From little things, big things grow: health’s local champions
If health promoters ruled the world, they’d start at a local level and drive change from there says Professor Evelyne de Leeuw, a long-time advocate for the development of healthy cities.
Upending the existing policy paradigms may be the first step towards creating the healthy communities of tomorrow. In place of the old ‘trickle down’ model for health policy, academic and consultant Professor Evelyne de Leeuw argues for a ‘trickle-up’ approach, with community members and local governments driving the agenda from the grassroots.
Professor de Leeuw is a former director for the World Health Organization Collaborating Centre for Research on Healthy Cities and now the director of the Centre for Health Equity Training Research and Evaluation (CHETRE) at the University of New South Wales and South Western Sydney Local Health District. She contends that those most immediately impacted by health policy decisions and their local government representatives should become key influencers either inspired, empowered or facilitated to take action.
This ‘glocal’ approach aligns with the idea of ‘Healthy Public Policy’, first identified in the Ottawa Charter for Health Promotion of 1986 and more recently articulated by the World Health Organization (WHO) as the Health in All Policies (HiAP) framework. The principle at play is that health should be a consideration in government policymaking across all sectors, from transport to agriculture, housing and education, and more.
Think global, act local
It may seem idealistic but a global ‘power to the people’ approach for health promotion and policymaking, where change percolates up from the grassroots, works in practice, says de Leeuw. ‘It happens on a daily basis.’
As individuals, we often feel powerless and think it’s up to national governments to do something – but we have influence through local members, and that’s where action can begin.
Change can begin at a very local, very personal level. The example of the Opzoomeren movement in Rotterdam is one de Leeuw likes to cite. Since it began on Opzoomeren Street in 1992, the movement has seen more than 1700 streets self-organise to improve their streetscape and establish their culture, formalised in agreements that include points like ‘we welcome new neighbours’ and ‘we care for the front of our houses’.
An example with a political dimension was provided in 2017 when US President Donald Trump shocked the world by renouncing the US commitment to the Paris Accord for Climate Change, glocal action took over. Within days numerous US cities and states had committed to lower emissions and carbon neutrality.
‘As individuals, we often feel powerless and think it’s up to national governments to do something – but we have influence through local members, and that’s where action can begin.’
Traction for glocal thinking continues to grow. In early 2018, the WHO European Regional Office convened a strategic session with local government leaders where hundreds of mayors committed ‘to improve the health and wellbeing of all who live, love, learn, work and play in our cities’. The eight pillars of their Copenhagen Consensus outline how healthy cities can lead by example with activities based on equity and inclusion in social, physical and cultural environments and the participation of all individuals and communities in decision-making towards the 2030 Sustainable Development Goals agenda.
Victoria is already part-way there due to a state policy – The Public Health and Wellbeing Act – that requires local government to establish Municipal Public Health and Wellbeing Plans. Policy implementation is supported by a range of tools including the ‘Environments for Health’ Municipal Public Health Planning Framework which was launched in 2001. ‘Victorian councils are facilitated to do something that might trickle up,’ says de Leeuw. The framework has been adopted across a range of other areas including early learning, neighbourhood renewal and emergency management.
Local is the level of government and governance where things happen, according to de Leeuw, but bringing on glocal action and its potential for trickle-up policy requires a pervasive shift in mindset, both in the community and in government.
Don’t mention the ‘h’ word
For many people, the word health is commonly construed to mean ‘health care’ or even ‘disease’, while health promotion is often taken to mean ‘behaviour change’ or ‘disease prevention’. The current language and framing around the word health is too simplistic, argues de Leeuw.
‘Health in All Policies (HiAP) starts with equity, opportunity, engagement, network, solidarity, community, sustainability, resilience,’ she says. ‘It starts with everything ‘health’ without mentioning the word.’
Indeed, it kicks off at an individual level with ‘investing in health by being a positive person, feeling good, connecting with neighbours, sharing ideas with friends, reading a nice book,’ she asserts. All have flow-through and potential for trickle-up influence.
Evidence for this comes from a 2002 study. When participants were asked ‘What determines your health?’ they provided standard answers such as healthy food, alcohol in moderation, quitting smoking. ‘These are lifestyle issues, not upstream drivers of health and health equity, the social determinants of health such as poverty, being in work, public transportation, the quality of your environment,’ says de Leeuw.
