Healthy public policy, settings and supportive environments

CHAPTER 4 Healthy public policy, settings and supportive environments

Developing healthy public policy to create supportive environments for health is examined in this chapter. We explore the key issues in the development of regulatory activities to improve health at a global and local level. Healthy public policy is defined here as regulatory activities including executive orders, laws, ordinances, position statements, regulations and formal and informal rules. Developing healthy public policy has been identified as central to effective health promotion practice since the development of the Ottawa Charter for Health Promotion in 1986. Developing public policy that lays the foundation for healthy living may be one of the most challenging areas of health work.

In Chapter 1 we outlined a continuum of health promotion approaches. At one end of that continuum is the population approach to health highlighting regulatory activities that create supportive environments for health. These activities offer scope for developing effective long-term change with wide-ranging impact on the determinants of health and illness. Regulatory activities may be developed at the international, national and local levels, or all three working in concert with one another.

Working to build healthy public policy and create supportive environments for healthy living has resulted in the development of the settings approach for health. In the settings approach, work for structural change occurs through partnerships. Community members and professionals from all sectors work with government to improve people’s health chances in communities and organisations.


The regulatory activities discussed in this chapter are those activities that involve the application of legislative and financial frameworks that create opportunities for healthy living. ‘Regulatory activities include executive orders, laws, ordinances, policies, position statements, regulations and formal and informal rules’ (Schmid et al 1995 in McKenzie et al 2005: 187). These regulatory actions or healthy public policies can be for broad activities aimed at social change, change at the local/community level or change within organisations. On the continuum we outlined in Chapter 1, these activities are associated with the socio-ecological approach. In this chapter, we use the term healthy public policy, to include all of the activities defined here.

The Ottawa Charter for Health Promotion (World Health Organization [WHO] 1986), with its emphasis on building healthy public policy as an integral component of health promotion action, marked the formal recognition of the role that all public policy plays in influencing health and the role of the environment in shaping opportunities for health. People’s social and physical environments impact strongly on their opportunities for health. All public policies, mandated activities or regulated activities, not just those labelled as ‘health’ policies, have health consequences.

Healthy public policy is central to the promotion of health because, without the support of healthy public policy, other health promotion actions are likely to be of limited value. As Milio (1990: 295) has expressed it:

Until relatively recently health workers have been concerned primarily with health sector policy, because it was assumed that this was the major policy that impacted on health. It is now recognised that health sector policy in developed countries has a limited impact on health by comparison with the impact of social, economic and environmental policy because it focuses largely on the structure of health care delivery. Social policy, for example, deals with such issues as income distribution, housing and transport provision, while economic policy affects such things as employment rates, inflation and taxation policies. Policies that impact on the physical environment include policies on urban planning, air quality and water quality. It is clear that all of these things do a great deal to structure the environments in which people live. The notion, then, of public policies having a substantial impact on health makes good sense, and the need for economic, social and health policies to be responsive to the requirements of the community is quite apparent. Two recent results of the growing recognition of the importance of population health protection through public policy are the increasing concern for the link between health and the state of the environment, set out in Chapter 3, and concern for the impact of economic globalisation and neo-liberalism, especially in increasing inequities and impacting on the quality of life (Ife & Tesoriero 2006; Labonté & Schrecker 2006; Verrinder 2005).

Healthy public policy ‘cannot be developed in a moral vacuum’ (WHO 1998: 210). In Chapter 2 we discussed the values of equity, equality and social justice, underpinning Primary Health Care. The development of health public policy requires political will and, in particular, a commitment to equity and human rights, ensuring that all members of society receive the health benefits of social change. It is important, therefore, to understand what health policy is and how it can be influenced.


Health policies are policies that have been considered as ‘an authoritative statement of intent adopted by governments on behalf of the public with the aim of improving the health of the population’ (Palfrey 2000: 3). There seem to be two characteristics common to all policies, whatever the context, and these are:

Policies imply particular values. They are driven by the values of the government of the day and organisations express their values in the mission statements, aims and objectives, which underpin the policies of the organisation. Some are very general and provide a guide to action. These might be found in the speeches of politicians before an election. Others make very specific statements or proposals implying that something definite will happen. These might take the form of a program with a specific group of people, or a particular process of a program.

