Creating Favourable Health Conditions in Municipalities - Local Agenda 21 in Practice

At the Second European Conference on Environment and Health in Helsinki in 1994, the World Health Organization (WHO) presented the Environmental Health Action Plan for Europe (EHAPE). The ministers of health and the environment present at the conference agreed to initiate "National Environmental Health Action Plans (NEHAP) in their countries. In 1999, at the Third European Conference on Environment and Health in London, the German Federal Ministry for the Environment, Nature Conservation and Nuclear Safety and the Federal Ministry of Health jointly introduced the National Action Programme for Environment and Health (Aktionsprogramm Umwelt und Gesundheit - APUG).

APUG aims to create closer links between environmental and health protection, adopting a holistic strategy to put them on a sustainable footing which corresponds to current and future requirements. The scheme as such constitutes a basis for the further development of environmental and health policy (Seifert et al. 2000, p. 324). It is managed by the Federal Ministry for the Environment, Nature Conservation and Nuclear Safety, the Federal Ministry of Health and Social Security and, since autumn 2002, the Federal Ministry of Food, Agriculture and Consumer Protection. Scientific back-up for the programme is provided by the following federal authorities: the Federal Institute for Risk Assessment (BfR), the Federal Office for Radiation Protection (BfS), the Robert Koch Institute and the Federal Environmental Agency (UBA). The APUG offices are at the UBA.

Cross linking of environmental and health issues increases the importance of activities prompted by local authorities and the Länder. At local level in particular, more action is needed to create healthy and sustainable environmental conditions (healthy living conditions, ample space for recreation and relaxation, traffic and noise pollution reduction, etc.). Yet establishing parallel structures at local level through "Municipal Environmental Health Action Plans alongside existing structures with similar scopes and procedures appears ill-advised and inauspicious. In fact, experts advocate intensifying structures already in place and more intensively networking individual players. The structures of the Healthy Cities Network, and particularly those of Local Agenda 21, warrant mention in this context (Koordinierungsgruppe zum Aktionsprogramm Umwelt und Gesundheit 2002, p. 56, 76).

Local Agenda 21 was launched in 1992, with the formulation of Agenda 21, the document concluding the United Nations Conference on Environment and Development in Rio de Janeiro. The latter's 40 chapters include the basic tenets of environmentally friendly and sustainable development in key policy areas. The action programme advises local authorities to make their own contribution in the form of a "Local Agenda 21 (Chapter 28). Local Agenda 21 aims to fuse ecological approaches with economic, social and development policy aspects. At the same time it entreats local administrators to consult with residents, the private sector and local organizations; communication, participation and cooperation play major roles in Local Agenda. Since the mid-90s, a number of German local authorities have launched local agendas. In the meantime 2471 cities, local authorities and administrative districts, or 19% of all municipal authorities, have formulated Local Agenda 21 resolutions (as of July 2004, cf. www.agenda-transfer.de and Fig. 1).

Figure 1: Local Agenda 21 resolutions in Germany

Source: agenda-transfer 2004.

The focus of the Rio action programme is on protecting and promoting human health (Chapter 6). A whole area is devoted to tackling health problems. Pertinent measures include crafting municipal health plans, forming political and expert interdisciplinary committees, introducing monitoring procedures to determine the effectiveness of health programmes, and establishing city networks.

Although health has so far played a significantly smaller role than the environment in the programme's implementation (Rösler 1999, p. 22; Pierk 2003, p. 16).

Local Agenda 21 appears to have created promising conditions in local authorities for better integrating the expertise of the environmental and health fields and for exploiting interdisciplinary synergy potential where the two fields intersect.

1.2 Questions

In the framework of the National Action Programme for Environment and Health (APUG) and under the auspices of the Federal Environmental Agency (UBA), the German Institute of Urban Affairs and various partners (agenda-transfer, Agentur für Nachhaltigkeit GmbH; Magdeburg Stendal University of Applied Sciences, Department of Social Services and Health; the Institute of Medical Sociology at the University of Hamburg's Eppendorf Clinic; the North Rhein-Westphalia Institute of Public Health) conducted a study (Böhme/Reimann/Schuleri-Hartje 2005)1 investigating the following:

Is the potential of Local Agenda 21 to link the health and environment fields at local level being exploited? If so, to what extent?
What successful strategies and projects are local authorities developing and practising?
In which areas do cooperation and communication barriers or other obstacles exist?
What information and support services do local players require?

