates developers to create high-quality buildings and an environment that makes people feel ‘at ease’ and that facilitates social interactions. To create an attractive environment the municipality promotes the combination of high density and human scale. To realise these two objectives the city, for instance, makes it compulsory to develop office and residential towers with an attractive ground level containing shops or other public functions. Through public functions on street level the city stimulates walking in a high-density area such as the downtown. In addition, the municipality invests in the quality of public space, with the development of many parks and courtyards and a relatively large network of walking and bicycle routes (Greenways) compared to other North American cities. The City of Vancouver uses various taxation instruments to enforce privatesector contributions to the Living First strategy. One of the instruments of this so-called Financing Growth policy is the Development Cost Levy: a fixed amount per square meter to be spent on the development and maintenance of parks, infrastructure, social services and social housing. Developers of high Vancouver’s public transport system is well developed in comparison with other North American cities, but not compared to most European cities.

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density projects (e.g. residential or office towers) have to pay a second levy, as a non-voluntary contribution to the development of community amenities. The height of this levy is subject to negotiation between the city and the developer; sometimes developers agree to invest in amenities themselves. Through citizen consultation and research both public and private actors get insight in the demand for amenities. Living First has resulted in an increase of the downtown population: from only 5,910 in 1986 to 43,417 in 2006 (Statistics Canada, 2006). In only five years time (2001–2006) the downtown population increased by more than 55 per cent. This is, however, not only good news. The municipality fears that the downtown will loose its healthy balance between homes and jobs, as the residential function seems to have become too dominant. In 2004 it was decided to stimulate economic development in the downtown, resulting in changes in the zoning plan but not to changes in the other principles of Living First (limited access for cars, complete neighbourhoods and high-quality urban design). EcoDensity The second urban planning policy of Vancouver we consider relevant for the development of healthy communities is EcoDensity. The EcoDensity Charter – accepted in 2008 – fits in the city’s policy to realise high densities: in the City Plan of 1995, the city expressed its ambition to raise densities in order to secure sufficient housing opportunities for the growing population while avoiding urban sprawl. EcoDensity adds some new elements to this strategy as it combines principles of sustainability, livability and affordability with higher densities if possible. The local government argues that that high densities also fit in an eco-strategy, presenting various arguments: the city uses less land for the same amount of people, taking away the need to expand; economies of scale facilitate smart solutions that reduce energy and water use and enable a more efficient disposal of garbage; high densities give relatively small neighbourhoods the opportunity to attract higherlevel facilities (e.g. shops, leisure, public transport), and to create a varied offer of housing opportunities, also for low-to-moderate income groups. The Redevelopment of South East False Creek One of the urban development projects in which the principles of Living First and EcoDensity are applied, is the redevelopment of South East False Creek: a brownfield area covering 32 hectare at a strategic location near the city centre. Part of this area has been developed into the Olympic Village for the Winter Games in 2010. Already in 1991, the local government decided to develop this former industrial area into a ‘model sustainable community’ with approximately 5,000 new housing units for 10–12,000 inhabitants. In line with the principles of Living First (social) facilities will be available at walking or biking distance. The area will be designed in such a way that it stimulates walking, biking and travel by

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public transport. South East False Creek is also an example of EcoDensity: it is presented as a sustainable development concept that combines high densities with a broad mix of different types of dwellings, including affordable housing. One of the instruments that has been used to make sure that South East False Creek really becomes a model sustainable community, is LEED certification. LEED is short for Leadership in Energy and Environmental Design and measures the sustainability of a building by means of a multi-criteria assessment. Relevant aspects are, for instance, energy and water use, waste disposal, indoor air quality, and the use of environment-friendly materials in construction. The minimum level for buildings in South East False Creek is a golden certificate, the second highest level following platinum. In addition to the LEED certification for buildings, South East False Creek also participates in a pilot project that introduces LEED certificates for entire neighbourhoods. In this multi-criteria assessment neighbourhoods can earn points if they have, for example, sufficient pedestrian areas and bicycle lanes, a broad mix of functions and housing types, a high-quality public space and a high share of LEED certified buildings. It is expected that South East False Creek will score high on these criteria. The Olympic Winter Games have facilitated the redevelopment of South East False Creek, although this area would have also been redeveloped without the event. Hence, the event has not been a real catalyst for urban change as in the famous example of Barcelona. What could be said, however, is that the event created opportunities to get support for additional investments in sustainability (LEED), but also for investments that support the (re)development of the inner city and benefit the citizens. The three levels of government (state, province, city) have signed so-called ‘inner city inclusive commitments’ which formulate the ambition to enable inner-city residents to take advantage of the event. They agreed the Games had to be accessible and affordable, and other events had to be organised in the two weeks of the event to give people the opportunity to participate. Moreover they promised to invest in the quality of the environment, the access to health and social services, housing and the business climate: all aspects that are relevant for a healthy urban environment. Inner-city inclusiveness has also been enforced in the contract between the city and the developer of South East False Creek: Millennium Properties. This contract includes a so-called ‘community benefit agreement’ which implies that the developer guarantees that inner-city residents – including the people who live in Downtown Eastside – benefit from the development. In this contract the developer promises to: 1) invest $750,000 in training and education for inhabitants of the downtown; 2) provide jobs to at least one hundred inner-city residents; 3) procure goods and services worth at least $15 million from local businesses.

 Developed by the American Green Building Council.  As in other tendering procedures the city has stimulated candidate-developers to take community benefits and sustainability aspects into account when writing their proposals.

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The Olympic Games and the redevelopment of South East False Creek in particular have created opportunities for the downtown of Vancouver. It is obvious, however, that inner-city inclusive commitments and community benefit agreements are not sufficient to solve the severe problems the Downtown Eastside is struggling with. That is why now we shift our attention to the redevelopment of Downtown Eastside itself.

