Urban Health in Urban Planning—Exploring the Status: A Survey in Greek Local Authorities

Abstract

Health and urban planning have long diverted their courses since their initial common evolution as a remedy for infectious diseases that spread out in Western European cities during the late 19th century. Today, this link is still missing, as urban planning seems to overlook health as a strategic parameter. In designing sustainable cities, attention has been shifted towards the environmental effects of urban planning, leaving behind the direct and indirect effects on human health and jeopardizing citizens’ quality of life. Despite global efforts (WHO, Urban Agenda), urban health continues to be examined in relation to illness research and health care provision in urban environments, while policy-making in cities refrains from engaging in urban health interventions through urban planning. A survey conducted among Greek municipalities explores the status and discloses the absence of the parameter “health” from urban planning and the implementation of only fragmentary actions. The main results presented in this article record the status and mentality of local authorities, elected representatives, and higher executives regarding health through urban planning. To promote a change in the mindset of planners, local actors, and decision-makers, the article proposes a conceptual framework for implementation in local authorities and highlights its main attributes.

1. Introduction

Cities and urbanization have become one of the major environmental problems the modern world is facing. Seto et al. [1] point out the three main characteristics of modern cities: they have been expanding faster than the urban population; they have been affecting the local and regional climate; and the rapid urbanization has increased the pressure on natural resources to support the functions of the city and the wellbeing of city dwellers.

As cities differ dramatically from one another in size, shape, geography, development patterns, and cultural and social characteristics, it is difficult to define a clear and homogenous path towards their sustainability. Although the blueprint for urban sustainability is put together on a global scale, the components of a sustainable city must be sought for each city individually in the specific local context.

In this context, urban planning is called upon to play the role of the instrument through which actions for a sustainable city will be adopted and implemented. The key challenge to be addressed is to achieve an integrated strategy and/or policy that can produce positive outcomes both for the health of residents and the sustainability of cities. This challenge can only be met at the local level by incorporating integrated management into everyday governance practice, whether through the formulation of a broader policy strategy or a spatial intervention or project [2].

Urban planning plays a significant role in shaping the physical and social environment of cities, and it has a direct impact on public health. The importance of public health for sustainable development has been highlighted early by the World Health Organization and the Healthy Cities Network, created for this purpose. Increasing evidence shows that physical and mental health problems are related to the built environment, including human-altered spaces such as homes, schools, workplaces, parks, industrial areas, open spaces, roads, and motorways [3,4,5,6,7,8]. Either directly or indirectly, the urban fabric, its characteristics, and its functions reflect on citizens. This is why the relationship between the built environment and public health is of crucial importance and requires special attention and consideration [9].

Urban planning affects public health in many ways. Among them, the most significant are air quality and environmental hazards; social interaction and mental health; noise pollution and stress; access to healthy food; active transportation and physical activity; safety and crime prevention; accessible infrastructure for persons with disabilities; access to healthcare; and health equity.

WHO was the first organization to re-introduce the need for a health perspective on all urban issues through the “Healthy Cities” movement. Despite this effort, which would enable urban planning and public health to re-converge, there is still little progress, especially in local authorities.

Urban planning has a profound impact on public health by shaping the built environment and influencing various aspects of daily life. A well-planned and designed city can foster physical activity, provide access to healthy food, mitigate environmental hazards, promote social interaction and mental well-being, enhance safety, reduce noise pollution, and contribute to health equity among its residents. The physical and built environment (urban geometry, infrastructure, and availability of green spaces) may affect citizens’ health. As we discuss urban planning and its characteristics, we must consider the urban dimension of public health: urban health. A definition of “urban health” by Wuerzer sets the context. According to this definition, “urban health reflects the outcomes of the physical and social environment that impact residents’ and communities’ well-being and quality of life within an urbansetting” [10]. This research is restricted to the effects of the physical environment—the urban form, which is the subject of urban planning.

Tackling urban health is a challenge that requires an approach that focuses on the social and environmental determinants that affect health outcomes and an understanding of the complex interactions between them in the urban context [11]. The authors’ long experience in urban affairs and local strategic management was the impetus to further explore the inclusion of health in local urban planning. For this reason, a research study was designed and carried out.