1.3 Study methodology

The empirical study combined and applied various quantitative and qualitative methods:

a written survey of the heads of the Local Agenda 21 coordination offices and local health departments and environment agencies in every county or city with county status which has drafted a Local Agenda resolution;
case study analysis in Heidelberg, Magdeburg, Munich and Viernheim;
discussions with experts long active in political administration, research and/or NGOs in health-related environmental protection fields or environment-related health protection fields; written survey of the Lander ministries of environment and health.

The aim of this mix of empirical methods was to gain qualitative and quantitative insight into the handling of the "environment and health" rubric in the context of Local Agenda 21. This approach makes it possible to combine the predominantly quantitative results of the city and district survey with the qualitative findings of the case study analysis, the expert discussions and the survey of the Länder ministries. The empirical studies were supplemented by systematic research and analysis of published and unpublished literature and materials. In addition, the results of a two-day symposium held as part of the research project as well as those of the sessions of the specialist task force set up to monitor the scheme were incorporated into the expert report.

2. Integrating the "environment and health rubric into Local Agenda 21

2.1 The current status of Local Agenda 21 implementation in Germany

Resolutions to initiate local agendas as a basic requirement for integrating "environment and health into Local Agenda 21 have been passed by one fifth of German local authorities.

However, there are major discrepancies between the Länder. While over 60% of local authorities in non-city states of Hessen, North Rhein-Westphalia and Saarland are committed to Local Agenda 21, the percentages in Saxony-Anhalt, Schleswig-Holstein, Rhineland- Palatinate and Saxony are well below 10%. All told, there is a glaring southwestnortheast divide between the Länder. The number of resolutions passed also varies depending on the size of the municipality (cf. Fig. 2).

Figure 2: Municipalities which have passed Local Agenda resolutions, categorized according to size (status: March 2001)*

Source: agenda-transfer 2004.

Although every municipality with over 100,000 inhabitants and more than 80% of municipalities with populations between 50,000 and 100,000 have signed up to the programme, the share of municipalities with fewer than 50,000 inhabitants which have subscribed is ebbing significantly and continuously. The share falls to a mere 7% for municipalities with fewer than 10,000 inhabitants (920 of 12,667). It can generally be asserted that the share of local agenda resolutions is smaller the less populated the municipalities are.

Summary 1: Key terms in the study

Environment

"Environment denotes the natural and constructed physical environment; social environment, as a broader interpretation of the term environment is not included.

Environmental protection

In this study, "environmental protection encompasses all measures undertaken to safeguard the environment (soil, water, air, climate, animals, plant life, landscape, cultural and other material goods) and to avoid disrupting influences on or damage to the environment, i.e. soil, water, air and noise pollution, global warming and soil sealing. Environmental protection begins with preserving the health of human beings and their habitats.

Health

The term "health used here corresponds to the preamble of the WHO founding charter of 1946, which defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Cited from Trojan/Legewie 2001, p. 20).

Health protection and promotion

"Health protection and promotion describes all measures aimed at avoiding disease and infirmity, at informing people how to lead healthier lives and at influencing factors in the physical and social environment which affect human health (cf. Naidoo/Wills 2003, p. 87). Health promotion measures particularly include building and strengthening individuals' health-related resources and capabilities to prevent disease, and establishing and bolstering health structures in local communities (Bundesregierung 2005, Article 3, Paragraph 5).

The "environment and health rubric

In this study, the "environment and health rubric comprises environmentrelated health protection and promotion and health-related environmental protection.

There has frequently been a failure to establish lasting and sustainable structures for fostering continuous and stable Local Agenda processes and thus to ensure successful integration of the "environment and health rubric.

However, the resolution statistics do not give the complete picture. The drafting of a Local Agenda resolution does not reveal whether a municipality is actually pushing forward with the Local Agenda process, or how far the process has progressed. Numerous innovative approaches have been developed towards sustainability, new cooperation and participation models and sustainable structures through Local Agenda, yet stable and tenable structures are absent in many places. The lack of consolidation and advancement of the Local Agenda 21 process poses the threat that Agenda activities - including those geared towards "environment and health" - may be scaled down or in some cases even entirely discontinued as voluntary municipal tasks because of insufficient financial resources in light of more pressing obligations.

