- Email: [email protected]
Housing, health and master planning: rules of engagement
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 3 5 4 e3 5 9
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Housing, health and master planning: rules of engagement P. Harris a,*, F. Haigh a, M. Thornell b, L. Molloy c, P. Sainsbury b a Centre for Health Equity Training, Research and Evaluation, Part of the Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW 2052, Australia b Population Health, South Western Sydney & Sydney Local Health Districts, Sydney, Australia c Faculty of the Built Environment, University of New South Wales, Australia
article info
abstract
Article history:
Objectives: Knowledge about health focussed policy collaboration to date has been either
Received 28 June 2013
tactical or technical. This article focusses on both technical and tactical issues to describe the
Received in revised form
experience of cross-sectoral collaboration between health and housing stakeholders across
14 January 2014
the life of a housing master plan, including but not limited to a health impact assessment (HIA).
Accepted 14 January 2014
Study design: A single explanatory case study of collaboration on a master plan to regen-
Available online 20 March 2014
erate a deprived housing estate in Western Sydney was developed to explain why and how the collaboration worked or did not work.
Keywords:
Methods: Data collection included stakeholder interviews, document review, and reflections
Intersectoral collaboration
by the health team. Following a realist approach, data was analysed against established
Public health
public policy theory dimensions.
Health impact assessment
Results: Tactically we did not know what we were doing. Despite our technical knowledge
Housing master plan
and skills with health focussed processes, particularly HIA, we failed to appreciate com-
Public policy
plexities inherent in master planning. This limited our ability to provide information at the right points. Eventually however the HIA did provide substantive connections between the master plan and health. We use our analysis to develop technical and tactical rules of engagement for future cross-sectoral collaboration. Conclusions: This case study from the field provides insight for future health focussed policy collaboration. We demonstrate the technical and tactical requirements for future intersectoral policy and planning collaborations, including HIAs, with the housing sector on master planning. The experience also suggested how HIAs can be conducted flexibly alongside policy development rather than at a specific point after a policy is drafted. ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Interest in collaborating with other sectors has a long history within the health sector.1e6 Supporting knowledge to date has
been either tactical or technical. The tactical focus is on the strategic conditions and processes which allow for collaborative ‘healthy’ public policy.3e5,7 The technical focus is on the information requirements to enable policy options to be ‘healthy’.5,8 Health impact assessment (HIA) is increasingly
* Corresponding author. Tel.: þ61 296120779; fax: þ61 296120762. E-mail address: [email protected] (P. Harris). 0033-3506/$ e see front matter ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2014.01.006
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 3 5 4 e3 5 9
presented, focussing mostly on technical issues, to facilitate policy level collaboration.8e11 HIAs are often conducted on plans related to land-use12,13 as in the case reported here. Recent evaluations of HIAs have shown that an important outcome is building partnerships between the sectors involved.14 HIA is however just one mechanism for public policy collaboration and other activities are required.3,7,15 Few examples have been provided in the peer reviewed literature of policy collaborations which include but are not limited to HIA and where the analysis is explicitly tactical and technical.31 Since 2008 in South Western Sydney, New South Wales, Australia ‘The Health and Housing Partnership’ has been a collaboration between a local health department, a university centre, and the local department of housing. One goal of the partnership is to build capacity to collaboratively engage in how the Housing Department plans for the renewal and regeneration of public housing estates. In 2011 the partnership identified an opportunity which arose, to collaborate on a Master Plan for a housing estate in South Western Sydney. The three partners agreed that the Master Planning process provided an important opportunity to understand requirements for health to engage across a planning process, including using HIA. Specifically four preliminary objectives were identified: 1. influence the Master Plan to take health impacts into consideration; 2. identify capacity building issues and opportunities; 3. learn each other’s systems and language concerning Master Planning and potential health input into this; and 4. understand which processes are most useful concerning health input and whether that input was influential or not and why.
355
being addressed e and ‘procedural’ e to do with the procedures involved in adopting a policy option.5,20,21 Units of analysis are ideas (the content of what goes into policy), institutions (systems and structures which produce rules, procedures and mandates) and actors (roles, values, and relationships).20
Results Results are presented against each aspect of policy making, with the exception of ideas which are embedded throughout the analysis. We develop rules for engagement for each aspect, supported by our findings.
Substantive influence Substantive influence concerns the problems that the Master Plan sets out to address (which included renewing ageing substandard housing stock, bringing in private ownership while retaining stock, and underutilization of green space and other community assets) and how health can provide information to these. Overall, we did not achieve substantive influence on the Master Plan itself. Notably the HIA however did eventually, as a stand-alone document,22 provide substantive connections between proposed Master Plan activities (e.g. housing quality, access and quality of green space, and services) and health.
Rule At the outset of the collaboration, review early documentation and discuss with stakeholders to develop a clear understanding of the various substantive issues, problems and drivers that a Master Plan addresses.
Findings supporting the rule
Methods A single explanatory case study design16 was adopted by us as the health stakeholders involved in the collaboration. Data included meeting documentation, reporting, written correspondence, our reflections, and six interviews (independently conducted by LM) with stakeholders including us (representatives from housing, health, and the consultant responsible for the urban design plan). Ethical approval was granted by UNSW Human Research Ethics Committee (HREC 125025). The data analysis and reporting was led by PH with support from FH, MT, and PS. To encourage external validity16 we provided a draft report to the housing stakeholders involved. The only requested change was to clarify the context of the Master Plan. We took a realist approach to data analysis, incorporating insights from public policy theories to add explanatory depth17,18 and identify areas where future activity and change could occur.19 The analysis is drawn around a framework provided by Howlett et al.20 who explain public policy as developed across stages and within institutions. We have recently used this framework to analyse the experiences of HIA practitioners.31 This framework differentiates two aspects of policy making: ‘substantive’ e innate to the nature of the problem
As we proceeded all the partners in the collaboration, including us, were keen for health information and evidence to support the options and what one housing stakeholder described as ‘the story of the Master Plan’. At the outset we understood some but not all of the substantive policy drivers for the Master Plan. We initially focussed on process rather than substantive content. Also, despite entering into the collaboration through the health and housing partnership not all the stakeholders with responsibility for driving the Master Plan had attended the partnership or were known to us. Nor was health linked to the Master Plan in the early documentation driving the process. Therefore despite ‘health’ being the reason for our engagement, the perceived substantive value of health was not clear for the housing stakeholders developing the plan. For us, many of the substantive issues driving the Master Plan were connected to health, although we failed to make a technical assessment of these connections to the evidence until the HIA (which, as will be discussed, came too late to influence the Master Plan document).