4  The Redevelopment of Downtown Eastside As we already explained above the Downtown Eastside is by far the most deprived area of Vancouver with an accumulation of health, physical and socio-economic problems. To tackle these problems several actors have committed themselves to the so-called Vancouver Agreement and a comprehensive redevelopment scheme. This scheme has resulted in various concrete policies and projects. Vancouver Agreement In 2000, three levels of government – state, province and the city – signed the Vancouver Agreement. Although this agreement formulates the general ambition to make the entire city a sustainable, healthy and safe place, it clearly concentrates on the need to regenerate the Downtown Eastside in response to the ‘public health emergency’ of the late 1990s. Through this agreement – updated in 2005 – public actors promise to adopt a coordinated approach to the redevelopment of the Downtown Eastside. This implies that they aim for interaction between the three governmental layers (vertical connections) but also for cooperation between departments within the three levels of governments (horizontal connections). By organising regular meeting and working groups, on levels that vary from operational to strategic, the actors involved in the Vancouver Agreement try to share information and to align public investments (Mason, 2006). Furthermore the Vancouver Agreement provides financial support to many studies and projects, either through the redistribution of government budgets or via the budget of the Agreement itself. Since 2003 the Vancouver Agreement has its own budget, with the province and the federal government as main sponsors. Interestingly, there is also one private actor that subsidised the Vancouver Agreement: Bell Canada, one of Canada’s biggest telecommunication companies, contributed $1.5 million to the programme (Vancouver Agreement Financial Report 2002–2009) as proof of good citizenship. The City of Vancouver participates via in-kind contributions including space in city buildings, zoning and development cost compensation, heritage preservation incentives, administration and financial management. More importantly, however, the city has the taken the lead in the development of a comprehensive revitalisation programme for the Downtown Eastside.

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The Revitalisation Programme In 2003 the City of Vancouver decided to integrate all projects, programmes and strategies for the Downtown Eastside into one comprehensive revitalisation programme. A cross-sectoral team has been set up to manage the programme, bringing together representatives of various municipal departments. The Downtown Eastside revitalisation programme aims for ‘revitalisation without displacement’. Since the area is located at short distance of the central business district, gentrification is considered a serious threat. One part that already gentrified is the district Gastown located immediately adjacent to the central business district. Revitalisation in the 1960s helped to turn this historical neighbourhood into a popular area with boutiques, restaurants, night clubs, galleries, apartments and offices of lawyers and architects. The problems of this area have been solved largely, but most of the people who used to live have been displaced to other parts of the Downtown Eastside, for instance near Hasting Street. As indicated earlier Downtown Eastside is one of the few places in the city with a substantial supply of affordable housing. Revitalisation puts pressure on housing prices but also on the availability of affordable facilities (e.g. retail and care) for people with a low income or no income at all. To revitalise Downtown Eastside without the displacement of the people who live there, the cross sectoral team of the city acts in line with three principles: •

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No quick fixes – The municipal departments agree that a long-term approach is needed. Although there are many urgent problems that need to be solved quickly they also give attention to the underlying and interrelated causes of problems. Focus on competences – Policy makers not only look at the problems of inhabitants but also focus on heir competences (talents) and ambitions. The argument is that a focus on competences is needed to diminish the (financial) dependency of inhabitants on other people and institutions, thus also reducing the costs of healthcare and other facilities. Attention to the environment – The actors involved pay attention to the social, cultural and physical environment (public spaces, housing, buildings) of inhabitants and the influence of the environment on the social-economic functioning of the area.

Below we discuss several concrete projects and policies to illustrate the three principles of the revitalisation without displacement strategy. Community Development One strategy to make better use of the competences of the citizens’ talents is to involve them in the design and implementation in the revitalisation programme. The project Community Development aims to align the programme to the needs of

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inhabitants, but also to help people discover how they can solve their own problems. In a sub-project called Community Directions the city organises working groups for inhabitants – notably lower income groups – to discuss strategies and actions on themes such as alcohol and drugs, and children and youth. The idea is that this form of consultation adds to civic pride and stimulates grassroots leadership, cooperation and cohesion in the local community. Four Pillar Drug Strategy To tackle the drugs-related problems in Downtown Eastside – as well as other parts of the city – the local government has developed a drug strategy that is built on four pillars: prevention (e.g. educating young people), treatment, enforcement (reducing drugs-related crime) and harm reduction. In 2003, Vancouver was the first city in North America to open a safe injection site, referring to successful examples in Europe (e.g. The Netherlands). It offers a clean and safe environment where addicts can use drug under supervision of medical staff. In addition the city tries to help – notably young – drug users to solve their own problems, trying to influence the choices they make for their own future. By teaching them basic skills the city wants to improve the locus of control and the employability of this highly vulnerable group. It is an example of how the city focuses on competences and ambitions, giving attention to underlying causes. The Homeless Action Plan Another relevant policy is the Homeless Action Plan (City of Vancouver, 2005a) which identifies three interrelated problems homeless people are confronted with: obviously the lack of affordable housing, but also the access to employment and income and supporting services. Many homeless people have to cope with an accumulation of problems that also affect their health and employability. One way to get them out of the downward spiral is to improve the possibilities to receive welfare benefits. By offering them training and education (also on basic skills such as personal hygiene) the chance they find a job will increase. Homeless people can get advise and support at Community Health Centres but also at so-called ‘drop-in centres’. Building Opportunities with Business The aim of the foundation Building Opportunities with Business is to stimulate the socio-economic development of the Downtown Eastside – creating employment opportunities and enhancing the vitality of the community – by supporting businesses and stimulating inward investments. To that end the foundation has taken the following initiatives:

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Cluster development – The foundation promotes cooperation between companies (of different sizes) favouring the development of clusters, notably in tourism, construction, the creative industry and ICT. Support for start-ups – Building Opportunities with Business supports new firm start-ups by giving out loans (which can be used as leverage to obtain other loans), providing assistance in finding office space and information about procedures and by helping entrepreneurs to identify market opportunities and to find staff. Promoting local procurement – The Vancouver Social Purchasing Portal is a website that lists companies from the Downtown Eastside which make a positive contribution to the area’s socio-economic development, for instance by providing jobs for the inhabitants. The Purchasing Portal enables public and private organisations to express their commitment to the area’s revitalisation by means of local procurement. Training and education – The foundation offers courses for drug addicts and homeless people as well as other residents of the Downtown Eastside. The content and the level of the courses are adjusted to available employment opportunities, but also to the preferences and abilities of the population. General support – Building Opportunities with Business supports inhabitants on their way to a job, but also assists those who just got employed since they run a high risk of losing their job again.

