THE POLICY CONTEXT
In September 2001, the Department of Human Services (DHS) in the state of Victoria released the municipal public health planning (MPHP) policy framework, known as Environments for Health.1 Drawing on the social model of health, this framework provides an ecological approach to planning that considers the overall impact on health and wellbeing of factors originating across any or all of the built, social, economic and natural environments. Through Environments for Health, the state government acknowledges that local governments, with their clearly identified populations and geographic boundaries, are a distinct sphere of government. Environments for Health recognises that local governments have the authority and responsibility to provide leadership to their citizens, working in partnership with the communities they serve to create a community vision and goals. Local governments have the mandate and responsibility to promote integrated planning by fostering community participation, advocating for local needs, building intersectoral partnerships, and facilitating local change (DHS 2001 p 10).
Environments for Health draws strongly on the principles of the World Health Organization’s (WHO’s) Ottawa Charter and Healthy Cities Program. Healthy Cities initiatives, of which there are thousands worldwide, are characterised by a broad-based, intersectoral political commitment to health and wellbeing in its broadest ecological sense, a commitment to innovation, an embrace of democratic community participation, and a resultant healthy public policy (WHO 1997). The Healthy Cities approach is based on the recognition that city and urban environments affect public health, and that healthy municipal public policy is needed to effect change (Ashton 1992). Environments for Health demonstrates the ways in which all local government planning activity – across the economic, social, built and natural environments – impacts on a community’s overall quality of life, health and wellbeing. Therefore, local governments need to find ways to show how their planning activity is interconnected, and demonstrate how health and wellbeing can be enhanced by promoting integrated planning across these environmental domains. Integrated planning can be achieved through a number of means, including better communication systems across planning departments, improved whole-of-council governance systems, workforce development, new policies, as well as ensuring that planning documents clearly identify cross-linkages (Hay et al. 2001).
Environments for Health was developed throughout 2000–01 using an extensive, iterative process of systematic research and development through questionnaire, feedback, and stakeholder engagement. More than 500 people have participated in the development of the framework, and its evaluation. During its development, a range of approaches was undertaken to promote integrated planning, and developing links between state policy makers in the areas of public health and urban planning. A strong effort was made to establish a culture of participatory enquiry among representatives from all sectors involved. As a result, the policy framework has been strongly ‘owned’ by stakeholders throughout the local government sector, and has been used by practitioners in other sectors (Centre for Health through Action on Social Exclusion 2006).
Integral to the development and implementation of Environments for Health was the formation in 2000 of the Local Government Partnerships Team (LGPT). The team was established to develop the policy framework by providing leadership, support and coordination on MPHP to the local government sector and all stakeholders; its mission was to strengthen public health infrastructure and capacity by sharing information, identifying and encouraging best practice, stimulating research, developing collaborative relationships, and developing and implementing public health policy.2
The LGPT was situated within the Public Health Division of DHS,3 in the Partnership Development Section.4 Between September 2000 and August 2003, I was a team member and then team leader of the LGPT. Situated within this large, complex bureaucracy, the three members of the LGPT consciously adopted an approach that embraced all tenets of the Ottawa Charter, namely: creating supportive environments; developing personal skills; enhancing community action; reorienting health services; and creating healthy public policy (WHO 1986). We agreed to model, in our team philosophy and approach, the philosophical and intellectual spirit of Kickbusch’s (1989) definition of public health as being:
ecological in perspective, multisectoral in scope and collaborative in strategy. It aims to improve the health of communities through an organised effort … Public health infrastructures need to reflect that it is an interdisciplinary pursuit with a commitment to equity, public participation, sustainable development and freedom from war. As such it is part of a global commitment and strategy.
Securing the development and ministerial release of Environments for Health was not a straightforward process, but rather a constant tactical process of negotiation, consultation and networking, grounded firmly in community development principles and embedded in a clearly articulated vision and long-term strategic plan. Indeed, there were many occasions in which the framework’s more innovative elements, and the LGPT’s attempts to embrace a timely, inclusive approach, could have been lost. This forms the essence of the challenges discussed in this chapter: that those responsible for developing progressive policy can often find their efforts challenged by a complex and sometimes contradictory bureaucratic ‘authorising environment’, complex and conflicting political directives, and unrealistic timelines.
In this chapter, the historical analysis of the development of the policy framework and the insights are those of the author as a member of the LGPT. This is by necessity a personal reflection, and no claims are made for objectivity.5 Readers who are interested to learn more about Environments for Health from other perspectives might care to explore the Local Government Partnerships website,6 and to seek the report of the 2006 evaluation study conducted jointly by Deakin University’s Centre for Health through Action on Social Exclusion (CHASE) and Melbourne University (CHASE 2006).
The way a community functions is the result of a complex interrelationship between its history, the way that people, groups, and institutions are organised and interrelated, and the way that power and resources are dispersed (Sarason 1974). Anyone interested in developing, evaluating and analysing health policy would be advised to heed Sarason’s warning that the degree of complexity of a community and its interrelationships largely will determine any efforts to change any aspect of it, including the psychological and physical wellbeing of that community’s inhabitants.