Local Agenda 21 consolidation and advancement strategies must account for various stabilizing conditions.

If Local Agenda 21 is to establish itself as a long-term municipal political process, attention must be paid to the local situation and to a number of general stabilizing conditions and how they interrelate. These include: political involvement and pertinence, efficient process management, thematic integration, networking of relevant community players, increased participation, education, awareness raising and sustainability checks (Brand et al. 2001, p. 47 ff.). Rooting Local Agenda 21 in the everyday business of politicians and administrators is the key to success.

In the long term it appears essential to transfer the contents of Local Agenda 21 to different municipal activity fields such as "environment and health and to link them with existing programmes, initiatives and projects.

The "environment and health rubric focuses on both ecology and society and as such links two Local Agenda and sustainability target areas, making it particularly suitable for incorporating and implementing Local Agenda content. Many local authorities have a myriad of programmes, initiatives and projects apart from Local Agenda which promote local sustainability. Healthy City Network projects, the federal-Land Socially Integrative City programme as well as diverse concepts from citizen-friendly local authorities are especially germane to "environment and health. New action alliances and potential winwin situations can help stabilize Local Agenda processes.

2.2 Integrating the "environment and health rubric

At this point two thirds of local authorities participating in the survey have integrated "environment and health into their Local Agenda 21 initiatives.

Two thirds of the Local Agenda coordination offices surveyed reported that their local authorities are implementing projects within the "environment and health" rubric. However, it must be assumed that the situation in cities and counties which did not participate in the survey is considerably worse and that the fact that they are not dealing with "environment and health as a topic was very often the reason for them not choosing to take part.

The lack of action in this regard does not necessarily mean that the "environment and health rubric is being completely ignored by these local authorities.

Municipal action on the environment and healthcare is in no way limited to Local Agenda 21. A series of local activities for environment-related health protection and promotion are being implemented independently of Local Agenda. The actual scope of "environment and health activities undertaken by non-Agenda projects only becomes clear when we look at the survey results regarding the significance the "environment and health" rubric within Local Agenda and as part of environment agency and health department work as a whole (cf. Figs. 3 and 4). Only 18% of environment agencies felt that the rubric's significance within Local Agenda was high or very high. However, 47% of environment agencies said that its significance to their working processes as a whole was high or very high. The differences in the health departments' answers are even starker.

Only around 9% felt that the rubric was highly or very highly significant to Local Agenda, whereas 43.5% considered it important or very important to their working process as a whole.

"Environment and health is rarely handled separately within the context of Local Agenda; it is nearly always integrated into other rubrics.

The correlation between health and the environment is not always properly emphasized in this integrated approach. Aspects of environment-related health protection and promotion are more likely to be implicit parts of superordinate rubrics such as transport, housing, energy, etc. Therefore, it is clear that many places have not yet consciously and systematically combined health and the environment within Local Agenda. At the same time, however, implicit handling of the rubric can make a significant contribution to creating a healthy environment.

Figure 3: The significance of the "environment and health rubric for environment agencies

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, environment agencies, 2004, n=115 (Local Agenda) or n=126 (work process as a whole).

Figure 4: The significance of the "environment and health rubric for health departments*

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, health departments, 2004, n=107 (Local Agenda) or n=131 (work process as a whole).

2.3 Factors promoting and inhibiting incorporation

Onsite players perceived certain conditions and factors as promoting the incorporation of "environment and health into Agenda 21. These were the same factors seen as beneficial to Local Agenda processes in general.

There is a distinction between external and internal promoting factors (Brand et al. 2001, p. 23). One particularly useful external promoting condition identified was political and administrative support for the rubric's incorporation. Decisive internal promoting factors are those relating to individuals, such as the commitment and skills of players, and those relating to structures, such as the existence of a culture of cooperation and communication, particularly between administrators and external players but also between environment agencies and health departments. Visible, successful projects are deemed the best factor for promoting the rubric's incorporation.

Onsite players consider limited resources, low ranking on priority lists and lack of interest in the "environment and health rubric as the major inhibiting factors for handling "environment and health within Local Agenda.