However, when the researchers reframed the question to ask, ‘Who determines your health?’, different answers came back: school teachers, the housing authority, my boss, the supermarket.
‘Health is created in the street, in the community where you live, in schools, in shopping centres. People do recognise the social determinants of health, and that HiAP and what happens at the systems level is important, but prompting them to think about it requires sophistication in the language,’ explains de Leeuw.
Policy transfer in action
Galvanising action for the trickle-up approach demands fresh thinking. At CHETRE, where de Leeuw is based, locational disadvantage is in focus. The centre is working with the people of Miller in western Sydney, one of the state’s most socially disadvantaged areas, where lower education levels, greater unemployment, poor housing conditions and lower health outcomes prevail. ‘Miller has more fast food restaurants and bottle shops. People have a hard time making healthy choices,’ observes de Leeuw.
Rather than tackling Miller’s issues top down by writing a policy brief for the chief executive of the local health district, CHETRE has opted for place-based interventions, working with the people of Miller to assist them to fight an influx of poker machines and a proposed 24/7 liquor licence.
Trickle-up is happening. Since its first forum on alcohol-related harm in the community in 2013, lockout laws have been introduced in some areas of NSW, and Miller residents have successfully fought a battle with a hotelier wishing to establish a late-night hotel and gaming venue in the nearby suburb of Casula. People power was organised in various forms, from street corner meetings, door knocks and rallies to letters and petitions to raise awareness and action.
‘In other areas, we’re helping people organise against climate change due to its health impacts,’ says de Leeuw, who mentions as an example the poor design leading to urban heat islands and its effect on health, especially during summer. ‘It’s getting warmer and [yet] we’re building … in concrete and surfaces that warm the environment tremendously. Parts of Penrith are 60 degrees at “nose” level during the day.’
Scale up and scale wide
The intention behind these endeavours is to drive policy in other suburbs and towns, by using the experience gained in Miller, Casula and elsewhere to adopt similar strategies suited to local circumstances in other parts of the country. Professor de Leeuw refers to it as ‘scaling up and scaling wide’.
‘Scaling wide is talking to your neighbours about seemingly tiny initiatives like play streets, community gardens, street parties, a food system that works, or a protest against poker machines or a 24/7 liquor licence, and saying, ‘This is a good plan, why don’t you do this too?’.
‘You need to document these actions and spread them horizontally so more people in more neighbourhoods see what happens and do that. It’s not about control or formal checklists and policies, it’s a mindset that needs to pervade the attitudes and beliefs of everyone with a good heart who believes in values for health.
‘Trickle-up comes from scaling up, moving from the local government level to state/territory level and the federal level, as you accumulate the evidence.’
Using the feelgood factor
How can policymakers encourage local authorities to lead by example? Popular thinking is that HiAP must be shown to be economically advantageous. For example, a policy of restricting fast food restaurants and providing healthy food options could reduce the number of hospital admissions and healthcare costs, notes de Leeuw.
‘Our research suggests economic benefits are part of a jigsaw puzzle that local governments need, but they are not enough. More important than dollar value is a moral community engagement, values like equity, participation, empowerment, resilience – all the feelgood stuff,’ says de Leeuw. ‘Feelgood stuff mobilises communities. It’s what makes communities tick, and clever local governments resonate with those values. By showing leadership in that, they get followership. People say, ‘This is inspirational stuff, I’m ready to go with you’.’
‘We found richer inner-city councils have a far easier time doing that than poorer councils or regional governments. In relatively poor councils, the person who looks after health policy also has a portfolio in sports and parks recreation and public lighting … They are dealing in crises during the week and on Friday afternoon they say, ‘Let’s start to think about health’. It is a relatively peripheral issue. We found we needed to continue to support workers in local councils – the bureaucrats – to think about wider perspectives in health.’
It’s not a matter of giving a training course once, but constantly monitoring whether people have the capacity and capability to think about health in a wider way.
‘If I had my way – if health promoters did rule the world – I would mandate that people responsible for municipal public health planning are given a day’s refresher course every year on the broader public determinants of health and the conditions for shaping HiAP. It should be part of performance management and written into KPIs (key performance indicators),’ de Leeuw insists. ‘Send them back annually to keep up the momentum.’