# Session Overview While completing this session, take time to reflect on some of the following questions: · What is the purpose of each local initiative? · Who defines what is and is not local? · Whose involvement is important in the design and development of local initiatives? · What could be the principles of good local policy design? · What defines the effectiveness of such initiatives and how their effectiveness can be assessed? · How do local initiatives link with the global efforts on environmental health protection and sustainable development? · What are the power relations between local, national and global stakeholders? ## Learning outcomes · Explain the concept of local governance and identify different types of decentralisation of resources and decision-making authority · Illustrate how environmental health problems can be addressed through local policy initiatives in various settings in low and high income countries · Differentiate between top-down and bottom-up local initiatives and their associated policy development processes · Discuss the effectiveness and challenges of local policy initiatives and approaches to its evaluation # 1. Introduction While the policy are formulated or coordinated by global institutions, the implementations often occurs through national and sub-national organisations. It is increasingly considered that meaningful implementation work best through the participation of local communities and other organisations. It is also often the case that specific environmental health cocerns that come to be understood as global policy issues, originate from local communities, scientists, politicians and other groups' observations and action. # 2. Local governance Who, what and how stakeholders come to participate in local initiatives, including policy advocacy, design and implementation, greatly depends on the forms and actors involved in sub-national (i.e. ‘local’) governance; an important aspect of which are any national governments’ policies with relation to the decentralisation of political, financial and administrative authority, including health care provision. ## 2.1 De/centralization The roles of local government have expanded, and sometimes shifted, from public service provision and regulation towards the facilitation of other network forms of local governance in a multi-centred, multi-ordered, and multi-level systems (Shah and Sana Shah 2006). At national and subnational scales, this can partly be understood as part of the processes of decentralisation. Decentralisation is understood and practiced in different ways, depending on the contexts and functions it is intended to play. Typically in global and public health, decentralisation is understood as a ‘top-down’ process (Abimbola, Baatiema, and Bigdeli 2019), where a combination of political, financial and administrative authority over ‘public planning, management and decision making’ are transferred ‘ from a national or higher level of government to sub-national or lower levels’ (Sumah, Baatiema, and Abimbola 2016; Mitchell and Bossert 2010). [[How does power came to be?]] This way of understanding decentralisation is often divided into four different typologies of how power (see Session 3 for a discussion of power) and authority are transferred from central state governments to lower levels, as well as to other organisations: 1. ==De-concentration==: tends to be viewed as the most limited form of decentralisation with its focus on transferring ‘…administrative responsibilities to local offices of central government ministries’ (Sumah, Baatiema, and Abimbola 2016). In other words, it seeks to extend local stakeholders’ roles in delivering government services. It is also sometimes referred to as administrative decentralisation (Mitchell and Bossert 2010). 2. ==Delegation==: involves the transfer of designated government functions (including managerial responsibilities) to organisations outside the central government, often more or less autonomous from it. For example, the role of medical societies to set standards for clinical care (Saltman, Bankauskaite, and Vrangbæk 2007, 48–49; Sumah, Baatiema, and Abimbola 2016, 2–3). This might include financial decentralisation, which involves equipping lower-level government authorities with greater control over the collection and spending of revenues at local levels (Mitchell and Bossert 2010). 3. ==Devolution==: is the transfer of political authority (often including financial authority, for example related decisions on taxation) to lower levels of locally elected government organisations (e.g. regions, municipalities and districts), which may include not only greater control over the delivery of government services, but also citizens and other local organisations role in policy design (Mitchell and Bossert 2010). 