Additional impediments are information deficits and communication problems between players in the fields of healthcare and the environment, arising due to disparate attitudes and approaches. Promoting inclusion of the "environment and health rubric in Local Agenda 21 would seem to require clarifying the symbiotic relationship between health and the environment, and providing more information on the topic.

Successful incorporation of the "environment and health rubric demands that local politicians, citizens and environment and healthcare players both inside and outside local government be made aware of environment-related health risks and how better environmental conditions can contribute to improved health. Health reports which make reference to environmental factors, continuous publicity campaigns and the publication of good practice examples can greatly assist in this mission. It is also useful to involve local educational facilities and healthcare and environment protection schemes in disseminating information and raising awareness.

3. Goals, fields of action and projects in the "environment and health rubric of Local Agenda 21

3.1 Goals and indicators

The goals of the "environment and health rubric in the context of Local Agenda 21 are largely ecology oriented and geared towards promoting a sound environment.

Empirical findings reveal that the vast majority (around 80%) of local authorities which include "environment and health in their Local Agenda 21 planning have specific goals for the rubric. Many of the stated objectives are primarily ecological in nature and geared towards promoting a sound environment. However, they also implicitly refer to maintaining a healthy living environment. Objectives explicitly referring to health issues such as reducing air pollution, ensuring healthy indoor climates, limiting health risks from food, preventing road accidents and minimizing the threat of radiation are less common (cf. Fig. 5).

An independent "environment and health target area is a rare occurrence. The specification of environment-related healthcare aims or healthcare-related environmental goals, and the rubric's integration in general (cf. Chapter 2.2) - are more likely to be included in topic areas with some connection to the environment and healthcare, and goals are much more likely to be implicitly formulated.

Clearer emphasis on environment-related healthcare goals and healthcare-related environmental goals is desirable. This would allow better coordination of common health and environmental protection goals.

Environmental goals may implicitly include ensuring healthy living environments but the explicit formulation of concrete environment-related healthcare objectives and healthcare- related environmental protection goals would better communicate and emphasize the interrelationship between healthcare and the environment in the goal development phase.

Figure 5: Goals of the "environment and health rubric*

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, Local Agenda 21 coordination offices, 2004, n=69 (cities: 38, counties: 31), multiple responses.

The best way of testing the attainment of "environment and health objectives is to examine environmental indicators. The sustainability indication system used to assess healthcare still has its weaknesses.

In the survey, around three fifths of local authorities which have formulated "environment and health goals stated that they have developed and employed indicators for assessing goal attainment. The main indicators of environmental protection mentioned in the survey were energy consumption, waste levels, traffic, extent of sealed-soil areas and the number of recreational and green spaces. Investigations into these areas allow us to draw some conclusions about how healthy or unhealthy a living environment is. Local Agenda 21 coordination offices made much less reference to explicit inhabitant health and safety indicators such as the numbers of overweight children, children with allergies, children involved in road accidents and children affected by noise pollution. Environmental indicators can usually provide clear hints on the interrelationship between the environment and healthcare issues. However existing weaknesses in the current healthcare indicator system must be removed through the development of an appropriate, more advanced system and practical health indicators.

Regular sustainability reports drawing on a system of indicators are helpful in stabilizing Local Agenda processes and incorporating the "environment and health rubric.

Such sustainability reports can form the basis of a continuing expansion of municipal sustainability objectives, indicators and measures, but the idea is still in its infancy and these reports are the exception rather than the rule. Without an appropriate monitoring system and the possibility of demonstrating to players that their investment of time and money is worthwhile, Local Agenda procedures cannot be stabilized, and there is little chance of handling the environment and healthcare as inherently related issues. Sustainability reports can also be integrated into existing departmental reporting on the environment and health. Moreover, sustainability reports can provide the impetus for introducing municipal sustainability management. However, in order to write sustainability reports we need useful models, quality objectives, quantifiable goals and appropriate sustainability indicators.

3.2 Fields of activity and projects

In many places, Agenda procedure assigns projects to fields of activity which touch on the environment and healthcare.