The main aim of this work is to present the results of a survey conducted among Greek municipalities that explores how the parameter “health” is considered in urban planning in Greece. Thus, this paper is structured as follows: In Section 2, the main elements of urban planning as well as the general context of public health implications in relation to urban planning are given, while in Section 3, the main characteristics of the survey are presented. Finally, in Section 4, the survey results are described, and in Section 5, the main conclusions are recorded by discussing the survey’s results.

2. Public Health in Urban Planning Context

As stated in the United Nations Agenda 21 for Sustainable Development, “sound development cannot exist without a healthy population” [12]. Therefore, it is essential to direct the focus toward the city and how it can provide all the necessary channels among different stakeholders (professionals, planners, politicians, and the community) [13] that form urban plans and policies. The role of the central government, which shapes and implements the health policy, should also be considered when combining urban plans and health provisions. The emphasis, nevertheless, is on the local authorities, as this is the level of governance closest to the citizens.

2.1. The Effects of Urbanization

The evolution of city forms and, subsequently, the patterns of urbanization are highly heterogeneous, both within and across countries [14]. The urbanization rate influences the economic, social, and political context in cities and, to a greater extent, the environment and wellbeing of citizens.

Urbanization is an important prerequisite for economic growth, but it must be managed effectively if cities are to fulfil their potential as drivers of growth in a national and, by extension, European context [15].

As Europe’s level of urbanization is expected to rise to around 83.7% in 2050 [16], it becomes more and more evident that cities need to develop policies and tools to mitigate its negative effects. Literature shows that urbanization is associated with adverse health effects and the rise of non-communicable diseases—the “urban disease” [17,18,19,20]. With the effects of climate change [21,22,23] having a toll on cities’ vulnerability, the importance of the “health” parameter is even more accentuated and needs to be urgently addressed by local governments and integrated into their planning and policies. As NCDs are further aggravated by the changing climate, people will be increasingly affected by environmental health risks in cities [24].

All systems necessary to support the expanding cities (housing, infrastructure, energy, transport, resource depletion) have been proven to affect the environment (air pollution, ecosystem services, urban heat island) with a negative connotation, which has a severe impact on citizens’ health. Therefore, we could extrapolate that urban planning is the constituent of all changes in urban tissue that directly or indirectly affect human health [25,26]. Densification, as well, although a preferred solution for urban sprawl, presents adverse health effects when considering different parameters [27].

In Greece, as well, urbanization has been a dominant characteristic of the last century, mainly post-WWII. Figure 1 shows the increase in the urbanization rate in Greece over time (1960–2020) at the expense of the rural population. This trend is expected to intensify in the upcoming years as the rural population is projected to shrink further by 2050.

The excessive concentration of population in cities, combined with the intensification of all anthropogenic activities, has brought about particularly significant changes in the climatic conditions of the environment of modern cities and has degraded the ecological systems of urban agglomerations and their surroundings. The built environment, including the composition and shape of settlements, transportation systems, and green infrastructure, has been recognized as an important determinant of health worldwide. The places where we spend our lives have a profound impact on our physical, mental, social, environmental, and economic wellbeing [29,30], as well as on health equity [31,32,33]. Therefore, cities must redirect their attention towards the connection between urban planning and urban health.

2.2. Urban Planning and Urban Health

Urban planning evolved as a solution to jointly address health emergencies (infectious diseases) that derived from unsanitary conditions and poor infrastructure planning in the nineteenth century [34]. Despite their common origin in the sanitary movement of the 1840s [35], both disciplines evolved separately, dismissing this connection.

Today, as the pressure from the urbanization rate is becoming critical not only to systems but to humans as well, it is becoming widely accepted that urban planning and urban health share common missions and perspectives. They both aim to improve the well-being of citizens based on a needs assessment, manage complex social systems, keep their focus on the population level, and rely on community-based participatory methods. During their development, both disciplines have broadened their perspectives since their initial scope of practice. As a separate discipline, public health has most often used a biomedical model (examining the normal/abnormal functioning of the human body), while urban planning often relies on a geographic model (analysing human necessities or interactions in a spatial context). However, both fields have expanded their tools and perspectives, partly due to each other’s influence. Urban planning and public health have been intertwined for most of their history [36].