The foundation gets financial support from the municipality, the national government and project developer Millennium Properties (as part of the Community Benefits Agreement, discussed above). Cultural Facilities Priorities Plan The city’s Cultural Facilities Priorities Plan (2008) presents a partnership-based strategy to enrich the supply of cultural facilities citywide. This plan identifies the Downtown Eastside as one of the key areas for investments in culture. The assumption is that cultural facilities for the local population (e.g. community centers, libraries, studios and theatres) add to the identity of the area and help to improve cohesion and wellbeing. The supply of affordable housing and the inspiring, lively, rough and dynamic environment make the area attractive for artists. This also explains why Building Opportunities with Business identified the creative industry as one of the (potentially) strong clusters in the area. Great Beginnings To celebrate the 150th birthday of the Province of British Columbia, the city developed the programme Great Beginnings, funded by the Province. This

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programme includes investments in historical parts of Vancouver, resulting in physical improvements of various streets, buildings, parks and squares of historical importance. These first urban areas are all located in the Downtown Eastside. The programme comprehends, among other things, the cleaning of streets, the removal of graffiti, the development of community gardens, the renovation of building facades and the rehabilitation of historical neon lighting. The programme also supports arts and cultural activities for both residents and visitors. Carrall Street Greenway The Carrall Street Greenway is part of the city’s policy to expand the network of bicycle and walking routes that connects parks, cultural facilities, historical places and shopping centers. This greenway for bicyclists and pedestrians – which runs straight through the Downtown Eastside, from north to south – is decorated with threes and plants, attractive street furniture and places where citizens can organise social events. The Greenway not only stimulates people to walk or bike but also creates a lively atmosphere which makes the area more vital as an economic place. Expectations are that businesses located alongside this corridor – e.g. shops, restaurants and cafes – will profit from the creation of the Carrall Street Greenway. Housing Strategy According to Vancouver’s Housing Plan (2005b), the Downtown Eastside will remain the most important concentration of affordable houses in the region. The quality of the housing stock will be improved by replacing the Single Room Occupancy hotels with newly built affordable houses. In addition the city wants to add more expensive houses to the area, in order to realise a better mix. This will make the Downtown Eastside more attractive and enable inhabitants to make a housing career without leaving the area. A crucial issue, according to the City of Vancouver, is the speed of the transition. The challenge is to prevent that people with lower incomes are suddenly confronted with facilities (shops, restaurants, and cultural facilities) that no longer serve their needs or fit within their budget. The municipality aims for a mix of facilities that matches with the mix of income groups and housing prices.

5  Conclusions In the previous sections we discussed various policies and projects of the City of Vancouver that all share the aim (explicitly or implicitly) to create a healthier environment for the citizens. Some of these policies and projects are implemented on city level while others clearly focus on the Downtown Eastside. In this final

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section we analyse and test the relevance of the three conditions for investments in healthy cities that we identified in our research framework. Citizen Empowerment The first condition is citizen empowerment. Are citizens empowered by the City of Vancouver? If we consider the projects and programmes we analysed on city level the answer to this question is probably negative. Programmes such as Living First and EcoDensity are typical examples of government-led initiatives that aim to create a healthier environment for citizens without truly involving them. If we consider the revitalisation of Downtown Eastside it seems that citizen empowerment gets more attention. The revitalisation programme has the ambition to empower the inhabitants of this area, including the most ‘problematic groups’. The challenge is to revitalise the area without displacement which implies that citizens have to keep pace with their changing environment. In order to empower citizens the municipality not only tries to solve (short-term) problems, but also stimulates citizens to make better use of their competences. Another way in which citizens are empowered is through consultation: citizens are invited to discuss policies and actions that affect their living environment. Corporate Responsibility The second condition is corporate responsibility: does the private sector accept its responsibility in improving the health situation? In general we conclude that the division of tasks between the public and private sectors is rather traditional: the government is clearly leading in the development of the city. The City of Vancouver owes it success as one of the most attractive cities in North America to a proactive local government with a strong planning tradition due to exceptional autonomy in the Canadian system. The prevailing argument is that without government interference the private sector would control urban development resulting in undesired urban sprawl, an unbalance in residential and office functions and negative externalities such as pollution and congestion. The government enforces the private sector to make contributions to healthy urban development rather than expecting business to do so on a voluntary basis. Apart from taxation (developers pay levies to co-finance the development of social infrastructure), the city also asks developers to sign contracts (agreements, commitments, etc.) in which they promise to make a contribution to the wellbeing and prosperity of the city and its inhabitants. Also in tendering procedures the municipality clearly prefers suppliers that create jobs and income for the city. If companies change their behaviour to meet the requirements, this can hardly be seen as an example of corporate responsibility. In fact, they are more or less forced to change their behaviour. It is not the private sector’s interests in an attractive or healthy living environment, but rather its interest in reputation and profit that drives corporate community involvement strategies. The same can

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be said about initiatives such as the Vancouver Social Purchasing Portal and the LEED certification programme. Both initiatives stimulate companies to care about sustainability and health, not because they have a direct interest in sustainable and healthy urban development, but because they are forced by the market and the government (their customers) to invest in such development. Coordinated Improvement of Urban Health Conditions The third condition is a coordinated improvement of urban health conditions. First of all we must conclude that health improvement is not a key theme in Vancouver’s policies. Discussion partners emphasize that the provincial government and the regional health authority play a leading role in improving health. Nevertheless we can draw the conclusion that many policies we analysed implicitly aim to create a healthier environment for the inhabitants of Vancouver. Policies such as Living First and EcoDensity are based on the assumption that the design of the urban environment can stimulate people to make healthy choices, e.g. to walk or to bike instead of going by car. Coordination seems particularly relevant in the revitalisation of the Downtown Eastside. The actors involved realised that the health emergency could not be simply solved through intervention in care. The health problems in this area are, in fact, only the tip of the iceberg, with many more fundamental problems under the surface. The Vancouver Agreement and a comprehensive revitalisation programme are examples of a coordinated approach to urban health improvement, in which governments on various levels and different departments cooperate. The Four Pillar Drug Strategy, the Homeless Action Plan, Building Opportunities with Business, the Cultural Facilities Plan, Great Beginnings, the Carrall Street Greenway and the Housing Strategy aim to improve different elements of the urban environment while they share the same principles and general aims (revitalisation without displacement). Moreover most of these projects intervene in various health determinants simultaneously, arguing that the vulnerable target groups often struggle with several interrelated problems (health, employment, education, housing, environment, etc.).