Over 80% of the local authorities which have an "environment and health rubric as part of their Local Agenda approach reported in the survey that they had implemented concrete projects under this heading. Projects were implemented in a relatively broad spectrum (cf. Fig. 6). The most frequently mentioned activity field was "climate protection. This finding corresponds to the study results on objectives, which revealed "energy conservation and promoting the use of renewable energy sources to be the primary goal. The second most frequently mentioned field was "healthy eating, an explicitly healthoriented area. "Educational and public relations projects was another oft-cited field. Looking at the results for cities and districts separately, we see that development of parks and green spaces, sport, play and leisure facilities in housing areas, noise abatement and air pollution control were less important project areas in the counties than they were in the cities.

The relationship between the environment and healthcare is still not explicitly addressed in project development. This area still needs attention.

Although many Local Agenda 21 projects contribute towards a healthy local environment, they often fail to establish a systematic link between the fields of environmental protection and healthcare. To make people aware of this link, a good first step would be devising projects in fields of activity where the interrelationship between the environment and people's health is particularly evident (e.g. healthy eating, noise abatement, mobility, climate protection, water and groundwater protection). The relationship between health and the environment can be more easily communicated in such fields than in those where the connection is not so obvious (e.g. soil protection, nature preservation). In addition, educational and public relations projects can make a particularly strong contribution towards stimulating an integrated perspective on the environment and health protection.

"Environment and health projects focusing on children and young people seem a viable option which should help promote "environment and health within Local Agenda. Senior citizens, however should not be neglected as a target group.

Children and young people are the most relevant target group since the chances are higher of activating and sustaining in them a healthier approach to life. At the same time, children and young people are more sensitive to environmental influences and the health risks and impairments these entail. Using the educational tools at our disposal is probably the easiest way to get children and young people to see the links between their living environment and their health. They can then function as multipliers and pass on the insight they have gained to their parents and other family members. But, as mentioned above, senior citizens should not be neglected as a target group. Today there is a much higher proportion of elderly people in our society than in the past. Their needs must be reflected in the form the "environment and health rubric takes. The possibility and usefulness of intergenerational projects and measures targeting both old and young should be investigated.

"Environment and health projects should pay more attention than in the past to the socially disadvantaged.

Social degradation and poverty still pose an enormous health risk in Germany. One reason for this is the increased likelihood of developing illness as a result of social disadvantage and unhealthy behaviour, and the reduced personal, financial and social resources to overcome the risks they entail. Traditional healthcare largely addresses the middle classes, meaning that poor people are very unlikely to accept them. Special, lowthreshold "environment and health services must be developed for this target group.

As was true for health promotion, "environment and health projects within the Agenda 21 framework must reflect the actual daily lives, attitudes and needs of the people concerned.

Empirical findings show that addressing the target group's living environment does play a role in the implementation of Local Agenda environment and health projects. Schools and childcare facilities are particularly important points of contact. Local Agenda "environment and health projects in some local authorities also seem to have successfully adopted the social urban development approach of the federal-Land Socially Integrative City programme, which aims to stabilize and upgrade disadvantaged districts.

Figure 6: Activity fields with projects in the "environment and health rubric*

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, Local Agenda 21 coordination offices, 2004, n=73 (cities: 38, counties: 35), multiple responses.

4. Collaboration in the "environment and health rubric within the context of Local Agenda 21

4.1 Partners

The collaboration of various players and participant groups is another central prerequisite for incorporating the "environment and health rubric, alongside thematic integration.

A key finding of the surveys of Local Agenda 21 coordination offices and of health departments and environment agencies and of case study analyses is that "environment and health projects are being implemented through partnerships. According to the Local Agenda 21 offices in cities with official county status and in counties, the local city or county council nearly always collaborates on projects. The second most common collaborators were citizens' initiatives, ahead of educational facilities (cf. Fig. 7).

Interdepartmental cooperation within local government is particularly significant for projects in the "environment and health rubric.

In many places municipal government has been persuaded to participate in the implementation of "environment and health projects as part of Local Agenda. However, discrepancies exist in the amount of collaboration stemming from individual departments. The municipal survey revealed that environment agencies more frequently participate than health departments. We must thus solicit the engagement of health departments and promote cooperation between environment agencies and health departments. Collaboration should by no means be limited to management; all administrative levels should be involved.

Figure 7: Partners in implementing "environment and health projects within Local Agenda 21*

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, coordination offices for local Agenda 21, 2004, n=82 (cities: 46, counties: 36), multiple responses.