Human and ecosystem health are building blocks for creating sustainable places. Clean air and water, access to natural resources, fuel and food, good-quality housing, education, income, safety, social justice, and equity are all essential for good health. These basic conditions and resources for people’s health come from healthy, stable ecosystems. A deliberate focus on sustaining the ecosystems that are the resources of our cities while actively shaping the conditions for health is of paramount importance to good urban design [37].

The key challenge to be addressed is to achieve an integrated strategy and/or policy that has shared positive outcomes for both the health of residents and the sustainability of cities [2]. Health is central to human development, both as an inalienable right and as a key factor in the growth and development of communities and societies. The role of local government is to promote every human right of the inhabitants and to ensure—as far as possible—a high standard of living. Cities need to stand above fragmented interventions and works and adopt a more integrated approach to urban health through urban policymaking and planning [38].

2.3. The Healthy Cities Program Paradigm

Healthy Cities is a global movement for urban health that started as a Canadian initiative in the ‘80s and eventually became an official program of the World Health Organization [39]. WHO launched the Healthy Cities in the European Region program as early as 1987 to bring the Health for All strategy to the local level of governance.

The Healthy Cities Network, currently in phase VII (2019–2025), pursues a strategic role to highlight and promote the important role that local governments have in developing health and well-being through integrated approaches. From its inception, the Healthy Cities program recognized that health is determined by a range of personal, social, economic, and environmental factors [40].

A successful example of a national network is the French “Villes Santé”, which offers a range of good practices from small and focused to larger and broader [41].

In Greece, the values of the network are being promoted through the Hellenic Healthy Cities Network (National Intermunicipal Network of Healthy Cities-Health Promotion—EDDYPY), a continuously developing network with, currently (according to the official website of the network—https://eddyppy.gr/ (accessed on 8 August 2023), 242 member local authorities in order to implement well-designed health actions and programs that will stand the test of time and have measurable results, according to the criteria of the WHO. Today, a remarkable 72.7% (242 members out of 333) of the total Greek municipalities are members of the network. Figure 2 indicates that the main objective of the Greek branch of the Healthy Cities Network is “to provide cities with the scientific and technical support they need to implement the Healthy Cities program, according to the criteria set by WHO for European national healthy cities networks and their member cities” [42].

However, of this large group of municipalities, only seven have been accredited for Phase VII. In studying the activities of the local network from the official website, a large number of activities for citizen awareness are being promoted along with policy papers on health issues: prevention and management of work-related stress (2021), organization and operation of health centres (2021), unemployment and its impact on health (2021), prevention of accidents, nutrition (2017), mental health (2016), physical activity and active living (2016), and healthy and active aging (2015). There is also an exhaustive list of cities’ health profiles, but no mention, paper, or study on the relationship between urban planning and health, a relative framework, or a proposed national strategy. Hence, this research will try to clarify the status of the incorporation of health in urban planning in Greek cities.

2.4. Current Policies in the National Context

WHO was the first international organization to re-introduce the close connection between urban planning and urban health. It has long been emphasized the importance of healthy human habitats, providing cities with tools and policies to support “healthy” urban planning.

Cities are an important driver for the implementation of the Sustainable Development Goals (SDGs) and the New Urban Agenda. The SDGs provide an operational framework for addressing urbanization globally while providing local mechanisms for action and attention to closing gaps in the distribution of health benefits. Both health and well-being, besides being addressed directly in SDG 3, are also present in SDG 11, which has as a target “inclusive, safe, resilient, and sustainable cities” [44].

At the European level, the EU Urban Agenda, launched by the Amsterdam Pact in 2016 to try and find solutions to major urban challenges, encourages cooperation between national and local policymakers to address urban challenges [45]. The New Urban Agenda also supports the reorientation of urban and territorial planning towards more people-centered practices. These two factors alone, although there are others, provide a strong basis for focusing on “health” as a key component for urban and territorial planning [2,46,47].