Rule Become involved in planning rather than waiting to assess plans. Focus attention, early and throughout, on the options which will form the substantive content of the Master Plan.
356
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Findings supporting the rule We failed to appreciate that ‘options’ (scenarios for development)arethesubstantiveanchoracrosstheMasterPlanandthat these remain similar across the process. This development of substantive detail, ‘the story’, under each option could have been informed by health evidence and been the focal points for our collaboration across the life of the Master Plan. Crucially this differs from our approach which, mistakenly, was to wait until some level of detail was provided, make an appraisal or assessment of this, and then arrive at a preferred option from a health perspective while adding health focussed detail. We were waiting for specific details (in terms of actual written or visual changes to the built environment and people) of the Master Plan to appear when our colleagues were waiting for us to provide detail of relevant health evidence. Several content and process challenges led to this fundamental mistake. One was that the early six ‘options’ developed were re-named as four ‘scenarios’ (and later three options again), while retaining the same substantive content. This meant that our original plan to use a ‘health proofing’ tool to appraise each option prior to the consultations was no longer seen as required. Also, later, in the early stages of the HIA we waited for detail in the form of options to assess their impact on health. We even delayed completing the literature review commissioned at the start of the HIA because we were not clear about what to assess. In hindsight we should have proceeded with the literature review to provide substantive links between core Master Planning options and health even in the absence of details to assess. Eventually the HIA22 did make substantive links between the activities presented in the Master Plan and their health impact. These proposed activities in the Master Plan were more detailed than the broader options (for example improve housing quality, reduce concentrations of disadvantage, improve safety, improve access to green space compared with the options of business as usual, bring to code, changing assets only and full land transfer) while being clearly linked to the substantive drivers of the Master Plan. However by focussing on the substantive drivers and options at an earlier stage we could have helped develop the detail within the activities and the story of the plan rather than wait for that detail to make an assessment of this. This is discussed in more detail the procedural section.
Rule Develop accurate health profile data at a local level to identify health issues and present this at the earliest stages of Master Planning to inform options.
Findings supporting the rule A demographic profile of the area provided substantive input into the development of options. However, health related data was not included. Hospitalization data in particular, we and all the other stakeholders were convinced, would be of great value for the Master Plan. Hospitalization data was the only health data accessible at the local level and it was hoped that this would provide the HIA with information about the particular health issues for the community living on the estate. However this required us to request the data from the state department of health which then took time to analyse and present.
Procedural influence Procedural influence concerns how Master Planning unfolds and how health can provide input into this at different points in time. Overall we were aware, but did not fully appreciate the implications, of Master Planning being non-linear. Master Planning is more of a process than the production of a written document. However, there were four critical procedural points for health focussed collaboration and technical input.
Rule Collaborate with technical processes at the right time with the right people, while being prepared to wait until those points (suddenly) come about.
Rule Design and undertake health impact assessment flexibly alongside Master Planning to provide input into the plan as this is being developed.
Findings supporting the rules The process driven and politicized nature, in terms of the implications of making changes to existing communities, of Master Planning meant that we needed to be flexible to provide the right type of technical and substantive input at the right procedural point in the process. Four core procedural points became apparent (shown in Table 1) and the opportunities for input are discussed below. Health, one housing stakeholder suggested, could have been positioned as a driver for the Master Plan in the original tender for funding. Then health could have been incorporated into the three standard studies, including the demographic data, which informed the initial options. A stand alone health study could also have been undertaken. We did provide health input into the social impact assessment workshop in which stakeholders collectively ranked each option against various social indicators (health was one). We also, as discussed, developed a ‘health proofing’ process whereby each option could have been appraised against items in a ‘healthy urban development checklist’. Additionally the first step of an HIA ‘screens’ potential proposals for their impact on health and well-being. This could have been used here to inform both the urban design plan and an HIA running alongside this. The urban design plan took the options and ran them through three stakeholder and community consultations to inform subsequent iterations of the plan. Health representatives attended each consultation. The interviews suggested that all stakeholders were pleased with the consultation process and the engagement of health within this. We, however, would have preferred to have held a health specific consultation to identify health and equity issues. These workshops could have informed the middle steps of an HIA, which identify information on impacts and assesses these, alongside the urban design plan. However, other stakeholders commented how additional consultation was neither required nor wanted. They did however note that in future greater collaboration could occur in the design of the consultations. These core procedural points occurred but in a haphazard fashion and were unpredictable, thereby combining elements
357
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Table 1 e Critical procedural points for health input. Housing master planning points Tender process Options development and appraisal - Market appraisal - Environmental Legislation review - Demographic profile - aSocial impact assessment workshop of options
Health input
Did this occur in the case
Health as conceptual driver for estate renewal Either a health focussed study, OR include health as an economic issue AND health in relevant legislation AND health data as part of the demographic profile
No No
Health input into social impact assessment workshop
No
HIA ‘screening’ on the options
Yes
Not explicit
‘Health proofing’ the options No
Urban design plan Stakeholder and Community consultations (to inform) Urban Design Plan
Health input into community consultations AND health focussed consultations (to inform identification of health impacts for an HIA)
No Yes
No
Health input into design plan HIA providing evidence into urban design plan activities AND Assessing health impacts of urban design activities to refine for final draft
Business case a
HIA as stand-alone document for business case
Partially through consultations No Yes Yes
The social impact assessment workshop is not a standard procedure.
of rational and incremental policy making.20 Some activities were held off for long periods only to take place suddenly. Often by the time they happened we had turned attention to other more pressing work and missed various windows of opportunity for influence in terms of content and, crucially, people.23 The reason for this, the housing stakeholders explained in the interviews, is that Master Planning is very complex because of the large geographical areas covered, political sensitivities and the many stakeholders involved. Dealing with these complexities, it was suggested, is learned over time and across different projects.