4.2 Collaborative structures

Collaborative efforts of various players in the "environment and health" rubric require the appropriate structures.

Collaboration cannot rise of its own accord; it requires the appropriate forms and structures. Target-group-specific networking options must be established for player groups and cooperatives working in the "environment and health rubric. Round tables and projectrelated setups - i.e. concrete participation forms with limited durations - have proved to be ideal. They give players with different time demands and expertise the perfect chance to get involved. Local Agenda 21 structures often provide a useful point of contact (cf. Fig. 8). Additional moderation and mediation methods can be utilized if necessary.

Interdepartmental cooperation demands special collaboration forms and structures.

In many cases the environment agencies have taken on responsibility for local agendas. Addressing all aspects of the "environment and health rubric necessitates opening up contact to other administrative departments and cooperating with them. Many varied forms of cooperation already exist between environment agencies and health departments (cf. Fig. 9). The environment agencies surveyed stated that most cities and counties regularly exchange information and experiences. This would seem to be an important prerequisite and the first stage of collaboration. Concrete cooperation forms emerge through the joint organization of events such as "environment and health congresses. And organizing projects together is very much a valid form of cooperation between environment agencies and health departments. Joint reporting on environmental and health questions is rarer.

Figure 8: Participation forms for administrators and external players/citizens*

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, coordination offices for local Agenda 21, 2004, n=81 (cities: 46, counties: 36), multiple responses possible.

Incorporating various players, including those who have not been particularly active to date, into a collaborative network is a central prerequisite for effective incorporation of the "environment and health rubric.

The content and players of a cooperative are closely linked. New debate on integratives rubrics such as "environment and health requires new constellations of players. Whereas obtaining the support of municipal government and NGOs for implementing Local Agenda "environment and health projects has been mainly successful in many places, the participation of other partners largely excluded until now, such as health insurance companies, medical organizations, businesses, experts and sponsors, is becoming increasingly important to the adequate handling of the rubric.

Figure 9: Existing forms of cooperation in the "environment and health rubric between environment agencies and health departments (from the perspective of environment agencies)*

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, Environment agencies, 2004, n=34, multiple responses possible.

4.3 Promoting and inhibiting factors

Several promoting factors are the key to successful collaboration on "environment and health projects both inside and outside local administrative structures. Given the various disciplines and departmental cultures within local government, both personal and professional factors are important for generating willingness to cooperate and successful collaboration.

The commitment, personal involvement, creativity and intuition of individual members of staff in local government have often been highlighted as "the deciding factor in the success of collaborative efforts. This crucial "human factor can be influenced by motivational discussions, training, past rapport, etc. It must be remembered, however, that there are differences among the disciplines and departmental cultures. Professionalism requires accommodating these differences and the determination to cooperate. The political conditions and needs of the programme take precedence over personal likes and dislikes.

Collaborators must be persuaded to collaborate.

In order to persuade various players to cooperate on "environment and health projects, Local Agenda 21 must appeal to the motives and interests of these groups. One of the main guiding principles of successful cooperation is the creation of "win-win situations. Such situations are characterized by complementary skills, pooling of strengths and finances, and tapping synergies. Consequently, success comes easily and results are better. Important incentives to collaborate are a clear desire of all partners for fairness, consideration of everyone's uniquenesses and protection from exploitation.

Partners cooperating in the "environment and health rubric are bound to be heterogeneous and differences will exist in levels of information, skills and power. These should be taken into account in the framework of Local Agenda 21. The information gap should be eliminated or reduced as much as possible.

Players cooperating on implementing Local Agenda "environment and health projects have very different interests and backgrounds. Various loosely-organized or nonorganized players such as individual citizens, societies, self-help groups and citizens' clubs work alongside political players such as parties and administrators and organized mediators like environmental associations. Specially targeted participation opportunities and appropriate cooperation structures must get the less organized groups involved on equal terms, and thus dismantle existing barriers to participation.

To encourage citizens and NGOs to participate in implementing "environment and health projects, the results of such participation must later become reflected in concrete policies.

Citizens' willingness to participate is drastically staunched if they get the impression that the results of their participation have little or no relevance for political processes. A possible reason why their findings might not be implemented is the fear among local politicians that too much leeway may be given to non-authorized "shadow parliaments, to the detriment of municipal politics or established democratic institutions. But if the ideas, objectives and results of their participation are not implemented or if implementation is delayed, citizens become reluctant to invest their time and creativity in local projects. The flip side is that implementation of project ideas and findings increases citizens' willingness to get involved in Local Agenda "environment and health projects.