‘Health’ policies can be about health or for health. Policies that are developed within the health sector have four distinct ways of affecting people. Several authors, for example Salisbury & Heinz (1970) and Palmer & Short (2000), have found Lowi’s (1964) typology useful. These policy types are not mutually exclusive.

Policies are viewed differently depending on your values. Health workers working within the philosophy of Primary Health Care, for example, would support redistributive policies because of their commitment to social justice. Their work might include being an advocate for a particular group of people and lobbying government to ensure that redistributive policies are considered. It is, therefore, important not only to understand how policies affect people but how they are developed.


Public policy-making is a dynamic social and political process (Milio 1988: 3), but the process has also been described as ‘messy and circuitous’ (Lin, Smith & Fawkes 2007). Public policy-making is not a smooth linear progression because it must synthesise ‘power relationships, demographic trends, institutional agendas, community ideologies [and] economic resources’ (Brown 1992: 104). Evidence-based research may also inform policy development.

There are three key groups of people involved in the policy-making process — the public, including formal interest groups, industry and professional representatives and stakeholders; political and bureaucratic policy-makers; and the mass media (Milio 1988; Lin et al 2007). Some interest groups involving themselves in the policy-making process have a great deal more power than others because of their political position and their ability to influence the views represented in the mass media.

Public comment on new and developing policies is valuable and, in health, seems to have developed as a result of two quite different phenomena. Firstly, there has been greater acknowledgement of the importance of community participation resulting from recognition of the Primary Health Care approach and the New Public Health movement, although this has been taken up to different degrees by various governments. Secondly, there has been a growing distrust of politicians to act in the community’s best interest and an increasing demand by many community members to influence decisions made by governments; controversy about environmental protection has been an example of this (Ife & Tesoriero 2006). Nevertheless, it is usually the politicians, bureaucrats and powerful interest groups who set the agenda and decide the framework and philosophy of a policy. Members of the public commenting on a document are often in the position of trying to change the policy after the framework has been set (Lin & Gibson 2003).

Several authors have described the public policy-making process using a variety of relatively similar models. Palmer & Short (2000) have described it as a five-stage model, and more recently Lin and colleagues (2007: 136–7) have presented the eight-stage process listed below and represented in Figure 4.1. It is important to note, however, that this model accounts only for policies that are formally developed, not those that develop incrementally and never reach the public agenda.

1. Issue identification and agenda setting — a public problem is recognised as a political issue and is placed on the political agenda. This often occurs in response to pressure from an interest group and interest from the media who both may play powerful roles in raising the public profile of an issue, defining it and portraying the perspectives around the issue and the potential impacts from the issue.

2. Policy analysis — relevant data and information is collected by those formulating the policy. Policy objectives are framed.

3. Policy instruments — options and proposals for solving key policy objectives are explored.

4. Consultation with stakeholders — key informants in industry and professions who may be affected by the policy and community organisations are canvassed for feedback on potential implications. Dugdale (2008 Ch 10) provides a very comprehensive discussion of the dilemmas for policy-makers in this process.

5. Coordination with relevant decision-makers — government departments at all levels (with the hope that new policies will dovetail with the approaches in other sectors).

6. Decision — a new policy is formally accepted, through either legal enactment in parliament or approval by the appropriate minister.

7. Implementation — the policy is translated in legislation and from there into programs and local strategies. The ‘product’ seen at this point may be quite different from what was imagined when the policy was first formulated. For example, its power may be eroded by the way in which it is implemented, or it may have unforeseen consequences when it is put into practice. The outcome of policies that are implemented with an inadequate budget may be quite different from that envisaged when they were originally formulated.

8. Evaluation — this can take various forms. Implementation processes can be monitored or assessed as to whether the policy has met the intended objectives. This may trigger re-commencement of the policy cycle.