In Greece, the competent authority for the design and implementation of urban planning and urban policy in general is the Ministry of Environment and Energy. On the ministry’s official website, it is stated that “based on its executive role, the ministry is shaping a modern urban regeneration policy with a comprehensive approach to urban problems, coordinated multi-level actions, and updating the institutional framework to make it operational and effective”. To fulfil this role, the Ministry of Environment suggests the following targets to be pursued in urban planning: environmental protection, urban functionality, urban mobility, social cohesion, increasing entrepreneurship and innovation, urban aesthetics, housing conditions, construction economy, energy and environmental urban footprint, participatory processes, management, and protection of open public space [48]. It encompasses all possible parameters that affect human health without explicitly and formally acknowledging them.

2.5. Current Urban Planning Practice in Greek Municipalities

The evolution of the Greek urban planning framework has undergone many changes until this day, following, parallelly, the transformation of the Greek cities and the different needs dictated by the rapid urbanization after WWII. There are two main instruments that shape policies at the local level: the operational program (development-based) and the general urban plan (design-based).

On the one hand, the main instrument for local planning and local policy development is the operational or strategic program of each municipality, an integrated program of local development and improvement of the administrative capacity of the municipality, and a product of the collective operation of the municipality’s services.

As an integral part of the day-to-day operation and management of the municipality and part of its programming cycle, it must be easy to use, concise, and comprehensive, codifying, as far as possible, the information it provides to facilitate its monitoring and updating when necessary. It emphasizes diagnosis in relation to mapping the external and internal environment and identifying key development priorities. It emphasizes the identification of critical issues on which the municipality should focus its efforts, considering local problems, national and regional development priorities, and its organizational capacity.

It is divided into two distinct phases: strategic planning and operational planning. The first phase is conducted internally with the cooperation of all municipal services and the administration to set the overall policy and the vision to be accomplished.

The strategic planning axes are predefined and in line with the organization of responsibilities and are divided into four thematic areas:

• Environment and quality of life,
• Social policy, health, education, culture, and sports
• Local economy and employment
• Improvement of the administrative capacity and the financial situation of the municipality

During the second phase (operational planning), the strategic planning document undergoes a public consultation procedure to fine-tune the distinct actions to be implemented or to get new insights from citizens into possible neglected or undervalued issues. Then, all aims are further specialized into distinct interventions for implementation.

On the other hand, local urban (and peri-urban) planning policy is conducted via the General Urban Plans, which aim to set directions for the rational organization and development of the urban fabric (municipality borders). The GUPs aim to define the guiding principles of urban planning for sustainable residential development. In particular, they aim at the organization of space, ensuring the residential organization of settlements with the desired correlation of residential parameters, the protection of the environment, and the cessation of unregulated construction by defining development criteria, the upgrading of the environment, especially in degraded areas, by ensuring the necessary social and technical infrastructure, and the control of land uses in accordance with urban planning and development criteria—the improvement of the environment, especially in the case of degraded areas.

In this framework, which enables local authorities to implement integrated urban plans where the factor of health is embedded, this research attempts to examine the status quo and propose a way forward.

3. Research Methodology

3.1. Survey of Greek Local Authorities

To explore the status of the provision of health in local planning procedures, a relative survey has been conducted among Greek local authorities (municipalities). The aim of the research was to assess the level of incorporation of health considerations in the urban planning processes of municipalities in Greece. Through this survey, existing gaps and challenges in integrating urban health into urban planning efforts have been identified.

In planning the survey, the consideration of choosing the most appropriate method is linked to the individual approach to the research question, its immediacy and weight, the comparison of the positive and negative features of each method, and the limitations and availability of resources and time according to the individual capabilities of the researcher [49].