5. Combination of integrative programmes in the "environment and health rubric

Cooperation between Local Agenda 21 and other integrative programmes benefits environmental protection and health promotion in city and county development plans.

For a while now, both within the framework of Local Agenda 21 and in various other municipal policy areas, attempts have been made to transform traditional political and administrative procedures into holistic approaches. The WHO Healthy City Network, which emerged from the Ottawa Charter, the federal-Land programme Socially Integrative City and the Development and Opportunities for Young People in Social Hotspots (E&C) programme are schemes particularly relevant to "environment and health, alongside Local Agenda 21. These integrative programmes with a focus on municipal, environmental and health issues have several things in common with Local Agenda 21, such as the use of preventive strategies, an interdepartmental political approach, collaboration with NGOs and citizen activation and participation. These similarities suggest that a collaborative network of all these programmes could streamline attempts to achieve effective, sustainable development of our cities and boroughs concentrating on protecting the environment and promoting good health. Advantages of collaboration would include more quickly and easily attaining common goals and generating synergy effects, thanks to resource pooling of personnel and finances.

To date, however, collaboration on project and strategy design to implement integrative programmes remains the exception.

Despite the clear advantages of collaboration, there have until now been very few attempts to club together on project and strategy design in local authorities. Cities and boroughs usually implement programmes in isolation from one another or only work together on a very occasional basis on the briefest project elements. An important reason behind this segregation of neighbours is administrative tradition.

Political obligation to collaborate, realistic targets for stabilizing and improving local living conditions and established structures for joint programme management can help ensure successful collaboration between integrative programmes.

Better cooperation between programmes requires the political will to work together. In addition, local authorities must formulate realistic strategies for stabilizing and improving standards of living. The objectives they develop should constitute a binding target to guide implementers of various programmes. Another important prerequisite for cooperation is that local administration build new structures for joint programme management, whilst retaining its own autonomy (structures include staffed offices, a coordination committee, an advisory board). The objectives of joint programme management could be:

regular exchange of information between programmes,
formally structured mutual involvement in task forces and project groups,
consensus on various activities,
development and implementation of joint projects, including those which encourage citizen participation,
pooling of personnel and financial resources when implementing projects,
joint publicity activities,
mutual obligation to report on developments.

Municipal attempts to improve collaboration between integrative programmes require the support of federal and Land governments.

It is helpful if the relevant ministries at these levels have already cooperated interdepartmentally on establishing crucial networks for the individual programmes. Coordinated action between the various sponsors and the concerted application of financial and human resources from various policy areas at federal and Land level should no longer be the exception, but become the rule. Good examples to follow are APUG and in the Development and Opportunities for Young People in Social Hotspots (E&C) programme set up by the Federal Ministry for Family Affairs, Senior Citizens, Women and Youth as a complementary platform alongside Socially Integrative City.

6. Information and support needs of onsite players

6.1 Need for information and programme aids

Onsite players regard information and programme aids on guiding principles and methodology as not very useful.

The municipal survey asked Local Agenda coordination offices, environment agencies and health departments what information and programme aids they thought would be useful to them in implementing "environment and health projects within the context of Local Agenda. Only a little over a fifth of respondents found information and aids on "guiding principles and "methodology useful for their work. However, the items "guiding principles on health protection and promotion and "indicators were a different matter. A third of respondents stated that they found information on both these areas helpful (cf. Overview 2).

Many onsite players considered integrated information and aids on the intersecting areas of "environment and "health and on collaboration opportunities for environment agencies and health departments useful.

This clear need for integrated information and aids corresponds with the fact that "environment and "health are rarely explicitly linked in Local Agenda practice. The majority of the information and aids that onsite players considered useful were health-related. These included guiding principles, objectives, areas of activity, tools and players.

Onsite players clearly favoured "environment and health good practice examples over handbooks on concepts and principles.