Those affected by the policy concerned may be able to influence the policy-making process at any stage in its life, but this is more likely to happen during policy formation and policy evaluation. In addition, because of the cyclical nature of the stages in the public policy-making process, interested groups can be part of the process that puts issues back onto the policy agenda (Dugdale 2008). With regard to issues that have never been formally discussed as policy issues, but have developed incrementally, community members may be involved in the important process of getting them onto the public agenda and reviewed critically, perhaps for the first time.

Influencing public policies through social advocacy and lobbying are discussed in more detail later. It is important to note, however, that affecting public policy in this way is often a slow process and it may take several years of concerted effort by a number of people to change the major direction of a policy process (Fitzgerald & Sewards 2003; Lin et al 2007).

In health promotion, regulatory activities such as international laws that address issues such as pollution of the oceans, national laws such as quarantine and local laws such as garbage disposal, are developed for the ‘common good’. These healthy public policies may be as controversial as the redistributive polices, previously described. These laws invariably infringe upon the rights of individuals. Whatever the level of policy development, the same principles apply. In health promotion, the philosophy of Primary Health Care needs to underpin the policy development process to maximise the health of the population. Ideally, the need should be identified by the community and the policy developed with community and expert knowledge combined with the experience of policy-makers. This collective wisdom will make it socially acceptable to most and scientifically sound.


If the social determinants of health are to be addressed then new policies relating to a broad range of sectors in addition to health will be necessary. It is now acknowledged that health is created outside the health system and regulatory activities are those activities that involve the application of legislative and financial frameworks that create opportunities for healthy living. Policy and regulatory activities are developed at international, national and local levels and may be developed or adopted to work in concert with one another. The Declaration of Human Rights, Agenda 21, Healthy Cities, and the WHO Framework Convention on Tobacco Control are all examples of regulatory activities developed at the international level and adopted at national level and local level that aim to create supportive environments for health. Organisational development involving regulatory activities internal to an organisation can also create supportive environments and opportunities for health in smaller settings. Supportive environments are created in settings such as the workplace, schools and recreational clubs. VicHealth, for example, provides leadership and funding for organisations to create supportive environments for health. In these settings health promotion principles are integrated into the policies or service directions of the organisation. At any of these levels healthy public policy usually requires advocacy by groups to gain political commitment, social acceptance and systems or management support for the change.


Developing healthy public policies that can be adopted at all levels is obviously going to have the greatest impact on creating supporting environments for health. The successive policy development on the use of tobacco is a good example.

Australia’s tobacco strategy

The Australian government has been responsible for a mixture of regulatory activities in tobacco control over many years. For example, it has imposed an excise tax on tobacco products since 1901, although at that time, the tax would probably have been a revenue-raising activity rather than imposing an economic incentive to help create a supportive environment for health. More recently, the National Health Policy on Tobacco (Commonwealth of Australia 1991) was followed by national tobacco strategies. The most recent, the National Tobacco Strategy 2004–2009 (Commonwealth of Australia 2005), reaffirmed the WHO’s FCTC and extended the national agenda to reduce the social and physical harm of tobacco. The strategy states that jurisdictions will:

Strategies designed to achieve each of these key areas include abolishing any remaining forms of tobacco promotion, reducing the visibility of tobacco products, reducing the affordability of tobacco, eliminating exposure to environmental tobacco smoke, providing further advice to consumers about the dangers of tobacco smoking, and ‘developing a regulatory system for tobacco products’ to reduce the harm of tobacco-delivered nicotine (Commonwealth of Australia 2005: iv).

While the federal government has taken responsibility for a number of coordinated nationwide strategies, service delivery primarily rests with the states and territories. The State of Victoria, for example, has been an international leader in tobacco control programs.