To study and research issues of urban interest, a lot of knowledge is required for well-designed, functional, and accessible planning. The same applies to a multitude of other activities within the architectural and planning profession, such as policy development, spatial planning, requirements programming, construction, etc. In-depth knowledge of the status of the urban issue in question can contribute to well-thought-out policies and justified decisions. One methodological way of collecting knowledge is to accurately describe reality [50]. The best way to describe issues of urban affairs is to conduct a descriptive survey to explicitly illustrate the current situation.

3.2. Survey Characteristics

The survey was conducted with the aim of collecting, describing, analysing, and capturing the expression of the views of elected officials and local government officials in order to capture and record the current situation, perceptions, and possibilities around the link between urban planning and environmental parameters affecting health in cities.

Of particular importance in the design and conduct of scientific research is the identification of the research population and, in particular, the selection of the sample. In this case, the entire research population was used due to its specific nature and size, i.e., all Greek municipalities.

The survey took place in late 2022 and the beginning of 2023 through an electronic questionnaire that was distributed to all 333 Greek municipalities. The questionnaire was addressed to elected officials (mayors and vice mayors) and municipality officials supervising relevant departments (programming and development departments or technical services).

3.3. Questionnaire Characteristics

The questionnaire prepared consists of closed-ended, one-word (yes/no), verbal, and numerical (Likert scale) questions that were checked for validity through piloting by the researcher with local authorities’ employees. To ensure a high response rate, the anonymity of the participants was guaranteed, as no information was requested from which the respondent could be identified. The collection procedure resulted in a 27.6% response rate (87 municipalities responded).

The questionnaire, after being drafted and checked for validity through piloting by the researchers with local authorities’ employees (5), was formatted in electronic format using Google Forms. It is divided into four sections: in the first part, the respondent is asked about the characteristics of the municipality on whose behalf he/she is participating in the survey; in the second part, questions are asked about the adequacy of the critical services involved, either from an urban planning perspective (technical service, planning/design service) or from a health perspective (municipal clinic, at-home help program, and other social welfare structures). The third part comprises “intention” questions about the integration of various health parameters in planning and actions implemented by the municipality, and, finally, the fourth section collects information about the education level and the status of the respondent in the organizational structure of the municipality. In this paper, the focus is on results from the second and third parts of the research questionnaire.

4. Survey Results

a.

Characteristics

Municipalities from all geographical areas of Greece participated in the survey (even if only to a minimal percentage, some of them), with most of the respondents representing a medium-sized city (15,001–50,000 inhabitants).

b.

Adequacy of municipal services

In their large majority (85%), the participating municipalities possess the organizational capacity and structures to support the development and implementation of operational planning and urban planning. Data for the majority of the participating municipalities regarding the current planning practice shows that there is neither a systematic assessment of health scores for the citizens nor a relevant monitoring plan for the environmental parameters that affect health. Nevertheless, all available instruments (operational planning—general urban plan) are in place.

Municipalities are familiar with strategic integrated planning and its decentralisation processes (the existence of operational and other strategic plans in individual sectors). A cross-tabulation of the existence of an operational plan and whether it provides for separate axes or separate actions for health reveals encouraging evidence. Most of the municipalities that have developed an operational plan also take health into account, at least in some of their actions. Herein, it would be interesting to look into the nature of the actions being envisaged and the implementation percentage at the end of the year.

Another piece of background information required in order to assess the awareness status in planning and decision-making was that of recording primary data and information related to both the monitoring of environmental parameters affecting health and the recording of perceived health among residents. Unfortunately, in this case, the data is discouraging because the majority of the municipalities that participated in the survey have never implemented any of these inventories. Few municipalities do occasional surveys at random intervals (Figure 3), and only one stated that it has on-line real-time monitoring of temperature, humidity, and air pollution measurements at 20 locations and real-time water quality recorders.

As far as health information actions are concerned, these are implemented even more occasionally (the highest frequency being 1–2 times per year, followed by 1–2 times per semester), as depicted in Figure 4.

Another important fact that this survey reveals (Figure 5) is that about 41% of the municipalities provide for separate health expenditures in their local budgets. Nevertheless, the survey lacks information on the nature of these expenditures and the needs they serve. It would be interesting to further analyse these data to define what part of this expenditure is channelled via urban planning actions and what percentage of the local budget they represent.

c.

