8 Municipal public health planning policy in Victoria

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.

Impact of Environments for Health

The 2006 CHASE evaluation, which inspected MPHPs and consulted stakeholders across Victoria, showed that Environments for Health has helped to contribute to: an increased understanding within local government that ‘health’ goes beyond health service delivery; increased awareness of the multiple determinants of health; and consequently, recognition of the importance of incorporating health planning into whole-of-council planning, and intersectorally, across council departments. ‘In its first five years, “Environments for Health” has raised awareness, allowed the trial of existing tools and resources, and generated considerable momentum for further change’ (CHASE 2006 p ii).

Much work remains to be done in terms of ensuring greater reach of the framework and sustained uptake of its principles across all councils and sectors. For example, there is still wide variability of capability and capacity in general for planning, monitoring and evaluation within councils. Indeed, CHASE (2006) offered 26 recommendations for improving the content of Environments for Health, and improving uptake of the framework in general through improved workforce development, and other enhanced resourcing and coordination by DHS.

While much remains to be done, the CHASE (2006) evaluation suggested that Environments for Health has been at the forefront of helping to promote a paradigm shift in the way that planners and policy makers consider the relationship between health, quality of life, environmental and social determinants of health, and the interrelated nature of much planning activity and policy development. It must be stressed, however, that this qualified success of Environments for Health was certainly not assured when the LGPT embarked on its strategic planning in 2000.

The next section will outline the problems – external and internal – faced by the team in attempting to develop and implement the framework. These include diminished capacity and morale across the local and state government sectors, and an authorising environment comprising multiple layers of management.

Problems faced when developing Environments for Health

In 2000, morale across the state and local government public sectors was extremely low. During the 6-year era of ‘small government’ and corporatist ideology, many senior government staff – who had held their departmental corporate histories – had left, been replaced, or had their positions abolished. As mentioned earlier, the local government sector had also been affected by state government ideology that had viewed local governments primarily as providers of services rather than as a discrete layer of government. Local councils’ capacity to engage substantively in MPHP had been diminished by the loss of staff, often with only skeleton staff remaining to ensure compliance with state legislation. In the case of MPHP, many councils were conducting perfunctory MPHP through their environmental health officers, who were employed primarily to conduct environmental health audits, as required through legislation. Many did not have the expertise or time to conduct substantive MPHP, with the result that many MPHPs had been hastily conducted (if at all), with minimal resources or commitment to implement or evaluate them.

At the start of 2000, relations between state and local government were tense. Furthermore, diminished levels of trust existed between local governments and other community agencies, which had been competing for funds to deliver services under the Compulsory Competitive Tendering legislation. The LGPT thus needed to take these issues into consideration when embarking on a strategy to build trustful relations and engage the meaningful participation of stakeholders. Yet the LGPT also had to take into consideration their own immediate work environment when devising their approach.

Given the time-sensitive nature of both community building and policy development, the LGPT frequently needed to act swiftly to capitalise on serendipitous connections and ‘small wins’ (Weick 1984). Yet within the DHS, the LGPT often had to contend with a highly bureaucratic, risk-averse organisational setting, with multiple layers of management ensuring regular decision-making bottlenecks. The department’s frugal organisational culture was further affected by a public perception – often espoused by talk-back radio journalists – that the health budget should be used to free up hospital beds rather than be spent on department employees. Ideological trends within the Public Health Division tended to oscillate between the social model of health, and the more traditional, medical model of health, whose proponents often held the balance of power. Power dynamics within DHS tended to reflect the convergent and often disparate public views about what should be the core business of public health: should it concentrate on managing disease outbreaks and ensuring access to sick care services, or on promoting healthier, more active, resilient, empowered communities?

Management turnover within the Public Health Division meant that the chain of command immediately above the LGPT was in a frequent state of flux. This often resulted in inconsistency in terms of decision making. However, as will be described below, it also often allowed the LGPT opportunities to make creative use of decision-making ‘holes’ resulting from vacant positions.

Factors affecting the success of Environments for Health

A number of key factors helped to ensure the successful development, endorsement and implementation of Environments for Health. These ranged from ministerial support, key internal and external allies, a strong LGPT, and, not least, to serendipity.

Ministerial support

The Minister for Health at the time was also the Minister for Planning. Received wisdom, filtered down through the network of ministerial advisors and support staff connected to the Director of Public Health and acknowledged by the Reference Committee, was that the Minister understood and supported the better integration of the health and planning portfolios. This level of endorsement thus provided symbolic and political support for the development of Environments for Health.