From policies to strategies

The personal and social costs of tobacco consumption provide a sound rationale for policy development to reduce this consumption. If we consider the health promotion continuum again and the approaches that have been used to reduce consumption we find that the regulatory activities have included legislation to increase taxes on tobacco, ban smoking in public places, ban smokeless tobacco and ban small ‘kiddies’ packets. Policies have enabled replacement of sponsorship in sporting organisations; for example, Victoria pioneered the use of a dedicated 5% rise in tobacco tax to enable the buyout of tobacco sponsorship (Chapman & Wakefield 2001 in Baum 2008). These activities are a socio-ecological approach to health and work at the population level. Similar health promotion foundations, funded primarily from the tax on tobacco products, have been established in other Australian states.

There has also been a considerable amount of community-led action to change policy. For example, BUGA UP, the graffiti movement in Australia, revolutionised ordinary people’s understanding of the politics of tobacco control (Chapman 1996).

The policies have also enabled some innovative strategies to improve health. Many of these have used social marketing techniques, with powerful messages displaying health warnings in large print on cigarette packets, and advertisements in various media with images such as measuring and displaying the tar and nicotine content of cigarettes, and graphic images depicting the risks associated with tobacco use, such as gangrenous toes and a diseased lung (Chapman & Wakefield 2001 in Baum 2008). These broader policy initiatives target individuals to change their behaviour.

The development of healthy public policy for any issue at a broad social level, at local/community level, and within organisations will create a supportive environment for health. The development of the policy may be ‘bottom-up’ or ‘top-down’ depending on the level and processes of development. Influencing the policy may be done at any stage in its development (as set out in Figure 4.1).


Although healthy public policy developed at the international and national levels has a great influence on the way our daily lives are structured, a remarkably large number of policy decisions that shape our environment are taken at the local level, particularly through local government. Responsibility for such issues as land use, urban development, placement of industry, housing standards, availability of recreational areas and location of shopping areas is all exercised at the local level. Local government, therefore, is quite a powerful influence on our environments. The health impact of public policy at the local level can be profound.

Policy development at the local level lends itself to the settings approach to health promotion.

The setting is typically a school, workplace or community. Clearly, this is different to a population approach or issue approach to health promotion. The advantages of the settings approach from a health worker’s point of view is that it is seen as manageable in scale.

There have been criticisms of this approach to health promotion. Some have argued that settings are relatively amenable to professional efforts at promoting health but that these efforts are often limited to behaviour change programs or programs where the underlying problems contributing to ill health are not addressed (Wenzel 1997 in Poland, Green & Rootman 2000). For example, management of a workplace may sanction stress management programs for workers without looking at the underlying cause of the stress of workers.

Healthy Cities project

There are many examples of healthy public policy being developed at the international level that have influenced policy development at the local level. The Healthy Cities project is one example well known to health promotion workers. It is an obvious example of the settings approach to health promotion.

The aim of the WHO Healthy Cities project is to promote healthy public policies and comprehensive local strategies to enhance health and sustainable development. The WHO project was launched in Europe in 1988 with 11 committed cities. There are now more than 1200 cities and towns in more than 30 countries which have adopted this policy approach to creating supportive environments at the local level. While each Healthy Cities project will necessarily differ according to the cultural norms, needs and characteristics of the locality, all share characteristics of:

There is a special emphasis on addressing the social and environmental determinants of health, health inequalities and urban poverty, and the needs of vulnerable groups (WHO 2008f).

Successful implementation of this approach requires explicit political commitment, leadership and institutional change, and innovative actions addressing all aspects of health and living conditions (WHO 2004). Healthy Cities projects have been adapted by some cities in Australia. Noarlunga Healthy Cities in South Australia is one example which provides insights into the sustainability of a Healthy Cities project. This project began in 1987 as a national pilot project. Among its many achievements are the clean up of a river, a community injury prevention project and a community forum taking action against drugs. Evaluations of the project conducted over a period of 16 years demonstrate the requirements that sustain a community-based health promotion initiative. The main factors that account for the sustainability of the project are:

International policy priorities change as a result of new evidence and emerging challenges. The latest phase of the Healthy Cities project has three core themes: healthy ageing; healthy urban planning; and health impact assessment. In addition, all participating cities focus on the topic of physical activity and active living. The Walk Bendigo plan is a good example of city planning to improve active living, even though this city is not part of the WHO Healthy Cities project.