Structural supports for collaboration Institutional structures influence practice as rules, mandates and procedures24 while becoming actual entities in organizations or systems e for example units or positions e to carry these out and, importantly for collaboration, facilitate policy networks.25,26
Rule Create a cross-institutional mandate for health and housing collaboration on Master Planning.
Rule Develop a position and structure within the health system to engage with housing across the Master Planning process. This
position, unit or other structure should use various tools and processes, develop others, engage in processes such as consultations or working groups, establish organizational mandates, cultivate and embed organizational and stakeholder relationships.
Findings supporting the rules Master Planning, like other policy instruments,21,27,28 involves a range of specialist agencies. Government, through the Department of Housing, overseas the process, while the activity itself is undertaken by external private consultants who develop the specific content of the plan in partnership with the department of housing. Our view from this case is that it is unreasonable to expect these non-health professions, given the core demands of their work, to take on health as a core concern, at least at the present time. The will and interest from all stakeholders was palpable early in the process. However this waned as time went on and the complexity of the engagement, and missed opportunities, became apparent. Additionally the core champions on the health and housing partnership e all except one e did not remain involved after the earliest stages because they were no longer in relevant positions following a restructure. Mandates did facilitate the process to some degree. The whole process of collaboration was influenced by a mandate, through the health and housing partnership, to engage in Master Planning. The partnership suggested that, at least
358
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locally, both housing and the health subsystems were ‘open’ to new ideas and ways of working.26 This facilitated health representatives being allowed into what was described as a political process, and housing representatives being open to engaging and sharing information. Additionally the engagement of the stakeholders in the health processes was facilitated by an amendment in the specifications guiding the consultants undertaking the Master Plan. However, this was not enough to make this collaboration successful. The case suggests how several other layers of structural activity are required. Crucial at the institutional level is the inclusion of health and well-being in the requirements for tendering, which in turn may need supporting policies to be developed in both health and housing departments or ministries.25 An additional benefit is sustainable policy direction when either sector is restructured (both were restructured during the life of this collaboration). At the operational level this requires skilled health representation, with a clear role and remit, to engage with the established governance structures21,29 in the housing sector which oversee the Master Planning process. This means identifying roles and responsibilities, and allocating time and resources to be able to work incrementally across the process with the right people at the right time. Despite all the good will between stakeholders the reality was that this project was one of a great many demands on all the stakeholders involved. The lack of a core organizational mandate meant our attention often focussed on other more pressing work.
The people collaborating People, ultimately, are the point at which institutional and organizational influences become a reality through policy regimes and networks, and roles and values.20,25,27
Rule Develop individual skills and competencies in collaborating across sectors generally and in Master Planning specifically.
Rule Establish working relationships with stakeholders involved in Master Planning as early as possible and foster these even when progress on the Master Plan itself has stalled.
Findings supporting the rules The preceding analysis has demonstrated that developing individuals’ abilities to influence substantive and procedural policy making are core requirements for collaboration. Additionally, relationships lie at the heart of successful collaboration. Ultimately health was not part of the policy regime20 directing the process of the Master Plan. For various reasons, even with support of the health and housing partnership, there was a divide between us looking into a process and others driving that process who were familiar with each other and the messy nature of Master Planning. The reality, as one stakeholder put it, was that; ‘Well they are not part of our team.’. We were offered early opportunities to engage more closely with the consultant team developing the plan but we were not confident enough to take the offer up. Over time we did not pay enough attention to fostering relationships with
all stakeholders, especially with those with whom we were not familiar, at all times. Even when progress seemed to have stalled there remained opportunities to engage with and provide information to stakeholders.
Discussion This case study demonstrates the need to be both technical and tactical when collaborating with other sectors’ policy and planning.8,20 Providing technically proficient input to the planning process must, to be useful, take on board the substantive and procedural dimensions of policy making instruments in the specific sector being collaborated with. This is facilitated by understanding how structures, actors and ideas influence collaborative activities. Fortunately each of the stakeholders has expressed willingness to work together again having learnt from this experience. To that end we have provided nine rules to facilitate future collaborations (see box one). Further, our analysis has provided theoretical depth to develop practical categories for cross-sectoral policy level collaboration activities, research and evaluation.
Box 1 Nine technical and tactical rules for inter-sectoral health focussed Master Planning collaboration 1. identify the substantive issues driving the policy under development; 2. become involved early to provide input about links between the proposed options and health rather than waiting to assess plans; 3. design and undertake health impact assessment flexibly alongside Master Planning to provide input into the plan as this is being developed; 4. focus on options early and throughout; 5. develop and provide appropriate demographic health data as early as possible; 6. understand the core procedural points and how to influence these while being prepared for these to occur haphazardly; 7. develop the necessary structural supports for collaboration including institutional mandates and organizational structures; 8. develop personal skill and competence to work collaboratively; and 9. foster relationships at all times.