4. Privatisation: is the transfer of government functions (e.g. health care provision) to private or voluntary organisations. Decentralisation is argued for improved access, equity and local control over health and other health services, but in practice the effectiveness of decentralization to address these issues is far from clear (Abimbola, Baatiema, and Bigdeli 2019). [[Successful implementation of decentralisation depends on the tools and capabilities the local governments are equipped with, plus the context in which and how the country operates.]] Therefore, it is important to look at the historical context of the decentralisation in each respective contry, as a phenomenon, before as an intervention of a central government. Not only is successful implementation of decentralisation (i.e. of health services and other government functions) based on access to sufficient financial, human and other resources, but its evaluation as a health policy intervention is complex, dependent on shared assumptions across different countries or settings (Abimbola, Baatiema, and Bigdeli 2019). This is where a more historical and contextually specific understanding of decentralisation as a phenomenon, rather than as an intervention or policy of a central government may help. the presence of a central government and its associated institutions have specific histories, whether they came into existence through colonisation, monarchic expansion or in a ‘bottom-up’ fashion, through voluntary aggregation of smaller territorial units (Abimbola, Baatiema, and Bigdeli 2019). Thus, the history of the centralisation of a nation’s power and authority plays an important role in how national governments, sub-national units and populations relate to one another and the extent to which decentralisation policies can effectively and equitably address environmental health problems, as well as recognise their health consequences in the first place (De Lima Hutchison 2014) Examples of such histories of state governance, include the US and Argentina or Argentina; both are nation-states, which have come into existence through European colonisation and have decentralised political and other forms of authority (i.e. federal systems) to their various state or provinces. India has also decentralised various aspects of its political, economic, health and environmental governance. Important to see [[Bourdieu]] capital to complement this. Decentralisation may trickle down right to the empower local communities to develop greater independence from state services and self-reliance in their environmental and health caring practices. ## 2.2 Intersectoral collaborations Due to the diversity of environmental health problems, intersectoral collaborations take many forms. They can involve ==horizontal== collaborations (include alliances, coalitions, partnerships, networks) between stakeholders from different sectors and ==vertical== (often hierarchical) collaborations between national, regional, and local governments or other organisations (Rantala, Bortz, and Armada 2014). # 3. Local policy initiatives, their development and implementation ## 3.1 Top-down local initiatives An example of such a [top-down] initiative is Agenda 21. [[Agenda 21]] was formulated as a non-binding global action plan for sustainable development aimed at all levels of governance (i.e. international, national, regional and local) and societies, established at the first United Nations conference on the Environment and Development in Rio de Janeiro in 1992 and ratified by more than 170 states (LaFond 1999). It emerged at a time when increasing attention was placed on the importance of local actions to solving and creating global problems. An example is the [WHO’s Healthy Settings initiatives](https://www.who.int/teams/health-promotion/enhanced-wellbeing/healthy-settings#:~:text=Healthy%20Settings%2C%20the%20settings%2Dbased,a%20%22whole%20system%22%20approach.), which was the outcome of the Ottawa Conference on Health promotion in 1986, and was enshrined in the Ottawa Charter for Health Promotion (Dooris 2013; Kickbusch 1996). The settings approach places an emphasis on: ‘The place or social context in which people engage in daily activities in which environmental, organizational, and personal factors interact to affect health and wellbeing. A setting is also where people actively use and shape the environment and thus create or solve problems relating to health’ (Takano 2003, 5). It aims to integrate health promotion and sustainable development, which includes the principles of equity, empowerment, partnership and community participation (WHO 2024). Its programmes developed further into the Healthy Settings movement - a set of initiatives aiming to promote health through different local settings, such as schools, work sites, universities, villages (Liverani et al. 2024), cities, islands, hospitals, and which now are implemented across all the WHO regions (WHO 2015; Kokko and Baybutt 2022). A central aspect of the Healthy Settings approach is that it recognises settings as the ‘the organisational base of the infrastructure required for health promotion’ (WHO 1997, 4). Healthy Cities is one of the many initiatives established through the Healthy Settings movement. It was launched by the WHO in 1987, with the aim of targeting city-level governments and fostering intersectoral collaborations to ensure health was central to local policies (Dooris 2013). It recognised that due to rapidly increasing urbanisation and environmental change, there was a need to actively improve living conditions and health, whilst attending to the diverse resources required and challenges different cities faced. Some argued that the WHO adopted the approach of addressing city-level governments to bypass national governments, some of which were resistant to the implementation of the principles of the Ottawa Charter (Dooris 2013). The Healthy Cities model was adopted and driven by a wide range of stakeholders, including city government authorities, such as