References Beasley, L. (2000), Living First in Downtown Vancouver, Zoning News, American Planning Association, April 2000. Canada Statistics (2006) [Online]. Available at: http://www.statcan.gc.ca. City of Vancouver (2002). Insights into Population and Housing, Information sheet, Planning Department. [Online] Available at: http://vancouver.ca/commsvcs/ cityplans/pop&house.pdf. City of Vancouver (2005a), Homeless Action Plan, Housing Centre. City of Vancouver (2005b), Housing Plan for the Downtown Eastside.

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City of Vancouver (2008), Cultural Facilities Plan, Final Report. Gijssen, J. (2008), Cultural Facilities Priorities Plan, Presentation, 2008. Gilmore, J. (2004), Health of Canadians Living in Census Metropolitan Areas, Health Statistics Division. Ottawa: Statistics Canada. Mason, M. (2006), Collaborative Partnership for Urban Development: a Study of the Vancouver Agreement, Environment and Planning A, 39, 2366–82. Vancouver Coastal Health (2006), Towards a Population Health Promotion Approach. Vancouver Coastal Health (2007), The Role of the Health Authority in Population Health.

Discussion Partners Jody L. Andrews, Deputy City Manager/Project Manager, City Manager’s Office, City of Vancouver Wendy Au, Assistant City Manager, City Manager’s Office, City of Vancouver Jason Blackman, City of Vancouver Planning Department Shirley Chan, CEO, Building Opportunities with Business Jessica Chen, City of Vancouver Planning Department Jill Davidson, Policy Coordinator, Senior Housing Planner, Housing Centre, City of Vancouver Albert Fok, Vancouver Chinatown Revitalization Committee Jacquie Forbes-Roberts, Project Civil City, City Manager’s Office, City of Vancouver Kira Gerwing, City of Vancouver Planning Department Jacquie Gijssen, Senior Cultural Planner, Public Art, Planning and Facilities, City of Vancouver Andrea Gillman, Housing Planner, Housing Centre, City of Vancouver Ronda Howard, Assistant Director, City-Wide and Regional Planning, City of Vancouver Katie Hume, Community Developer, Vancouver Coastal Health Authority Tanis Knowles, City of Vancouver Planning Department Rick Lam, Vancouver Chinatown Revitalization Committee Ken Lyotier, United We Can Helen Ma, City of Vancouver Planning Department Donald MacPherson, Drug Policy Coordinator, Drug Policy Department, City of Vancouver Kevin McNaney, Central Area Planner, Metro Core, Central Area Planning, City of Vancouver Michelle Neilly, Director General, Operations, Western Economic Diversification Canada Richard Newirth, Director, Public Art, Planning and Facilities Development, City of Vancouver

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Wendy Pedersen, Carnegie Community Action Project Brian Smith, Business and Social Enterprise Developer, Building Opportunities with Business A. Scott, Thompson, Inspector, Vancouver Police Department Jean Swanson, Carnegie Community Action Project Yan Zeng, City of Vancouver Planning Department

Chapter 7

Synthesis and Conclusions

1  Introduction In the present chapter we discuss the conclusions from the case studies in the five cities we selected: Helsinki, Liverpool, London, Udine and Vancouver. After a short summary of the city profiles and the policies and projects we focused on, we will assess the relevance of the three conditions for investments in healthy cities: citizen empowerment, corporate responsibility and a coordinated improvement of urban health conditions.

Figure 7.1

The three C’s for investments in healthy cities

Source: The authors

2  The Case Studies The research framework (Figure 7.1) has been applied to five different cities in four different countries. Before we discuss the relevance of the three conditions, let us first introduce some relevant context variables that may influence the development of healthy cities. Population and Demographic Structure The five cities are in different leagues if we consider their population numbers. London is by far the largest city, with 8 million inhabitants. Vancouver and Helsinki (almost 600,000 people) and Liverpool (less than 450,000) are comparable in terms of population size. The Italian city of Udine is significantly smaller than the other cities, with a population of about 100,000. Another relevant demographic characteristic is the share of ethnic minorities. London, Vancouver and Liverpool are typical examples of metropolitan areas with a melting pot of nationalities and races. Statistics on the share of ethnic minorities and people with a foreign

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background are often difficult to compare, but it seems that these three are cities have similar shares of ethnic minorities. In Helsinki and Udine the share of ethnic minorities is considerably lower (less than 10 per cent), though increasing. Social Economic and Health conditions The social economic status is an important determinant of health, as we discussed in Chapter 1. Health inequalities are related to inequalities in social economic status and the way health and welfare facilities (education, care, social housing, social benefits, etc.) are organised. The largest gap between the poor and the rich can be observed in Vancouver: the most attractive city of North America, though with an accumulation of socio-economic problems in a downtown area. London also faces major inequalities: not only between boroughs but also on a lower scale (sometimes even at the two sides of a street). Liverpool differs from London in the sense that the average socio-economic status is lower. The situation in Helsinki is completely different: because many public facilities are accessible for everyone and because the public sector invests in all parts of the city, the socioeconomic inequalities are relatively small. There are no problem areas in this city, although some neighbourhoods underperform, also in terms of health. In Udine, the differences in health and social conditions are larger than in Helsinki, but by far not as large as in the three other cities. Autonomy The third context variable is the autonomy of a city with regard to health improvement. The division of responsibilities between various layers of government determines the degree to which cities are able to intervene in urban health conditions. In four of the five cities we analysed we found that the local government is not leading in health care and promotion. In the cases of Liverpool and London, the National Health Service (NHS) plays a dominant role, although the local Primary Care Trusts are to some extent able to attune national policies to the local context. Furthermore both cities take advantage (or disadvantage) of a relatively strong national government that has developed a proactive policy on cities in which local strategic partnerships are facilitated. Also in Vancouver a higher-level government is primarily responsible for health care and promotion: in this case, however, not the State but the province takes the lead. A highly relevant context factor is the autonomy of Vancouver – laid down in a special charter which gives the city competences in the field of infrastructure, spatial planning and public services. Udine has even more autonomy in translating national policies to regional interventions due to the special statute of the region. But also in this case, the city has to deal with a relatively powerful national health organisation. Helsinki is probably the most autonomous city in our sample, being responsible for the delivery of health care – together with a regional organisation – as well as educational and social services.