Around two thirds of the coordination offices, environment agencies and health departments surveyed felt that having compilations of good practice examples available would enhance their work (cf. Overview 2). In addition, respondents called for all information material to be inherently practical in nature. Onsite municipal players treat handbooks on concepts and guiding principles with scepticism, seeing them as too theoretical and not realistically reflecting the dynamic of Local Agenda processes. Information and aids to help onsite players implement "environment and health projects in the context of Local Agenda should thus be largely integrative and practice-oriented in nature.

Overview 2: Onsite players clearly favoured "environment and health good practice examples over handbooks on concepts and principles*

	Coordination offices %n=114	Environment agencies %n=113	Health departments %n=129	Total (%)n=356
Guiding principles
"Sustainability of Local Agenda 21	19.3	15.0	10.1	14.6
"Health protection/promotion	33.3	18.6	45.0	32.9
Methodology
Model design	14.9	22.1	19.4	18.8
Reporting methods	11.4	14.2	28.7	18.5
Indicators	40.4	32.7	33.3	35.4
Methods for testing compatibility/ and collaboration on planning	11.4	18.6	27.1	19.4
Cooperation management methods	18.4	15.9	17.8	17.4
Deparmental information/ handbooks
Environmental protection goals, fields of activity and tools	14.9	23.9	16.3	18.3
Environmental protection players	7.9	5,3	7.8	7.0
Healthcare goals, fields of activity and tools	32.5	24.8	30.2	29.2
Healthcare players	14.9	12.4	16.3	14.6
Integrated information and aids
Joint fields of activity in "environment and "health	55.3	65.5	47.3	55.6
Collaboration possibilities for environment agencies and health departments	39.5	50.4	43.4	44.4
Good practice examples	76.3	66.4	62.0	68.0
Partners and contact addresses	34.2	28.3	31.0	31.2
Others	5,3	0.0	5.4	3,7

*Source: Municipal survey "Lokale Agenda 21 - Umwelt und Gesundheit, Local Agenda coordination offices, environment agencies and health departments, 2004, multiple responses.

The information and aids provided should concentrate on the relationship and interaction between environmental and health issues. They should consider the various fields of activity the two areas have in common and address concrete possibilities for collaboration between health promoters and environment protectors. They should combine brief theoretical explanations with a selection of good practice examples which illustrate transparent tried-and-tested approaches and solutions which players will be inspired to adopt and adapt.

6.2 Favourable conditions

Local authorities' handling of the "environment and health rubric can be improved and bolstered if federal, Land and municipal governments create the right conditions.

Communication on the environment and healthcare must be enhanced in order to better incorporate the "environment and health rubric into Local Agenda 21 activities. The federal, Land and municipal governments share the responsibility for this. All three levels should also set political targets as a binding framework for the future activities of the various "environment and health players. Practical indicators must be developed and applied to gather and analyse data on implemented projects and ideas. This allows us to measure their contribution to achieving the goals. Moreover, interdepartmental political action and approaches must be directly promoted by introducing the appropriate vertical and horizontal structures. And the introduction of formal structures for sharing experiences will make better use of existing know-how and practical experiences, e.g. a system for transferring good practice models. Federal and Land governments must establish or extend the communication platforms necessary for this. Last but not least, the federal, Land and municipal governments must work towards achieving improved networking of the various integrative local-level programmes promoting environment and healthfriendly city and district development (in particular Local Agenda 21, Healthy City and Socially Integrative City).

References

(1)This expertise was compiled as part of the research project "Umsetzung Aktionsprogramm Umwelt und Gesundheit - Teilprojekt: Handbuch Lokale Agenda 21 - Umwelt und Gesundheit (Implementation of the environment and health action programme - subproject: Local Agenda 21 handbook - The Environment and Health). The scheme is sponsored by the German Federal Ministry for the Environment, Nature Conservation and Nuclear Safety (sponsorship code* [UFO-PLAN] 204 61 218/01). The authors are responsible for the content of this publication. The handbook was published at the end of 2005: Christa Böhme, Bettina Reimann and Ulla-Kristina Schuleri-Hartje, Lokale Agenda 21 - Umwelt und Gesundheit. Expertise: Kommunale Praxis, Berlin 2005 (commissioned by the Federal Environmental Agency - UBA), download: DF9853.pdf.

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Creating Favourable Health Conditions in Municipalities - Local Agenda 21 in Practice

Creating Favourable Health Conditions in Municipalities - Local Agenda 21 in Practice