A crucial finding in terms of change for the future19 concerns HIA. There is currently a universal lack of clarity over where HIA is positioned in relation to policy making.30 We have demonstrated here how HIA could have been conducted flexibly from the initial options appraisal through to the final urban design plan. This provides detail to our previous research findings15 that HIA must be designed flexibly to fit with the established (non-linear) elements in policy formulation instruments:31
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 3 5 4 e3 5 9
appraisal, dialogue, formulation and consolidation.20 The critical lesson from this case is the need for confidence that an HIA can provide information as input into master planning decisions as well as assessing these to refine them. There are several limitations to the article. Policies and plans are connected but are not the same thing. We have demonstrated that policy theory can account for much of the data in this case of a master plan. However, caution should be taken when applying these lessons to policies which are less rooted in a geographical place. Also we have purposefully focussed on the health perspective. Those from other sectors or less overtly interested in collaborating around health evidence could have a different way of interpreting the data. We therefore strongly advocate for more funded systematic research which can accommodate the full range of perspectives in this important area of public policy practice.
Author statements Ethical approval Ethical approval was provided by the UNSW Human Research Ethics Committee (HREC 125025).
Funding Funding for this research was provided to the Centre for Health Equity Training Research and Evaluation by Population Health, South Western Sydney & Sydney Local Health Districts.
Competing interests None.
references
1. McKinlay JB. Epidemiological and political determinants of social policies regarding the public health. Soc Sci Med 1979;13A:541e58. 2. De Leeuw E, Polman L. Health policy making: the Dutch experience. Soc Sci Med 1995;40(3):331e8. 3. Koivusalo M. The state of Health in All policies (HiAP) in the European Union: potential and pitfalls. J Epidemiol Community Health 2010;64(6):500e3. 4. McQueen DV, Wismar M, Lin V, Jones CM, Davies M. Institutional governance for health in all policies: structures, actions and experiences. European Observatory on Health Systems and Policies: World Health Organisation; 2012. 5. Milio N. Making healthy public policy; developing the science by learning the art: an ecological framework for policy studies. Health Promot Int 1987;2(3):263e74. 6. Sta˚hl T, Wismar M, ollila E, Lahtinen E, Leppo K. Health in all policies: prospects and potentials. Finland: Ministry of Social Affairs; 2006. 7. Ollila E. Health in all policies: from rhetoric to action. Scand J Public Health 2011;39(Suppl. 6):11e8. 8. Kemm J. Health impact assessment: a tool for healthy public policy. Health Promot Int 2001;16(1):79e85.
359
9. Davenport C, Mathers J, Parry J. Use of health impact assessment in incorporating health considerations in decision making. J Epidemiol Community Health 2006;60(3):196e201. 10. Collins J, Koplan JP. Health impact assessment: a step toward health in all policies. JAMA 2009;302(3):315e7. 11. Mindell J, Boaz A, Joffe M, Curtis S, Birley M. Enhancing the evidence base for health impact assessment. J Epidemiol Community Health 2004;58(7):546e51. 12. Dannenberg AL, Bhatia R, Cole Brian L, Heaton SK, Feldman D, Rutt CD. Use of health impact assessment in the U.S.: 27 case studies, 1999e2007. Am J Prev Med 2008;34(3):241e56. 13. Haigh F, Baum F, Dannenberg AL, Harris MF, Harris-Roxas B, Keleher H, Kemp L, Morgan R, Ng Chok H, Spickett J. The effectiveness of health impact assessment in influencing decision-making in Australia and New Zealand 2005e2009. BMC public health 2013;13(1):1188. 14. Harris P, Harris-Roxas B, Wise M, Harris E. Health impact assessment and land use planning and policy development: lessons from practice. Plan Pract Res 2010;25(5):531e41. 15. Harris PJ, Kemp LA, Sainsbury P. The essential elements of health impact assessment and healthy public policy: a qualitative study of practitioner perspectives. BMJ Open 2012;2(6). 16. Yin RK. Case study research: design and methods. 3rd edn. Newbury Part, CA: Sage; 2003. 17. Pawson R, Tilley N. Realistic evaluation. London: Sage Publications Ltd.; 1997. 18. Sayer A. Method in social science: a realist approach. 2nd edn. Abingdon: Routledge; 1992. 19. Marsh D. Stability and change: the last dualism? Crit Policy Stud 2010;4(1):86e101. 20. Howlett M, Ramesh M, Perl A. Studying public policy: policy cycles and policy sub-systems. 3rd edn. Canada: Oxford University Press; 2009. 21. Howlett M. Managing the “hollow state”: procedural policy instruments and modern governance. Can Public Adm 2000;43(4):412e31. 22. Haigh F, Harris P, Ng Chok H, Coffey J, Thornell M. Villawood East Master plan health impact assessment report. Liverpool: NSW Centre for Health Equity Training Research and Evaluation, part of the Centre for Primary Health Care and Equity, Faculty of Medicine, University of NSW, www. HIAconnect.edu.au; 2013 (accessed 20 June 2013). 23. Kingdon JW. Agendas, alternatives, and public policies. 3rd edn, 2011. Glenview: Ill: Pearson Education Inc.; 1984. 24. March JG, Olsen JP. The new institutionalism: organizational factors in political life. Am Polit Sci Rev 1984;78(3):734e49. 25. Scott WR. Institutions and organizations: ideas and interests. 3rd edn. Thousand Oaks, CA: Sage Publications; 2005. 26. Howlett M, Ramesh M. Policy subsystem configurations and policy change: operationalizing the postpositivist analysis of the politics of the policy process. Policy Stud J 1998;26(3): 466e81. 27. Dunsire A. Modes of governance. In: Kooiman J, editor. Modern governance. London. Newbury Park. New Delhi: Sage; 1993. 28. Salaman LM. The new governance and the tools of public action: an introduction. In: Salaman LM, editor. The tools of government: a guide to the new governance; 2001. 29. Colebatch HK. Policy. 2nd edn. Open University Press; 2002. 30. Lee J, Ro¨bbel N, Dora C. Cross-country analysis of the institutionalization of health impact assessment. Geneva: World Health Organization; 2013. 31. Harris P, Sainsbury P, Kemp L. The fit between health impact assessment and public policy: practice meets theory. Soc Sci Med 2014;108:46e53.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Housing, health and master planning: rules of engagement P. Harris a,*, F. Haigh a, M. Thornell b, L. Molloy c, P. Sainsbury b a Centre for Health Equity Training, Research and Evaluation, Part of the Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW 2052, Australia b Population Health, South Western Sydney & Sydney Local Health Districts, Sydney, Australia c Faculty of the Built Environment, University of New South Wales, Australia
article info
abstract
Article history:
Objectives: Knowledge about health focussed policy collaboration to date has been either
Received 28 June 2013
tactical or technical. This article focusses on both technical and tactical issues to describe the
Received in revised form
experience of cross-sectoral collaboration between health and housing stakeholders across
14 January 2014
the life of a housing master plan, including but not limited to a health impact assessment (HIA).