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Economic Profile If we analyse the economic profiles of the five cities, some important differences can be observed. Vancouver and London are both important business centres with a strong growth in jobs, at least until the financial crisis that started in 2007. Both cities can benefit from the organisation of the Olympic Games (in 2010 and 2012 respectively) that may act as a catalyst for investments in the city (although the crisis has changed the outlook considerably). Helsinki is not a typical business centre, but rather one of the leading European cities in research and development. This explains why the city is well aware of the need to continuously invest in innovation in order to secure this position. Furthermore we concluded that both Helsinki and Udine are able to profit from the eastward extension of the European Union. In comparison with the other cities, Udine clearly has a distinctive economic profile: it is the centre of a rural region where agriculture and (non-urban) tourism are the major sources of income. Liverpool is an industrial city and one of the second cities in the United Kingdom (following London). In this case it is not the Olympic Games but the Cultural Capital event (2008) that has been used to invest in the city and its image. Tradition to Cooperate A relevant factor for cooperation and coordination in health improvement is the tradition to cooperate. For instance, we concluded that Helsinki may benefit from the Finnish tradition to cooperate on the basis of equality. The autonomous region in which Udine is located is known for the people’s strong sense of solidarity. Also in the Downtown Eastside of Vancouver the community spirit is relatively strong.

3  Policies and Projects To gain insight in the conditions under which investments in healthy cities are effective we analysed several policies and projects in the selected cities. It has not been our aim to give a complete overview of all relevant strategies and actions: due to time restrictions we focused on a limited number of initiatives. Helsinki In Helsinki we analysed the Healthy Helsinki programme, a joint initiative of various municipal departments, the business sector, knowledge institutions and third-sector organisations, supported by several national organisations. The programme comprehends the development of new digital products and services that stimulate people to live a healthy life, using one district (Herttoniemi) as reallife laboratory (living lab). To gain understanding of how this programme works

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we interviewed various actors that are involved in some of the projects under the flag of this programme. We also looked at how the programme relates to other initiatives such as the city’s innovation strategy. Liverpool In the case of Liverpool we discussed various strategies of the city to improve the health situation, looking at the city’s participation in the WHO Healthy Cities programme and how this relates to local strategic partnerships. We paid attention to the city’s strategy to bring healthcare closer to citizens and outside of hospitals, and analysed how this affects the development of health care facilities. By means of interviews with actors involved in the (re)development of healthcare facilities we managed to get insight in the relation between these facilities and their urban environment. London The case of London addressed three initiatives to improve the health conditions: a local strategic partnership in the borough Croydon, the redevelopment of the Thames Gateway and East London in particular, and Well London: a joint programme of the London government, various non-profit organisations and a knowledge institution – financed through lottery money – that has resulted in experiments with new health interventions in twenty areas across the city. Udine In Udine we focused on the local Healthy Cities programme: more in particular the way this programme is organised and the projects it generated. We analysed various projects that aim to improve the lifestyle of particular groups through new forms of cooperation and active involvement of the target groups. Various interviews with actors involved in these projects helped us to deepen our understanding of the relation between health policies and sustainable urban development. Vancouver In Vancouver we concentrated on the redevelopment of the Downtown Eastside: an area adjacent to the Central Business Districts with a high concentration of social, economic and health-related problems. Drug addicts and homeless people create an atmosphere that contrasts strongly with the prosperity and quality of life in other parts of the city. Through interviews with government representatives as well as external stakeholders we have been able to gain understanding of the revitalisation policy and the concrete projects this policy produced. We also looked at how this policy relates to other city-wide policies in the field of health and sustainable development.

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4  Citizen Empowerment The first condition we tested is citizen empowerment. We assumed that in the end citizens have to change their lifestyle: institutions (governments, businesses and other organisations) may help to create an environment that stimulates people to make healthy choices. The key challenge is to improve people’s internal locus of control: their ability to take and keep control of their own lives. The case studies demonstrate that this is indeed an important condition. In various ways institutions try to put citizens central in their efforts to improve the urban health conditions. Below we discuss a range of strategies and actions that we identified. Policy Documents The first step to citizen empowerment is formal recognition in official policy documents. By accepting the WHO Healthy Cities approach and/or the philosophy of Local Agenda 21 (the UN plan for sustainable development) cities such as Udine and Vancouver explicitly put citizens in the centre of their policies. Through so-called health maps local government try to gain insight in the health of citizens and the geographic distribution of vulnerable groups such as the elderly. Another example of a policy that puts citizens central is Vancouver’s revitalisation without displacement strategy. The aim of this strategy is to make sure that residents of downtown areas that are revitalised keep pace with the changes in their environment. The city wants to avoid gentrification, taking into account the specific competences and needs of the people who live in the Downtown Eastside such as drug addicts and homeless people. Another policy worth mentioning is the attention for the ‘human scale’ as leading principle in urban development, also with the construction of high-rise buildings. In Liverpool policy makers emphasise the city’s ambition to improve the match between the supply of healthcare facilities with the specific needs and demand of citizens in the various communities. Consultation The second step towards citizen empowerment in health promotion is consultation. In several cities we found examples of projects in which target groups are consulted in order to improve the effectiveness of interventions. A good example is the project Road Safety in Udine in which the city identified safety barriers for walking and biking by means of a survey. Udine, Liverpool, London and Vancouver regularly organise workshops to promote citizen involvement in health-related policies and projects. In London they also organise more informal community cafés as part of the Well London programme. In Liverpool they used similar sessions to gain input for the Big Health Debate, as well as for the redevelopment of children’s hospital Alder Hey. Most discussion partners agree that consultation helps to improve interventions. Some indicate that consultation directly improves the self-assessed