IDENTIFYING THE POLICY PROBLEM
Municipal public health planning was legislated through an amendment of the Victorian Health Act in 1991. Under the Health Act, section 29B, every council must prepare a MPHP and revise it every 3 years. The plan must identify and assess actual and potential public health dangers affecting the municipal district and outline the programs and strategies which council intends to pursue. The council must review the plan annually and, if appropriate, amend the plan. The state government developed a range of resources to support the 210 local governments that existed across Victoria at this time. However, the Labor Government, which had overseen the MPHP legislation, was voted out of office in 1993. During the subsequent radical neo-conservative administration, MPHP stalled through the impact of: (i) local council amalgamations, from 210 councils to 78 (there are now 79); (ii) replacing democratically elected councillors with state government-appointed commissioners until the restoration of democratically elected local councils; (iii) compulsory competitive tendering, which required local governments to compete for services that they had previously administered (see Blau & Mahoney 2005); (iv) rate-capping, which restricted the income that councils could derive from their residents in order to conduct essential services, such as street cleaning; and, as a result of these changes, the subsequent loss of council revenue, core staff, and the collaborative ethos central to MPHP.
Due to similar restructuring at the state government level, significant numbers of key public servants from the previous Labor administration left their posts. The Department of Health and Community Services amalgamated with the Department of Housing and Disability Services, Office of Aboriginal Affairs and Office of Youth to form the Department of Human Services (DHS), a bureaucracy of some 13,000 people. One key person who had introduced MPHP in 1991 remained at the new DHS, and continued to support MPHP (CHASE 2006). Later, he was to join the LGPT.
In November 1999, Victoria’s Liberal state government lost office in a surprise election result. During the election campaign, the Labor Party had promised to revitalise civic democracy through a renewed commitment to the local government sector, and to MPHP in particular. As a result, in early 2000 DHS central office established the LGPT to explore the potential for developing a state-wide MPHP policy framework to guide and support all local governments. In the next section I will outline the process by which the framework was developed, and describe the many factors that facilitated and impeded its progress.
THE POLICY RESPONSES
Environments for Health development strategy
The LGPT grounded the development of Environments for Health in a strong theoretical foundation in community and organisational development, in systematic research, a clear mission statement for the LGPT, a 3-year strategic plan for the framework’s development and implementation, and links to international literature. Importantly, the team also recognised that ensuring the successful carriage of the policy framework would necessitate a systematic effort to develop substantive partnerships with key internal and external stakeholders, many of whom had become disenfranchised during the previous Liberal state government administration. Stakeholders included: the Municipal Association of Victoria (MAV); Victorian Local Governance Association (VLGA); representatives from local governments; input from professional bodies such as environmental health; and key non-government organisations such as the Victorian Health Promotion Foundation (VicHealth). Other stakeholders included various program teams within the Public Health Division, public health staff in the (then) nine regional offices across Victoria, and other divisions within the DHS. A steering committee was established, made up of 18 key stakeholders from across these sectors.
Regional DHS health promotion staff and the MAV assisted the LGPT to identify key personnel in each council with the responsibility for MPHP. In a state-wide survey, respondents were asked to identify: the status of MPHP (whether a plan existed, whether it was being implemented, and whether any evaluation had been performed); the main focus areas of MPHP; the strengths of MPHP; limitations to MPHP and associated issues; and preferred components of a state-wide MPHP framework. This feedback was collated by regional DHS staff, and returned to the LGTP with a summative report representing a regional DHS perspective on local (and state) government capacity for MPHP in each region. These data were then analysed and compiled into an MPHP status summary report, which was delivered to the steering committee in late 2000. The LGPT worked with the steering committee over several months to develop a draft framework, which was then distributed for comment.
Approximately 300 people attended consultation workshops held in five locations across the state. Still others returned comments via email and fax. Feedback and outcomes were circulated via the LGPT website, via a special newsletter, and by email. Following its endorsement by the Director of Public Health and the then Minister for Health, a final version of Environments for Health was released in September 2001. Stakeholders, including those who offered comments throughout the development of the framework could see, in the final version, that their ideas had been included in a meaningful way. This cemented the notion of ownership, and created firm conditions for implementation.
Implementation
A comprehensive implementation program began in early 2002 (see Box 8.1). Implementation targeted two consistently recurring issues identified during the policy development phase. These were: (i) the need to generate examples of good practice based on use of components of the framework, with particular emphasis on the built environment and integrated planning; and (ii) the need to provide practitioners with opportunities to develop skills in key areas relating to the framework, particularly in relation to data collection, community participation, and evaluation.
BOX 8.1 ENVIRONMENTS FOR HEALTH IMPLEMENTATION STRATEGY
- Local Government Planning for Health and Wellbeing website.
- Workforce development seminars and programs, held in partnership with the Planning Institute of Australia and VicHealth to highlight the relationship between the built environment and health and wellbeing.
- Provision of on-site consultancy to local governments by the LGPT, and increasingly by the nine DHS regional Public Health teams established in 2002.
- A comprehensive good practice program (2002 to present), in which councils receive seeding grants to implement and evaluate aspects of Environments for Health and share research findings.
- Conferences held in 2003 and 2004 to share good practice findings and celebrate renewed capacity in the local government sector.
- Leading the Way (under the auspices of VicHealth, in collaboration with the MAV and LGPT) – a package directed to senior managers and councilors.
- Workforce development seminars and programs, held in partnership with the Planning Institute of Australia and VicHealth to highlight the relationship between the built environment and health and wellbeing.