Accepted 14 January 2014
Study design: A single explanatory case study of collaboration on a master plan to regen-
Available online 20 March 2014
erate a deprived housing estate in Western Sydney was developed to explain why and how the collaboration worked or did not work.
Keywords:
Methods: Data collection included stakeholder interviews, document review, and reflections
Intersectoral collaboration
by the health team. Following a realist approach, data was analysed against established
Public health
public policy theory dimensions.
Health impact assessment
Results: Tactically we did not know what we were doing. Despite our technical knowledge
Housing master plan
and skills with health focussed processes, particularly HIA, we failed to appreciate com-
Public policy
plexities inherent in master planning. This limited our ability to provide information at the right points. Eventually however the HIA did provide substantive connections between the master plan and health. We use our analysis to develop technical and tactical rules of engagement for future cross-sectoral collaboration. Conclusions: This case study from the field provides insight for future health focussed policy collaboration. We demonstrate the technical and tactical requirements for future intersectoral policy and planning collaborations, including HIAs, with the housing sector on master planning. The experience also suggested how HIAs can be conducted flexibly alongside policy development rather than at a specific point after a policy is drafted. ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Interest in collaborating with other sectors has a long history within the health sector.1e6 Supporting knowledge to date has
been either tactical or technical. The tactical focus is on the strategic conditions and processes which allow for collaborative ‘healthy’ public policy.3e5,7 The technical focus is on the information requirements to enable policy options to be ‘healthy’.5,8 Health impact assessment (HIA) is increasingly
* Corresponding author. Tel.: þ61 296120779; fax: þ61 296120762. E-mail address: [email protected] (P. Harris). 0033-3506/$ e see front matter ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2014.01.006
p u b l i c h e a l t h 1 2 8 ( 2 0 1 4 ) 3 5 4 e3 5 9
presented, focussing mostly on technical issues, to facilitate policy level collaboration.8e11 HIAs are often conducted on plans related to land-use12,13 as in the case reported here. Recent evaluations of HIAs have shown that an important outcome is building partnerships between the sectors involved.14 HIA is however just one mechanism for public policy collaboration and other activities are required.3,7,15 Few examples have been provided in the peer reviewed literature of policy collaborations which include but are not limited to HIA and where the analysis is explicitly tactical and technical.31 Since 2008 in South Western Sydney, New South Wales, Australia ‘The Health and Housing Partnership’ has been a collaboration between a local health department, a university centre, and the local department of housing. One goal of the partnership is to build capacity to collaboratively engage in how the Housing Department plans for the renewal and regeneration of public housing estates. In 2011 the partnership identified an opportunity which arose, to collaborate on a Master Plan for a housing estate in South Western Sydney. The three partners agreed that the Master Planning process provided an important opportunity to understand requirements for health to engage across a planning process, including using HIA. Specifically four preliminary objectives were identified: 1. influence the Master Plan to take health impacts into consideration; 2. identify capacity building issues and opportunities; 3. learn each other’s systems and language concerning Master Planning and potential health input into this; and 4. understand which processes are most useful concerning health input and whether that input was influential or not and why.
355
being addressed e and ‘procedural’ e to do with the procedures involved in adopting a policy option.5,20,21 Units of analysis are ideas (the content of what goes into policy), institutions (systems and structures which produce rules, procedures and mandates) and actors (roles, values, and relationships).20
Results Results are presented against each aspect of policy making, with the exception of ideas which are embedded throughout the analysis. We develop rules for engagement for each aspect, supported by our findings.
Substantive influence Substantive influence concerns the problems that the Master Plan sets out to address (which included renewing ageing substandard housing stock, bringing in private ownership while retaining stock, and underutilization of green space and other community assets) and how health can provide information to these. Overall, we did not achieve substantive influence on the Master Plan itself. Notably the HIA however did eventually, as a stand-alone document,22 provide substantive connections between proposed Master Plan activities (e.g. housing quality, access and quality of green space, and services) and health.
Rule At the outset of the collaboration, review early documentation and discuss with stakeholders to develop a clear understanding of the various substantive issues, problems and drivers that a Master Plan addresses.
Findings supporting the rule
Methods A single explanatory case study design16 was adopted by us as the health stakeholders involved in the collaboration. Data included meeting documentation, reporting, written correspondence, our reflections, and six interviews (independently conducted by LM) with stakeholders including us (representatives from housing, health, and the consultant responsible for the urban design plan). Ethical approval was granted by UNSW Human Research Ethics Committee (HREC 125025). The data analysis and reporting was led by PH with support from FH, MT, and PS. To encourage external validity16 we provided a draft report to the housing stakeholders involved. The only requested change was to clarify the context of the Master Plan. We took a realist approach to data analysis, incorporating insights from public policy theories to add explanatory depth17,18 and identify areas where future activity and change could occur.19 The analysis is drawn around a framework provided by Howlett et al.20 who explain public policy as developed across stages and within institutions. We have recently used this framework to analyse the experiences of HIA practitioners.31 This framework differentiates two aspects of policy making: ‘substantive’ e innate to the nature of the problem
As we proceeded all the partners in the collaboration, including us, were keen for health information and evidence to support the options and what one housing stakeholder described as ‘the story of the Master Plan’. At the outset we understood some but not all of the substantive policy drivers for the Master Plan. We initially focussed on process rather than substantive content. Also, despite entering into the collaboration through the health and housing partnership not all the stakeholders with responsibility for driving the Master Plan had attended the partnership or were known to us. Nor was health linked to the Master Plan in the early documentation driving the process. Therefore despite ‘health’ being the reason for our engagement, the perceived substantive value of health was not clear for the housing stakeholders developing the plan. For us, many of the substantive issues driving the Master Plan were connected to health, although we failed to make a technical assessment of these connections to the evidence until the HIA (which, as will be discussed, came too late to influence the Master Plan document).