in Europe, through the development of the WHO European Healthy Cities Network, which has been running for more 30 years; and continues to update and publish relevant guidance (see for example, WHO 2022). It has also developed independent of governments, in the case of Kiama/Illawarra in New South Wales and Noarlunga/Onkaparinga in the state of South Australia by civil society and has also been used by multinational corporations (De Leeuw and Simos 2017), such as BUPA, who have created a ‘Healthy Cities’ application as a means of ‘promoting healthy lifestyles among people and contributing to the creation of healthier and more sustainable environments in our cities’ (BUPA 2023). The application allegedly enables users to ‘unlock investment from Bupa (a health insurance company) into the restoration of the environment in urban areas – including tree planting to help with reforestation and creating new urban forests’ (BUPA 2023). However, it also gathers and shares or sells the users’ data to third parties, thus profiting off its users and local activities. This potentially reflects differing and maybe competing interests of stakeholders (i.e. private corporations, state providers of health services and users or patients). > A large part of the success of the Healthy Cities movement can be attributed to its focus on promoting and supporting locally driven initiatives that attempt to develop different visions of healthy cities and their residents’ health, and hence involve a diversity of stakeholders (e.g. national, city and local level government authorities, as well as civil society networks and even multinational companies) in and across these cities. This emphasis on engaging multiple stakeholders in intersectoral collaborations across governments and societies, including local communities and authorities, also resonates with the UN and WHO’s increasing promotion of holistic, whole society approaches, which seek to develop and implement successful coherent policies – from global to local. ## 3.2 Bottom-up local initiatives There are many examples of such efforts involving indigenous people, health workers, epidemiologists, and sometimes anthropologists, organising locally and transnationally in response to environmental health concerns stemming from what they believe are the actions of state and corporate extractive (i.e. mining and drilling) industries as well as deforestation (B. Brisbois 2016; A. Hurtig and Sebastián 2005; San Sebastian and Hurtig 2005; A.-K. Hurtig and Sebastián 2004; Sawyer 2022), industrial farming and industrial waste from factories (Brown 2005; Conde and Orta-Martínez 2023; Hoover 2020). For example, the Ecuadorian state and the US oil company Texaco (later acquired by Chevron), extracted billions of barrels of oil from the Ecuadorian Amazon. Since oil exploration began in the region in 1970s, small farmer movements, environmental groups and indigenous communities organised against the oil extraction and reported widespread environmental devastation (e.g. deforestation and oil contamination in soil and waterways) and negative human health consequences. However, no systematic action was taken to clean up the oil related pollution and address reports of associated adverse health outcomes. Around 1994, local indigenous communities and peasant groups came together to create Frente de Defensa de la Amazonia (FDA, Front of Amazon Defense), which sought to coordinate a legal case against the oil company, Texaco-Chevron (San Sebastian and Hurtig 2005). To make their case, the FDA sought evidence of an association between oil contamination and adverse health outcomes. Due to their lack of epidemiological expertise and official scientific authority, FDA began to work with epidemiologists at local NGOs and LSHTM to conduct popular epidemiology studies (San Sebastian and Hurtig 2005). The studies found higher than average oil concentrations in drinking water, higher risks of skin disease, gastritis (San Sebastián, Armstrong, and Stephens 2001), spontaneous abortions and incidences of cancer compared to those living in areas free of oil exploitation (A.-K. Hurtig and Sebastián 2004; A.-K. Hurtig and San Sebastián 2002; Sebastián, Armstrong, and Stephens 2002). On the basis of these studies, local groups tried to use such evidence to advocate for policy changes to protect the health of local populations and their environments, better access to health care, proper adherence to environmental health regulation, compensation and the cessation of extraction activities (e.g. of oil). However, some epidemiologists and lawyers, including those employed by Texaco-Chevron, contested the scientific validity of these studies (e.g. their sample size, methods etc) and also provided counter-epidemiological evidence based on their own studies . This is not uncommon for local groups evidence to be subject to strong contestation by corporate, state and/or scientific actors, who in many cases will have access to greater political, scientific, and legal authority, as well as economic and human resources (B. Brisbois 2016). In 2011, after two decades of legal battles, Ecuadorian indigenous peoples and other residents were awarded a $19 billion pay-out from Texaco-Chevron in compensation for loss of crops, animals and increased cancer rates. However, Texaco-Chevron refused to pay out, and later a US court judge and the Permanent Court of Arbitration in 2018 