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health of citizens, for instance because it helps to reduce stress caused by changes in the environment. Citizens as Co-Producers In three of the five case studies (London, Helsinki and Udine) we observed initiatives to actually active citizens as co-producers of an urban environment that promotes healthy behaviour. In Udine the institutions use contracts and bets to formalise – to some extent – the shared responsibility of citizens and institutions. The city enables individuals and groups to take initiatives themselves with (financial) support of the city through the Healthy Cities programme. For instance, a school director took the initiative to develop a contract between the school and the parents, agreeing on the shared responsibility for a healthy snack during the morning break. This initiative has been adopted by the Healthy Cities project bureau, resulting in a city-wide implementation: all schools supply healthy snacks three days a week – in cooperation with local businesses – on the condition that parents take their responsibility the other days of the week. Also in London individuals and community groups have access to subsidies (via the Community Initiatives Fund) for the implementation of their own projects and plans to improve their own environment. Because citizens sometimes lack the competences to translate their needs in concrete ideas, so-called health champions get the opportunity to follow courses on how to do this, as we saw in Croydon. A similar approach is used in the programme Well London: citizens are trained so they can be actively involved in the projects: by collecting information, implementing the project and evaluating the results. For example, teams of volunteers from the target communities have been set up to assist other community members with making healthy choices. People who have experience with mental illnesses are trained to make other people mentally stronger. For the revitalisation of the Thames Gateway volunteers attend free courses that turn them into neighbourhood consultants: community champions that help to identify and solve the problems of their neighbouring residents. Another good example is the project Do It Yourself Happiness (part of Well London) that stimulates people to think about their own wellbeing and the wellbeing of the community. This project stimulates people to make suggestions for small projects that require investments between £50 and £500. The institutions involved help citizens to translate ideas into concrete project proposals and products. Experiments Citizens can also be empowered by considering neighbourhoods as living labs for experiments with health promotion. Essentially this implies that institutions do not pretend to understand the needs of target groups a priori: they use experiments to gain insight in their needs, wants and fears. This can be done by pilot projects (as in the case of Udine), but also by appointing one or more areas as test locations,

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as in the programmes of Well London and Healthy Helsinki. Neighbourhoods turn into living labs in which specific citizen groups become co-producers of interventions in urban health conditions, for instance by giving their opinion on the user friendliness of interfaces and the effectiveness of incentives as we observed in the case of Healthy Helsinki. The case studies also demonstrate that experiments may provide insight in how parents can be influenced by children and the role of pressure from peers in general. A good illustration is Udine where children stimulate their parents to improve their consumption patterns (e.g. via the above-mentioned project on healthy snacks) and adopt an active lifestyle (e.g. by walking in groups). Discussion partners in Helsinki and Udine expect that experiments with interventions in urban health conditions result in information about what incentives work for particular community groups (e.g. competition or financial stimuli). The Internal Locus of Control The case studies confirm the importance of the internal locus of control. Several discussion partners refer to the ageing society and the increasing costs of healthcare as arguments to pay more attention to this aspect of citizen empowerment. A healthy lifestyle may improve the wellbeing of citizens, but not necessarily reduces the chance that (older) people get confronted with major changes in their lives. Loneliness is one of the most important causes of health-related problems in cities as we concluded in the cases of Udine and Helsinki. A simple way to improve people’s ability to take care of themselves – observed in Udine – is a free telephone number that provides access to a range of services. Helsinki has adopted a more innovative approach: they develop digital, (mobile) internet-based services that assist citizens to keep control of their lives. One of the services gives people the opportunity to chat with e-genitors: virtual parents. In both Udine, Helsinki and London much attention is paid to the findability of services. One project under the umbrella of Well London comprehends the distribution of maps that enable citizens to make healthy choices themselves. The project Closeby Sports Places in Helsinki tries to improve the findability of sports and recreational facilities, notably at walking distance taking into account the limited mobility of particular groups (e.g. young children).

5 Corporate Responsibility The second condition for investments in healthy cities we identified beforehand is corporate responsibility. We argued that not only the government and health authorities have the task and responsibility to create an healthy urban environment: companies and other private organisations need to get involved as well. The cases demonstrate the relevance of this factor: it has become clear that there are various ways to orchestrate private-sector involvement, ranging from

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enforcement to voluntary contributions and the development of public-private partnerships. Enforcement In the cases of Vancouver and London we concluded that the government uses its legislative power to enforce private-sector contributions to healthy, sustainable urban development. Through taxation, certification and special contracts they more or less oblige developers to make a contribution to the realisation of social and environmental objectives. Developers in Vancouver, for instance, have to pay two types of levies through which they contribute to the development of parks, infrastructure, childcare facilities, social housing and other amenities. Similar taxes have to be paid in the United Kingdom where the private sector co-finances social infrastructure via Community Infrastructure Levies. In continental Europe such additional taxes are not considered feasible, as the income tax is considerably higher than in the Anglo-Saxon countries. In a somewhat less compelling way certification such as LEED also promotes private investments in a healthy and sustainable environment. Another strategy we observed in Vancouver is that the municipality considers the sustainability performance of companies in their selection of suppliers. Developers are also obliged to pay attention to their local environment by making agreements on the benefits for citizens such as job creation. Examples are the Community Benefit Agreements and the Inner City Inclusive Commitments that have been signed for the development of South East False Creek (where the Olympic village is located). A simple method to raise the pressure on companies is the development of a website (Social Purchasing Portal, Vancouver) that lists firms with a good score on sustainability and local involvement. Voluntary Involvement In the cases of London, Helsinki and Udine we observed several examples of attempt to involve the private sector in healthy urban development on a voluntary basis. In Udine, for example, the Healthy Cities team cooperates with the Chamber of Commerce to stimulate voluntary private-sector contributions to a healthier living and working environment. In East London, several firms have joined an alliance that makes contributions to the revitalisation of neighbouring districts through sponsoring and management time. The most important contribution of the private sector, however, is the creation of jobs and the investments in housing and facilities, as can be seen in the redevelopment of London’s Thames Gateway. In other cases we observed more specific contributions to projects as in the case of Udine where a supermarket chain and a regional baker’s association are preferred suppliers for the project Contract for a Healthy Snack. Also in the case of Healthy Helsinki we came to the conclusion that privatesector involvement is mostly based on commercial motives such as product