Rule Become involved in planning rather than waiting to assess plans. Focus attention, early and throughout, on the options which will form the substantive content of the Master Plan.
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Findings supporting the rule We failed to appreciate that ‘options’ (scenarios for development)arethesubstantiveanchoracrosstheMasterPlanandthat these remain similar across the process. This development of substantive detail, ‘the story’, under each option could have been informed by health evidence and been the focal points for our collaboration across the life of the Master Plan. Crucially this differs from our approach which, mistakenly, was to wait until some level of detail was provided, make an appraisal or assessment of this, and then arrive at a preferred option from a health perspective while adding health focussed detail. We were waiting for specific details (in terms of actual written or visual changes to the built environment and people) of the Master Plan to appear when our colleagues were waiting for us to provide detail of relevant health evidence. Several content and process challenges led to this fundamental mistake. One was that the early six ‘options’ developed were re-named as four ‘scenarios’ (and later three options again), while retaining the same substantive content. This meant that our original plan to use a ‘health proofing’ tool to appraise each option prior to the consultations was no longer seen as required. Also, later, in the early stages of the HIA we waited for detail in the form of options to assess their impact on health. We even delayed completing the literature review commissioned at the start of the HIA because we were not clear about what to assess. In hindsight we should have proceeded with the literature review to provide substantive links between core Master Planning options and health even in the absence of details to assess. Eventually the HIA22 did make substantive links between the activities presented in the Master Plan and their health impact. These proposed activities in the Master Plan were more detailed than the broader options (for example improve housing quality, reduce concentrations of disadvantage, improve safety, improve access to green space compared with the options of business as usual, bring to code, changing assets only and full land transfer) while being clearly linked to the substantive drivers of the Master Plan. However by focussing on the substantive drivers and options at an earlier stage we could have helped develop the detail within the activities and the story of the plan rather than wait for that detail to make an assessment of this. This is discussed in more detail the procedural section.
Rule Develop accurate health profile data at a local level to identify health issues and present this at the earliest stages of Master Planning to inform options.
Findings supporting the rule A demographic profile of the area provided substantive input into the development of options. However, health related data was not included. Hospitalization data in particular, we and all the other stakeholders were convinced, would be of great value for the Master Plan. Hospitalization data was the only health data accessible at the local level and it was hoped that this would provide the HIA with information about the particular health issues for the community living on the estate. However this required us to request the data from the state department of health which then took time to analyse and present.
Procedural influence Procedural influence concerns how Master Planning unfolds and how health can provide input into this at different points in time. Overall we were aware, but did not fully appreciate the implications, of Master Planning being non-linear. Master Planning is more of a process than the production of a written document. However, there were four critical procedural points for health focussed collaboration and technical input.
Rule Collaborate with technical processes at the right time with the right people, while being prepared to wait until those points (suddenly) come about.
Rule Design and undertake health impact assessment flexibly alongside Master Planning to provide input into the plan as this is being developed.
Findings supporting the rules The process driven and politicized nature, in terms of the implications of making changes to existing communities, of Master Planning meant that we needed to be flexible to provide the right type of technical and substantive input at the right procedural point in the process. Four core procedural points became apparent (shown in Table 1) and the opportunities for input are discussed below. Health, one housing stakeholder suggested, could have been positioned as a driver for the Master Plan in the original tender for funding. Then health could have been incorporated into the three standard studies, including the demographic data, which informed the initial options. A stand alone health study could also have been undertaken. We did provide health input into the social impact assessment workshop in which stakeholders collectively ranked each option against various social indicators (health was one). We also, as discussed, developed a ‘health proofing’ process whereby each option could have been appraised against items in a ‘healthy urban development checklist’. Additionally the first step of an HIA ‘screens’ potential proposals for their impact on health and well-being. This could have been used here to inform both the urban design plan and an HIA running alongside this. The urban design plan took the options and ran them through three stakeholder and community consultations to inform subsequent iterations of the plan. Health representatives attended each consultation. The interviews suggested that all stakeholders were pleased with the consultation process and the engagement of health within this. We, however, would have preferred to have held a health specific consultation to identify health and equity issues. These workshops could have informed the middle steps of an HIA, which identify information on impacts and assesses these, alongside the urban design plan. However, other stakeholders commented how additional consultation was neither required nor wanted. They did however note that in future greater collaboration could occur in the design of the consultations. These core procedural points occurred but in a haphazard fashion and were unpredictable, thereby combining elements
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Table 1 e Critical procedural points for health input. Housing master planning points Tender process Options development and appraisal - Market appraisal - Environmental Legislation review - Demographic profile - aSocial impact assessment workshop of options
Health input
Did this occur in the case
Health as conceptual driver for estate renewal Either a health focussed study, OR include health as an economic issue AND health in relevant legislation AND health data as part of the demographic profile
No No
Health input into social impact assessment workshop
No
HIA ‘screening’ on the options
Yes
Not explicit
‘Health proofing’ the options No
Urban design plan Stakeholder and Community consultations (to inform) Urban Design Plan
Health input into community consultations AND health focussed consultations (to inform identification of health impacts for an HIA)
No Yes
No
Health input into design plan HIA providing evidence into urban design plan activities AND Assessing health impacts of urban design activities to refine for final draft
Business case a
HIA as stand-alone document for business case
Partially through consultations No Yes Yes
The social impact assessment workshop is not a standard procedure.
of rational and incremental policy making.20 Some activities were held off for long periods only to take place suddenly. Often by the time they happened we had turned attention to other more pressing work and missed various windows of opportunity for influence in terms of content and, crucially, people.23 The reason for this, the housing stakeholders explained in the interviews, is that Master Planning is very complex because of the large geographical areas covered, political sensitivities and the many stakeholders involved. Dealing with these complexities, it was suggested, is learned over time and across different projects.