Strong reference committee

Forming an intersectoral reference committee early in the development of the framework was integral to the success of the project. In an effort to build trust and ensure shared governance, the steering committee was co-chaired by senior personnel from the DHS and the MAV. This committee, comprising representatives from health policy and health promotion across state and local government and non-government organisations (NGOs), lent the policy framework theoretical and practical relevance and endorsement. The intersectoral steering committee served to create a sense of collective ownership of the process, and encouraged a commitment amongst council senior management, councillors and practitioners to use the framework.

Importantly, the steering committee offered the LGPT a strong external and internal coalition of support. The LGPT was able to draw on the support of steering committee members, both individually and collectively, to support the inclusion of concepts and content (such as participatory planning) which, given the prevailing historical sensitivity, otherwise might not have survived internal vetting within the DHS. In addition, the steering committee endorsed: the consultation process, which encouraged a heightened level of community engagement and collaboration by the DHS; the innovative layout of the document, which did not conform closely to DHS guidelines; and the implementation strategy, which clearly promoted cultural change, collaborative enquiry and intersectoral partnerships.

Key champion – Director of Public Health

A key internal ally was the then Director of Public Health, who had developed a vision for the division that anchored activity within the social model of health. As such, the tenets of Environments for Health, and the manner in which it was being developed, provided the division with a strong working example of how policy might be developed that embedded these principles in practice. The Director had direct access to the secretary of the DHS and also the Minister for Health; as such, the LGPT had a conduit to senior endorsement of their approach. However, the LGPT were separated from the Director of Public Health by two layers of bureaucracy; this meant that in order for the Director to endorse their work, the team first had to ensure the sequential endorsement of two levels of middle management, whose officers, working within their own constraints and agendas, brought their own levels of understanding and support. As a result, many decisions were delayed through the bureaucratic process of memo writing, endorsement and communication up and down the line of command. More than once, one layer of management was left vacant, or was filled by another manager in an acting role. These gaps, or changes in personnel, occasionally provided the LGPT with organisational ‘holes’, or opportunities to have key decisions made more swiftly, and/or gain closer access to the Director of Public Health.

Decisions frequently were further impacted by shifts in the political landscape wrought by events in parliament, and the occasional need to change immediate work priorities as a result of ministerial requests for information or action on other areas. The LGPT thus needed an approach that was dynamic and resilient, and could maintain a momentum for policy development – and community building – within a complex and occasionally contradictory authorising environment.

Strategic and entrepreneurial Local Government Partnerships Team

In its initial composition, members of the LGPT brought a unique combination of multidisciplinary perspectives that did much to ensure the success of Environments for Health. Through the serendipitous employment of three people with diverse skills and experience, for 2 years the LGPT enjoyed a combination of: research skills; communication skills; multidisciplinary experience in community development, environmental health, local government politics and governance, health promotion, community psychology, planning, urban sociology, and organisational development; knowledge of several decades of history of Victorian politics and health policy, both local and state; direct personal experience in enshrining MPHP in the Health Act, and responsibility for carriage of MPHP since its inception. Through a strong theoretical grounding, team members worked consistently to model the principles of community engagement outlined in the framework. As a result of members’ combined awareness of history and political experience, and a strong team culture of peer support, mentoring and shared leadership, the LGPT operated with some degree of sophistication in terms of political acumen and tactics.

With a clearly articulated mission statement, statement of values and 3-year strategic plan for development and implementation of Environments for Health, LGPT members were able to maintain sight of their goals, build a constituency of external support across the state, and argue strongly for endorsement of decisions that might have been more difficult in the absence of supporting documentation. Through the tactical prowess of their most experienced member (an urban geographer and social planner who had been mayor of a local council, managed a community health centre and shepherded the passage of MPHP legislation), the team made good use of ‘windows of opportunity’ afforded by the organisational ‘holes’ mentioned above, and the chance to provide the director with impromptu briefings at external meetings, at the water cooler, and in the elevator. The team understood the importance of serendipity, and the need to act swiftly to capitalise on fortuitous events. In this way, the LGPT acted as social entrepreneurs to offer catalytic leadership to the sector.