INSIGHT 4.1 Walk Bendigo — a pedestrian-focused city centre

Pedestrian friendly city streets alive with activity create a vibrant safe urban centre. Bendigo, in central Victoria, is implementing a new street model that will encourage people to get out of their cars and spend more time on their feet. Like many major population centres, the central business district of Bendigo is currently an ‘invaded city’1 with vehicle traffic dominating the public realm. The Walk Bendigo program will create ‘shared spaces’ that will provide better city amenity and safer streets for all.

Streets that provide a high quality pedestrian environment have been demonstrated to be associated with many positive health and community outcomes. In high quality pedestrian environments, more people walk,2 rents and land prices are higher3 and with more pedestrians retailers can capture additional trade. With more people walking, the negative health effects associated with a sedentary lifestyle are minimised4 and there are greater opportunities for social interaction and community connectedness. ‘Walking is a special mode of transport; it not only gets you from A to B, but it also helps cut crime, build a strong community and keep you fit.’5

There has been a strong strategic aim to improve pedestrian amenity in the City. A suite of development strategies and community plans and the recognition of Bendigo by UNESCO as Australia’s first Child Friendly City6 all indicate the community’s desire to have a safe, pedestrian focused city centre. High level policy initiatives identify issues and problems that are, in part, created by a car dominated city. Walk Bendigo is an urban design response intended to address the perceived lack of quality in the pedestrian environment.

The integrated planning undertaken by the City recognises that an accessible place is a successful place, and that that accessibility is primarily related to vehicular traffic, as public transport, cycling and walking are options used by only a small percentage of CBD users. The CBD Plan recommended that the Bendigo CBD be viewed as a unique place that requires special attention be given to pedestrians, cyclists and other vulnerable parties such as children and the aged.7

The intent of Walk Bendigo and the introduction of ‘shared space’ is to increase the levels of alertness and responsiveness of street users to their surroundings and in so doing make users safer. By increasing the level of ambiguity at intersections and streets, the psychology of street users can be modified to provide a safer and more amenable city. All built elements that give priority of any one form of transport over another are removed (traffic and pedestrian lights, zebra crossings, line marking etc). While this approach may seem counter intuitive in order to improve safety, it has been shown to be effective in reducing accidents and improving streetscapes.8 When things seem more dangerous and perceived risk is increased, individuals take greater care resulting in less actual risk.9 By encouraging unpredictability and creating uncertainty in the minds of all road users, vigilance and care are improved, resulting in safer streets and the potential for a higher quality pedestrian and cyclist environment.

One of the key features behind Walk Bendigo is the reduction in vehicle speeds. It has been shown that at speeds of approx 20 km/h10 in shared space, the incidence and severity of accidents is markedly reduced. 11 At low speeds, bicycles and vehicles can integrate and pedestrians can make eye contact with drivers. This creates a traffic mode of ‘passage by negotiation’ rather than a ‘right of way’. Pedestrians and cyclists are then equal in the road use hierarchy. While vehicles are travelling slowly but constantly, and not stopping and starting, time taken to traverse any given path through a city with this treatment is not necessarily affected.12

The scope of Walk Bendigo includes most of Bendigo’s CBD. While the full extent of the constructed works is yet to be determined, the adoption of this approach for a whole city centre and retail precinct is unprecedented anywhere in the world.13 The works commenced in 2007 and it is anticipated to continue for at least 5 years.

Walk Bendigo aims to create a continuous pedestrian network14 through the City rather than a vehicular network. A new form of intersection will have pedestrians and vehicles together on ‘raised table’ shared surfaces. Instead of pedestrians crossing the road surface, vehicle drivers will cross an extended footpath. The intersections will be treated as a quality pedestrian space with surfacing and fittings designed to match the existing palette of the City’s urban materials. The design of intersections and streets and the design of footpaths become integrated so as to maintain a consistent horizontal and vertical alignments for the pedestrian while the vehicles rise up to footpath level in order to cross the now pedestrian dominated space. The higher urban amenity and reduced speeds will create safer pedestrian spaces and encourage more pedestrian activity.