Structural supports for collaboration Institutional structures influence practice as rules, mandates and procedures24 while becoming actual entities in organizations or systems e for example units or positions e to carry these out and, importantly for collaboration, facilitate policy networks.25,26
Rule Create a cross-institutional mandate for health and housing collaboration on Master Planning.
Rule Develop a position and structure within the health system to engage with housing across the Master Planning process. This
position, unit or other structure should use various tools and processes, develop others, engage in processes such as consultations or working groups, establish organizational mandates, cultivate and embed organizational and stakeholder relationships.
Findings supporting the rules Master Planning, like other policy instruments,21,27,28 involves a range of specialist agencies. Government, through the Department of Housing, overseas the process, while the activity itself is undertaken by external private consultants who develop the specific content of the plan in partnership with the department of housing. Our view from this case is that it is unreasonable to expect these non-health professions, given the core demands of their work, to take on health as a core concern, at least at the present time. The will and interest from all stakeholders was palpable early in the process. However this waned as time went on and the complexity of the engagement, and missed opportunities, became apparent. Additionally the core champions on the health and housing partnership e all except one e did not remain involved after the earliest stages because they were no longer in relevant positions following a restructure. Mandates did facilitate the process to some degree. The whole process of collaboration was influenced by a mandate, through the health and housing partnership, to engage in Master Planning. The partnership suggested that, at least
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locally, both housing and the health subsystems were ‘open’ to new ideas and ways of working.26 This facilitated health representatives being allowed into what was described as a political process, and housing representatives being open to engaging and sharing information. Additionally the engagement of the stakeholders in the health processes was facilitated by an amendment in the specifications guiding the consultants undertaking the Master Plan. However, this was not enough to make this collaboration successful. The case suggests how several other layers of structural activity are required. Crucial at the institutional level is the inclusion of health and well-being in the requirements for tendering, which in turn may need supporting policies to be developed in both health and housing departments or ministries.25 An additional benefit is sustainable policy direction when either sector is restructured (both were restructured during the life of this collaboration). At the operational level this requires skilled health representation, with a clear role and remit, to engage with the established governance structures21,29 in the housing sector which oversee the Master Planning process. This means identifying roles and responsibilities, and allocating time and resources to be able to work incrementally across the process with the right people at the right time. Despite all the good will between stakeholders the reality was that this project was one of a great many demands on all the stakeholders involved. The lack of a core organizational mandate meant our attention often focussed on other more pressing work.
The people collaborating People, ultimately, are the point at which institutional and organizational influences become a reality through policy regimes and networks, and roles and values.20,25,27
Rule Develop individual skills and competencies in collaborating across sectors generally and in Master Planning specifically.
Rule Establish working relationships with stakeholders involved in Master Planning as early as possible and foster these even when progress on the Master Plan itself has stalled.
Findings supporting the rules The preceding analysis has demonstrated that developing individuals’ abilities to influence substantive and procedural policy making are core requirements for collaboration. Additionally, relationships lie at the heart of successful collaboration. Ultimately health was not part of the policy regime20 directing the process of the Master Plan. For various reasons, even with support of the health and housing partnership, there was a divide between us looking into a process and others driving that process who were familiar with each other and the messy nature of Master Planning. The reality, as one stakeholder put it, was that; ‘Well they are not part of our team.’. We were offered early opportunities to engage more closely with the consultant team developing the plan but we were not confident enough to take the offer up. Over time we did not pay enough attention to fostering relationships with
all stakeholders, especially with those with whom we were not familiar, at all times. Even when progress seemed to have stalled there remained opportunities to engage with and provide information to stakeholders.
Discussion This case study demonstrates the need to be both technical and tactical when collaborating with other sectors’ policy and planning.8,20 Providing technically proficient input to the planning process must, to be useful, take on board the substantive and procedural dimensions of policy making instruments in the specific sector being collaborated with. This is facilitated by understanding how structures, actors and ideas influence collaborative activities. Fortunately each of the stakeholders has expressed willingness to work together again having learnt from this experience. To that end we have provided nine rules to facilitate future collaborations (see box one). Further, our analysis has provided theoretical depth to develop practical categories for cross-sectoral policy level collaboration activities, research and evaluation.
Box 1 Nine technical and tactical rules for inter-sectoral health focussed Master Planning collaboration 1. identify the substantive issues driving the policy under development; 2. become involved early to provide input about links between the proposed options and health rather than waiting to assess plans; 3. design and undertake health impact assessment flexibly alongside Master Planning to provide input into the plan as this is being developed; 4. focus on options early and throughout; 5. develop and provide appropriate demographic health data as early as possible; 6. understand the core procedural points and how to influence these while being prepared for these to occur haphazardly; 7. develop the necessary structural supports for collaboration including institutional mandates and organizational structures; 8. develop personal skill and competence to work collaboratively; and 9. foster relationships at all times.