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development, access to new markets and publicity. Public-private cooperation seems to be easier if it involves larger firms as they tend to have longer planning horizons than SMEs. The Healthy Helsinki model facilitates a high level of private-sector involvement, though mainly based on commercial benefits. Several discussion partners have indicated that this is also a possible weakness of the model: the focus on commercial outputs may reduce the willingness to cooperate of other (public, non-profit) organisations. More attention for corporate citizenship could maybe reduce this problem. The case of Liverpool shows that ‘honest brokers’ – intermediary organisations that act as ambassadors for firms with a good performance on health and sustainability – may stimulate companies to take their responsibility. Developing Public-Private Partnerships The case studies also show that cities try to make public and private actors aware of the need to cooperate, thus promoting the development of public-private partnerships in health promotion. Most illustrative is the map ‘making the links for health’ (Figure 7.2) – using the same design as the famous tube map – which identifies the actors that (should) play a role in the development of healthy urban environment. Not only the London Health Commission but also the Healthy Urban Development Unit play an important role in getting stakeholders together and making them aware of the need to cooperate. The same applies to the project bureau of Well London which acts as an intermediary between various sectors (public, health, charity, businesses, knowledge institutions, non-profit organisations, etc.). In the Healthy Helsinki programme a committee and a steering group have the task to translate joint ambitions of the partner organisations from various sectors into concrete projects. In Udine, it is the task of the Healthy Cities bureau to bring actors together, while in London and Liverpool, the local strategic partnerships act as platforms for sustainable urban development, with health as one of the key themes. In the two English cities we also found that (potential) partner organisations are accommodated in the same multifunctional building, expecting physical nearness to smoothen cooperation.

6 Coordinated Improvement of Urban Health Conditions In our research framework we stated that citizen empowerment and corporate responsibility are needed to enable a coordinated improvement of urban health conditions: the third condition we identified. Coordinated improvement implies that interventions give evidence of a broad definition of health and health determinants, giving attention to social-economic as well as environmental conditions that influence lifestyle and health.

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Figure 7.2

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Making the links for health

Source: ‘London and Londoners: Making the Links for Health’ (London Health Commission, 2006), adapted by the authors

Our empirical study shows that cities are in fact concerned about this condition. Evidence can be found in the general policies they develop but also in the projects that result from these policies. Policies In all five case studies we observed attempts to integrate a coordinated improvement of health conditions in the city’s policies. Liverpool, Helsinki and Udine have all adopted the WHO Healthy Cities approach, which basically implies that recognise the impact of the urban environment – socially, economically and physically – on lifestyle and health. Udine even goes one step further by combining the principles of Healthy Cities with the principles of Agenda 21 concerning sustainable urban development with equality and diversity as important values. London’s strategy Living Well in London as well as the programme Well London seem to be in line with the Healthy Cities philosophy too. Well London focuses on the three essential elements of health (nutrition, exercise and mental wellbeing) but also   In this simplified version of the map developed by the London Health Commission the names of some organisations have been shortened. The original version (poster size) includes information about the missions and contact details of all organisations. It also says that the poster ‘is indicative and not intended to give a comprehensive description of all organisations in London and their role in health. Information was correct at the time of going to print’.

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looks at environmental and socio-economic determinants. Four of the five cities (London, Liverpool, Udine and Vancouver) try to anchor attention for health in spatial policies. Several discussion partners advocated the use of evaluation tools such as health impact assessments in order to promote healthy urban planning. Such tools help to raise the awareness and knowledge about the relation between health and the urban environment. Projects How to translate a comprehensive vision and strategy with attention for health into concrete actions? The five cases give several answers to that question. In Vancouver they set up special projects that aim to tackle the accumulation of problems vulnerable groups are confronted with. Examples are the Four Pillar Drugs Strategy (prevention, treatment, enforcement and harm reduction) and the Homeless Action Plan (employment, education, housing, services). Another example from Vancouver is the combined development of bicycle lanes (e.g. Carrall Street Greenway) and green facilities, attractive street furniture, meeting places and events to stimulate the use of public space. In London and Liverpool we concluded that coordination is facilitated by combining healthcare facilities with other facilities in multifunctional community centres. Another observation in Liverpool is that they used the redevelopment of a hospital – or another healthcare facility – as catalyst for the development of a healthier environment that stimulates healthy choices. An example of a coordinated approach in London is the project Healthy Spaces which aims to make better use of temporary public spaces (such as redevelopment locations) also by improving the accessibility by foot and bike and by reducing crime through better design. Also worth mentioning is the initiative to develop and maintain community gardens and the organisation of activities such as walking tours and festivals to stimulate the use of facilities and infrastructure. Furthermore we found that both Well London and Healthy Helsinki use horizontal projects to support and connect other more specific and targeted projects. In this way these programmes facilitate coordination between interventions in different health determinants. These horizontal projects focus on research (e.g. on lifestyle changes and the interaction between services and users), the exchange of knowledge and experiences, evaluation, training and network development. The most many-sided project in Helsinki is probably Personal Health Records which gives citizens the possibility to check their personal health information on the internet, including advises on how to improve their health for a range of determinants (nutrition, exercise, participation, etc.). A good example of a multilateral project in Udine is the development of a ring of bicycle and walking routes that connect sports and leisure facilities as well as agrotouristic attractions.

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7 Concluding Remarks In the present study we concluded that three conditions are relevant for investments in healthy cities: citizen empowerment, corporate responsibility and a coordinated improvement of urban health conditions. Experiences from the five cities we selected not only confirm the relevance of the three conditions but also provide insight in how cities can actually meet these conditions. An important conclusion is that the development of healthy cities is not only a task of the government, but of other actors as well: knowledge institutions, nonprofit organisations and the business sector play a key role in creating an urban environment that makes the healthy choice the easy choice. Cities are challenged to develop public-private partnerships with healthy urban development as a common goal for all stakeholders. Such partnerships are crucial to enable innovation in health promotion and to keep our cities healthy and viable.

Index

Alder Hey 48–51 Alder Hey Children’s Health Park 50–51 building of new hospital 49 process of redevelopment 49 redevelopment 48–51 sustainability partners 49 “why your health matters” 51 citizen empowerment 111–13 citizens as co-producers 112 condition for investment 10 consultation 111–12 experiments 112–13 internal locus of control 113 Liverpool 51–2 London 69–70 policy documents 111 Udine 86–7 Vancouver 103 conditions for investment 1–11 citizen empowerment 10 coordinated improvement of urban health conditions 11 corporate responsibility 10–11 research method 11 coordinated improvement of urban health conditions 115–17 Helsinki 37–8, 117 Liverpool 52, 117 London 71–2, 116–17 making links for health 116 policies 116–17 project 117 Udine 87–8 Vancouver 117 corporate responsibility 113–15 developing public-private partnerships 115 enforcement 114