The scale and cost of this program, and the fact that it is the first of its type in Australia, has ensured that there is a significant level of professional interest. The City has received awards from the Planning Institute of Australia ‘Planning for Health and Wellbeing (2007)’. An evaluation program has been established that includes the collection of baselines data sets for volume and direction counts for vehicles, bicycles and pedestrians. These data collection processes will be repeated in a given time frame, and the results compared. The analysis of these results will inform the City and all the stakeholders as to success of the project. The City has commissioned the Monash University Accident Research Centre (MUARC) to assist in a project evaluation.

The Walk Bendigo program is an exciting and unique approach to urban design in the public realm. It is intended to deliver a sustainable model for safe, pedestrian friendly city streets. With the expected increase in pedestrian numbers, reduction in traffic accidents and the improvements in public infrastructure, this is a model that will show an alternative way forward for traffic and pedestrian planning. The model can be used by other regional cities and urban communities to bring a change into the new century in urban design and traffic planning.

Tim Buykx (Coordinator, Landscape and Open Space Planning, City of Greater Bendigo)Note: References for the article in Insight 4.1 are available on the Elsevier EVOLVE website.

Municipal Public Health Planning

The Municipal Public Health Planning Framework in Victoria, Australia, is an excellent example of healthy public policy development. Environments for Health: Promoting Health and Wellbeing Through Built, Social, Economic and Natural Environments (State Government of Victoria 2001a) is an initiative of the State Government of Victoria that is consistent with the legislative planning requirement of the Victorian Health Act (1958) and the Local Government Act 1989 in that state. The framework was developed in partnership with the Public Health Division of the Department of Human Services, the Municipal Association of Victoria, Victorian Local Governance Association, local governments and community groups. It is a strategy for public health planning that aims to systematically address ‘individual, organisational, community, social, political, economic and other environmental factors affecting health and wellbeing’ (State Government of Victoria 2001b). The legislation that underpins this strategy ensures that Municipal Public Health Plans (MPHP) are reviewed annually and prepared every three years. Most local governments are using the Environments for Health framework to develop their plans (see Box 4.1). Application of the framework to local issues and actions means that MPHPs are very diverse across the state.

BOX 4.1 Environments for health: promoting health and wellbeing through health planning concepts

The MPHP framework uses the strengths of a number of approaches to public health planning including:

Strategic local area planning A strategic and integrated approach to municipal public health planning promotes a model for integrating physical, social and economic planning, with community participation.

Social model of health Participation, sense of community and empowerment are interdependent social factors contributing to individual and community wellbeing.

Health-promoting systems A strong relationship exists between people and place: people’s health and wellbeing reflects their socioeconomic status, and accordingly, where they live. Different locations afford varying degrees of access to healthy environments, food, services, amenities, health information, education, employment, housing and opportunities to experience a sense of community and sense of place. A holistic approach ensures that the interrelationships between all major issues impacting on individuals and families within the context of their local communities are taken into account (see Appendix 2).

Focusing on health outcomes Utilising information from the Victorian Burden of Disease Study (Victorian Health Information Surveillance System [VHISS] 2001) and other sources can identify issues and areas for consideration when planning health priorities.

Participation and partnership approaches People increasingly share in planning and decision-making and are empowered to affect the outcome of the process. Clients, community groups, government departments and other agencies need to participate in health planning, not only to ensure a match between local needs and priorities, but because participation itself promotes health. Clients/consumers and the wider community need to participate meaningfully to ensure appropriateness, community ownership of processes, programs and outcomes, and the promotion of accountability to the community for decisions on priorities and resource allocation.

Apr 17, 2017 | Posted by in NURSING | Comments Off on Healthy public policy, settings and supportive environments
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