Intentions

Administration and executives affirm that the responsibility of the municipality to take action to protect and/or improve the urban health status of its residents is at its highest level. This mission is also described in the main legal document for local authorities [51]. This affirmation is accompanied by a strong intention to change the way projects are designed so that the health dimension is integrated into the design (Figure 6).

The most prevalent factors affecting this declaration are presented in Figure 7. An interesting finding is that a key factor in shifting local policies towards integrating health into planning is the existence of a methodological framework for this purpose. Executives would welcome a guide who would assist and guide them in their efforts.

d.

Respondents’ status

The vast majority of participants have a university education (94%), while the percentage of those with higher education (master’s degree, doctorate) is also significant. Most of the survey participants are city executives holding a position of responsibility in their municipality, i.e., either department heads or heads at the directorate level. Only six participants are elected officials, and 31 are employees.

5. Discussion

The state of the urban environment and the way it is managed and used by city dwellers are fundamental to human health and well-being. Municipalities are the competent authorities for both urban planning and urban health protection.

A literature review has shown that the factor “health” is poorly represented in local urban planning strategies in Greece. Fragmented efforts and actions are being implemented with no official or formal strategy.

Other European research has also shown insufficient coverage of health issues in EIAs and SEAs, that health is addressed superficially and mainly through the analysis of “health and safety” criteria [52], or that regulatory development to support the inclusion of “health” in planning is still incomplete due to the current lack of resources and associated costs, both for administrations and project developers [53]. A review of “Current Global Health Impact Assessment Practice” by Winkler et al. [54] identifies the main barriers to HIA as limited technical expertise and capacity, a lack of policy and legal frameworks to support the use of health in impact assessment, and a lack of awareness among decision-makers and public health professionals.

Experience has shown that local planning processes for environment and health succeed only when they have a clear and unambiguous commitment from leadership at the highest political level—this in turn creates and supports similar commitment at the highest level in the local community [55]. For these reasons, urban planning and urban health agendas should be aligned at the local level and embrace common goals and priorities. Health priorities should be directly related to local specificities [33], so there is no horizontal measure that can be adopted. Participants in the research suggest that they are willing to embark on this new challenge if a guidance framework is created. This would offer the necessary capacity, flexibility, and adaptability to different citizen needs and urban characteristics.

5.1. Implications for Municipalities

The status of the Greek municipalities allows little room for major modifications in the urban form and especially the built environment. Nevertheless, the development of an “urban health in urban planning” framework would allow for solutions that have not been considered before in planning practice.

Local budgets are also seen as a major constraint for many local authorities, and any action concerning urban planning is not always financially feasible [56]. Municipal built environment professionals can improve health through policies and decisions that identify the need for and design new infrastructure, development, and redevelopment programs [57], and a framework with clear steps, tools, and procedures is expected to provide significant solutions.

5.2. Need for a Methodological Framework

From the conclusions of the survey, a new need has emerged: the need to develop a methodological framework as a prerequisite for the incorporation of health in local urban planning policies, works, and interventions. This framework must satisfy equally the need for sustainable development of the city and the quality of life and health of its residents. A conceptualization of such a proposed framework is depicted in Figure 8.

In order to record and assess all dynamic and diverse local needs, the proposed framework should include a circular and self-feedback structure. The main elements of this framework are (a) the urban planning procedure and (b) the implementation of strategic and urban plans, which should be based on supporting evidence regarding the influence of environmental parameters on citizens’ health. Analysis and detailed research of each segment will be the object of a follow-up study, and each component must be studied further in detail.

5.3. Suggestions for Future Research

This survey has led to further research on the issue and the development of an “urban health in urban planning” framework that would describe how local authorities can embed the health parameter into every aspect of urban planning and urban work implementation.

Another extension to this survey could be realized by a relative survey in European municipalities, using the same questionnaire, that could both offer new insights into local urban planning policy options and perhaps benchmarking and inspiration for Greek local authorities. Despite the numerous local or national studies on this issue, the implementation of the same parameters would offer valuable, comparable results.