Helsinki 35–6 Liverpool 70–71 empirical analysis 71 public sector 70–71 London 70–71 Udine 87 Vancouver 103–4 voluntary involvement 114–15 environmental Influences 8–9 Healthy Cities Programme 8–9 ability to improve 9 Friuli see also Udine Capitale della Guerra 75–6 earthquake 76 health and its determinants 2–6 broader definition of health 2–3 support of 2 World Health Organization (WHO) 2–3 environmental press and competence 5–6 ability to cope with 5 balance between competence and press 5–6 health field concept 3–5 see also health field concept health field concept 3–5 Dahlgren and Whitehead model 4–5 environment as important health determinant 5 groups of health determinants 3 health determinants 4 improvement to social and physical environments 3–4 health geography 7–8 Dutch Institute for Public Health and Environment (RIVM) 7–8

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studies on 7 Helsinki 17–38 administrative organisation of 20–21 health and safety advisory council, and 21 economic development of 19–20 general profile 17–22 health and social conditions 21–2 immigrants, and 22 Healthy Helsinki programme 28–38 aims of 28 citizen empowerment 34–5 Closeby Sports Places 33 competitive nature of 38 coordinated improvement of health conditions 37–8 corporate responsibility 35–6 development of 30–31 Finnish Centre for Health Promotion 30 Forum Virium and 29 Herttoniemi 29–31 history of 28–9 horizontal projects 34 involvement of municipal departments 36–7 involvement of natural organisations 36 Living Lab for new concepts 29–31 main goal of 28 mobile health 31–2 personal health records 32 projects 117 study on everyday life of children 33–4 technology-driven, as 37–8 vertical and horizontal projects 37 Initiatives to improve urban health 22–7 Finnish Healthy Cities Network 22–3 Forum Virium 24–5 Helsinki Living Labs 25–7 importance of 27 innovation strategy 23–4 National Technology Agency of Finland (TEKES) 23–4 stakeholders, and 27–8

major districts 18 policy and project 109–10 population with foreign background 19 statistics on 18–19 voluntary involvement 114–15 Initiatives to improve urban health Helsinki 22–7 Liverpool 44–8 Alder Hey redevelopment 48–51 Liverpool 41–52 Alder Hey see Alder Hey citizen empowerment 51–2 coordinated improvement of urban health conditions 52 corporate responsibility 52 development investments 41–2 economic development of 41–2 general profile 41–4 health and deprivation 42–3 short life expectancy, and 43 initiatives to improve urban health conditions 44–8 Big Health Debate 46–7 Healthy Cities 44–5 history of 44–5 Liverpool First 45–6 Outside of Hospital strategy 47–8 plan for Liverpool 45 results of 47 Sustainable Community Strategy 46 third phase 45 WHO, and 44–5 life expectancy 43 Liverpool Primary Care Trust 43–4 NHS, and 44 Outside of Hospital Strategy neighbourhood cities 48 policies 110, 116–17 projects 110,117 relative performance of economy 42 London 55–72 citizen empowerment 69–70 Health Champions 70 value of 70

Index coordinated improvements of urban health conditions 71–2, 116–17 corporate responsibility 70–71 empirical analysis 71 public sector 70–71 developing public-private partnerships 115 economic importance of 55 enforcement 114 general profile 55–7 health indicators 56 health inequalities 56–7 differences from UK average 57 history of 55 London Health Commission, and 57–9 see also London Health Commission local strategic partnership in Croydon 60–61 Healthy Croydon 60–61 partnership 60 statistics 60 strategic board and eight thematic groups 60 London Health Commission 57–9 activities 58–9 cooperation and coordination in health promotion 58 creation of 57–8 interdependence 59 making links for health 59 policies and projects 110 projects 117 Thames Gateway Redevelopment 61–4 see also Thames Gateway Redevelopment voluntary involvement 114–15 Well London 65–9 cohosts 67 eight thematic projects 68–9 funding of 65–6 “heart of the community” project 67–8 programme 65–6 projects 67–9, 117 target areas 66–7 Well London Alliance 65 London Health Commission 57–9

121 activities 58 health inequalities, and 57

policies and projects 109–10 elderly 79–80 Adding Life to Old Age 80 Healthy Cities Project Officers 79 Helsinki 109–10 Liverpool 110 London 110 Udine 110 Vancouver 110 research framework 107–9 autonomy 108 economic profile 109 population and demographic structure 107–8 social economic and health conditions 108 tradition to cooperate 109 Thames Gateway Redevelopment 61–4 Community Champions programme 63–4 community initiatives 63–4 contributions of the private sector 64 investments in housing 62 objectives 61–2 Olympic Legacies Programme 62 size and population 60 Skills Plan 63 THE Hub 64 Udine 75–88 Capitale della Guerra 75–6 children walking to school 84–6 aims of 84–5 phases of 85 school mobility 85 citizen empowerment 86–7 projects 87 coordinated improvement of urban health conditions 87–8 contract for a healthy snack 82–4 agreement between school and parents 83–4 development of 82

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Towards Healthy Cities institutionalisation of shared responsibility 83 new partners in project 84 Pediatric Department 82–3 corporate responsibility 87 earthquake 76 economic structure 77 elderly 79–80 environment 81–2 achievements of 82 collaboration between Agenda 21 and Healthy Cities Project Office 81 merger between Health Cities Project Office and Local Agenda 81 general profile 75–7 Health Development Plan 78–9 Healthy Cities 77–9 National Health Service 77 policies 116–17 policies and projects 110 Project Office 78 projects 79–82 size and population 75 strategic position 76 population increase 1871–1981 76 voluntary involvement 114–15 young and adolescent people 80 WHO, and 78

Vancouver citizen empowerment 103 coordinated improvement of urban health conditions 104

corporate responsibility 103–4 Downtown Eastside 92, 98–102, 104 “Building Opportunity with Business” 100 Carrall Street Greenway 102 community development 99–100 Community Health Advisory Committees 94 coordination 104 Cultural Facilities Priority Plan 101 four pillar drug strategy 100 Great Beginnings 101–2 Homeless Action Plan 100 housing strategy 102 revitalisation programme 99 Vancouver Agreement 98 general profile 91–4 health promotion 94 healthcare delivery 94 immigration 92 levels of government 93 population 91–2 urban planning policy 94–8 ecodensity 96 impact on health 94–8 increase in population 96 living first 94–6 Olympic Winter Games 97–8 public and private investments in urban design 95 South East False Creek 96–8 strategy of 95 taxation instruments 95