A crucial finding in terms of change for the future19 concerns HIA. There is currently a universal lack of clarity over where HIA is positioned in relation to policy making.30 We have demonstrated here how HIA could have been conducted flexibly from the initial options appraisal through to the final urban design plan. This provides detail to our previous research findings15 that HIA must be designed flexibly to fit with the established (non-linear) elements in policy formulation instruments:31
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appraisal, dialogue, formulation and consolidation.20 The critical lesson from this case is the need for confidence that an HIA can provide information as input into master planning decisions as well as assessing these to refine them. There are several limitations to the article. Policies and plans are connected but are not the same thing. We have demonstrated that policy theory can account for much of the data in this case of a master plan. However, caution should be taken when applying these lessons to policies which are less rooted in a geographical place. Also we have purposefully focussed on the health perspective. Those from other sectors or less overtly interested in collaborating around health evidence could have a different way of interpreting the data. We therefore strongly advocate for more funded systematic research which can accommodate the full range of perspectives in this important area of public policy practice.
Author statements Ethical approval Ethical approval was provided by the UNSW Human Research Ethics Committee (HREC 125025).
Funding Funding for this research was provided to the Centre for Health Equity Training Research and Evaluation by Population Health, South Western Sydney & Sydney Local Health Districts.
Competing interests None.
references
1. McKinlay JB. Epidemiological and political determinants of social policies regarding the public health. Soc Sci Med 1979;13A:541e58. 2. De Leeuw E, Polman L. Health policy making: the Dutch experience. Soc Sci Med 1995;40(3):331e8. 3. Koivusalo M. The state of Health in All policies (HiAP) in the European Union: potential and pitfalls. J Epidemiol Community Health 2010;64(6):500e3. 4. McQueen DV, Wismar M, Lin V, Jones CM, Davies M. Institutional governance for health in all policies: structures, actions and experiences. European Observatory on Health Systems and Policies: World Health Organisation; 2012. 5. Milio N. Making healthy public policy; developing the science by learning the art: an ecological framework for policy studies. Health Promot Int 1987;2(3):263e74. 6. Sta˚hl T, Wismar M, ollila E, Lahtinen E, Leppo K. Health in all policies: prospects and potentials. Finland: Ministry of Social Affairs; 2006. 7. Ollila E. Health in all policies: from rhetoric to action. Scand J Public Health 2011;39(Suppl. 6):11e8. 8. Kemm J. Health impact assessment: a tool for healthy public policy. Health Promot Int 2001;16(1):79e85.
359
9. Davenport C, Mathers J, Parry J. Use of health impact assessment in incorporating health considerations in decision making. J Epidemiol Community Health 2006;60(3):196e201. 10. Collins J, Koplan JP. Health impact assessment: a step toward health in all policies. JAMA 2009;302(3):315e7. 11. Mindell J, Boaz A, Joffe M, Curtis S, Birley M. Enhancing the evidence base for health impact assessment. J Epidemiol Community Health 2004;58(7):546e51. 12. Dannenberg AL, Bhatia R, Cole Brian L, Heaton SK, Feldman D, Rutt CD. Use of health impact assessment in the U.S.: 27 case studies, 1999e2007. Am J Prev Med 2008;34(3):241e56. 13. Haigh F, Baum F, Dannenberg AL, Harris MF, Harris-Roxas B, Keleher H, Kemp L, Morgan R, Ng Chok H, Spickett J. The effectiveness of health impact assessment in influencing decision-making in Australia and New Zealand 2005e2009. BMC public health 2013;13(1):1188. 14. Harris P, Harris-Roxas B, Wise M, Harris E. Health impact assessment and land use planning and policy development: lessons from practice. Plan Pract Res 2010;25(5):531e41. 15. Harris PJ, Kemp LA, Sainsbury P. The essential elements of health impact assessment and healthy public policy: a qualitative study of practitioner perspectives. BMJ Open 2012;2(6). 16. Yin RK. Case study research: design and methods. 3rd edn. Newbury Part, CA: Sage; 2003. 17. Pawson R, Tilley N. Realistic evaluation. London: Sage Publications Ltd.; 1997. 18. Sayer A. Method in social science: a realist approach. 2nd edn. Abingdon: Routledge; 1992. 19. Marsh D. Stability and change: the last dualism? Crit Policy Stud 2010;4(1):86e101. 20. Howlett M, Ramesh M, Perl A. Studying public policy: policy cycles and policy sub-systems. 3rd edn. Canada: Oxford University Press; 2009. 21. Howlett M. Managing the “hollow state”: procedural policy instruments and modern governance. Can Public Adm 2000;43(4):412e31. 22. Haigh F, Harris P, Ng Chok H, Coffey J, Thornell M. Villawood East Master plan health impact assessment report. Liverpool: NSW Centre for Health Equity Training Research and Evaluation, part of the Centre for Primary Health Care and Equity, Faculty of Medicine, University of NSW, www. HIAconnect.edu.au; 2013 (accessed 20 June 2013). 23. Kingdon JW. Agendas, alternatives, and public policies. 3rd edn, 2011. Glenview: Ill: Pearson Education Inc.; 1984. 24. March JG, Olsen JP. The new institutionalism: organizational factors in political life. Am Polit Sci Rev 1984;78(3):734e49. 25. Scott WR. Institutions and organizations: ideas and interests. 3rd edn. Thousand Oaks, CA: Sage Publications; 2005. 26. Howlett M, Ramesh M. Policy subsystem configurations and policy change: operationalizing the postpositivist analysis of the politics of the policy process. Policy Stud J 1998;26(3): 466e81. 27. Dunsire A. Modes of governance. In: Kooiman J, editor. Modern governance. London. Newbury Park. New Delhi: Sage; 1993. 28. Salaman LM. The new governance and the tools of public action: an introduction. In: Salaman LM, editor. The tools of government: a guide to the new governance; 2001. 29. Colebatch HK. Policy. 2nd edn. Open University Press; 2002. 30. Lee J, Ro¨bbel N, Dora C. Cross-country analysis of the institutionalization of health impact assessment. Geneva: World Health Organization; 2013. 31. Harris P, Sainsbury P, Kemp L. The fit between health impact assessment and public policy: practice meets theory. Soc Sci Med 2014;108:46e53.