In working to bring about systems change, frequently across often divergent sectors and political boundaries, the team worked as social entrepreneurs. Our approach was to ‘analyse, to envision, to communicate, to empathise, to enthuse, to advocate, to mediate, to enable, and to empower’ (Catford 1997 p 3). The LGPT worked to translate the social paradigm of health into concepts and approaches that could be embraced by stakeholders from various backgrounds and disciplines, including those within the DHS. The LGPT attempted to see things holistically, to be proactive, to be reflective, and make use of opportunities to help broker the political relationships needed to ensure the effective carriage of Environments for Health. The team worked as ‘boundary spanners’ – navigating the strong and weak connections in the network of information and influence, making use of the ambiguities and windows of opportunity that exist within and between organisations (Duhl 2000). As social entrepreneurs, the LGPT members acted as agents of social change within the health system by being mindful of, and attempting to address, issues of power, social structure, and social processes (Bunton 1992). As Catford noted: ‘Social entrepreneurs are vital for health promotion – but they need supportive environments too’ (1998 p 95). It was essential that the LGPT form an independent, broad-based coalition of support that could convince key stakeholders of the benefits of collaborating on Environments for Health and become its champions. Support also came from seasoned mentors within and outside the DHS, and from the peer support shared amongst LGPT members.

Strategic leadership plays a significant role in promoting collaborative health promotion across sectors (Catford 1997). In acting as social entrepreneurs, the LGPT embraced a form of ‘catalytic leadership’ to ensure broad-based support for, and input into, Environments for Health (Duhl & Sanchez 1999). Drawing on Duhl and Sanchez’ catalytic leadership framework, the LGPT worked to: focus attention on the social determinants of health by elevating the issue to the public and policy agendas; engage people in the effort to address MPHP by convening the diverse set of individuals, agencies, and interests needed to build a critical mass of support for a new approach; provide enabling mechanisms for MPHP to be developed and evaluated. The LGPT also sought to break down vertical (bureaucratic) structures and barriers and obtaining better horizontal integration (across sectors) for working together; stimulate multiple strategies and options for implementation; enhance relevant, innovative knowledge development and research; encourage improved data collection; sustain action and maintain momentum by offering effective communication and providing rapid feedback.

FUTURE DIRECTIONS FOR POLICY DEVELOPMENT

The CHASE evaluation study (CHASE 2006) offers some 26 recommendations for extending the reach and scope of Environments for Health and its implementation. The evaluation identified that a revised edition of Environments for Health is needed to incorporate new developments in the field, to address shortcomings, and encourage local governments to employ a more sophisticated application of the social model of health. To this end, revised and updated tools, templates and resources are needed in the framework document. The evaluation team also identified that to make any improvements sustainable, the whole-of-government approach espoused in Environments for Health needs to be modelled and demonstrated at the state level. For example, the local government planning roles in the DHS and other state government departments need to be better coordinated and integrated. The DHS needs to allocate additional resources to sustain and build capacity within the local government sector. Furthermore, the evaluation supported existing state government initiatives to map and review the diverse range of local government planning requirements in terms of governance, decision making, organisational collaboration, capacity development, legal context, and resourcing. Finally, the evaluation study recommended improved resourcing and visibility of the LGPT within DHS, such as elevating its role to a position of higher prominence within the department. (This recommendation comes at a time when the high-profile LGPT has effectively been disbanded within the Public Health Group, and its functions performed by a more generic unit.)

CONCLUSION

Whether DHS will reinstate the discrete identity of the LGPT to implement CHASE’s (2006) recommendations – and which of the recommendations it will implement – remains to be seen. Certainly, the 2006 evaluation – and the writer’s own subjective experience as an LGPT team member – suggests that the LGPT achieved a notable degree of trustful engagement with, and reach into, the many sectors and stakeholders of MPHP. The tasks that CHASE (2006) identified for the next generation of the Environments for Health policy framework suggest that an entrepreneurial, catalytic approach will be needed at least as much as during its initial development phase. To this end, those charged with the implementation of phase two also will need access to a range of skills, qualities and resources, including:

• a broad theoretical understanding of the policy development process, and appreciation of its complexity
• a clear strategic plan for phase two, including development, implementation and evaluation, and anchored in a strong mission statement and strategic plan for the team
• a sound understanding of the history of Environments for Health
• understanding of the complex political environment in which phase two of Environments for Health is being developed – drivers in federal, state and local government; the private and community sectors; international trends and public opinion
• a realistic appraisal of the culture and history of the organisation charged with the development of this policy
• access to networks of support, both externally, across government portfolios and sectors, and within the organisation
• a commitment to building community and an alliance of support, both within the organisation and between organisations and sectors
• patience and a long-term strategic view
• ways of measuring and documenting policy development efforts and ‘small wins’, including the networks that are established
• a keen, tactical eye for the opportunities afforded by serendipity
• mentors, both within the organisation and outside it, to help anchor the work historically, to make sense of the authorising environment, and to make sound tactical decisions to ensure the revised framework’s relevance and successful implementation.

These are not peculiar to Environments for Health but to anyone charged with developing and implementing innovative, empowering, intersectoral health policy.

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