in the Hague ruled against the award based on allegations that Ecuadorian courts were fraudulent (Sawyer 2022). The anthropologist Suzanna Sawyer (2022) demonstrates in her book The small matter of Suing Chevron, how the transnational political, economic and legal power of Chevron was able to shift the legal focus from an oil company’s environmental health impacts to Ecuador’s violation of US-Ecuador Bilateral Investment Treaty and the legitimacy of its courts and in doing so, obtain a ruling against awarding compensation and absolve themselves of any culpability (Sawyer 2022). This is a clear example of the power asymmetries local initiatives often face when attempting to address their environmental health concerns, especially when transnational corporations and state actors are involved, as they frequently have different priorities, access to resources (e.g. financial, legal, scientific etc) and views. An example of a local group based in a high income country is Surfers against Sewage (SAS) - now a charity , which seeks to raise public awareness, campaign for improved water quality and hold governments and other actors accountable for their role in polluting beaches and oceans. It was started by surfers in the southwest of England in the 1990s in response to the presence of raw sewage in the waters in the southwest of England and the failure of the government to ensure the various environmental health standards and laws it had put in place were properly met (Laviolette 2006; Wheaton 2007; Ward 1996). SAS’s advocacy work has since expanded beyond the UK and surfers to ‘water lovers’ in general, and includes organising beach clean ups, setting up campaign groups, producing and providing reports and learning material relevant to pollution (Surfers Against Sewage 2010; 2014), going plastic free and sewage free oceans etc. A central aspect of the work of SAS and groups like it, is the recognition that in order to get governments and corporations to address local environmental health concerns, local groups need to overcome power differentials. In the case of SAS, they have done this through campaign and advocacy work, which has built broader awareness, support and hence pressure on the UK government to improve the water quality through better adherence to legal standards. It’s important to note that improving water quality in the UK is an on-going process, which SAS continues to campaign on, including recently on the Thames Water scandals (Surfers Against Sewage 2024); where private water companies have been responsible for the mass dumping of sewage into English water ways. # 4. Assessing local initiatives Effectiveness and equity can be assessed by evaluating the impact of local initiatives on health outcomes of interest and relevant environmental risk factors (e.g. quantity of carbon dioxide emissions, presence of specific chemicals and infectious agents in water). This might include some breakdown and comparison of health outcome by different populations and demographic factors. Assessments may be performed through quantitative statistical and epidemiological assessments (e.g. according to specific health outcomes and relevant risk factors), as well as qualitative assessments (e.g. surveys and questionnaires with relevant stakeholders) (Liverani et al. 2024). Attention to environmental sustainability is a relatively new dimension for policy evaluations and presents a number of challenges, including determining at what level (e.g. local, national, global etc) a process or outcome is deemed sustainable and according to whose or what criteria. Sustainability may exist as a separate variable of policy evaluation or be integrated as part of any evaluations of effectiveness, efficiency and equity, which may be part of already existing frameworks (e.g. such as the SDGs, Agenda 21, Healthy Cities and Health in All Policies) or may involve especially tailored variables of analysis (Canavese, Ortega, and Queirós 2014; Corbiére-Nicollier et al. 2003). It is important to also reflect carefully on how and who conducts any initiatives and their assessments, as well as careful consideration of any groups or individuals who contest them, and their likely motivations (B. W. Brisbois et al. 2016). # 5. Summary This session introduced you to the role of local environmental health initiatives in relation to global health policy. It first discussed the question of local government and decentralisation, as important aspects of how and why local initiatives come about. It then discussed a range of top-down and bottom-up local policy initiatives aime and human health , as well as the challenges they face (e.g. power differentials). Local initiatives can differ greatly in their design and implementation processes, underlying theoretical principles, and the range of participating stakeholders. All these characteristics are context and issue specific and often vary from one setting to another. In most cases, the effectiveness, equity, efficiency and sustainability of local initiatives can be challenging to assess. However, such assessments are important and should be incorporated into the design of such initiatives, where possible. # 6. References ## 6.1 [[Essential readings]] Conde, Marta, and Martí Orta-Martínez. 2023. ‘Activism Mobilizing Science Revisited’. In The Barcelona School of Ecological Economics and Political Ecology: A Companion in Honour of Joan Martinez-Alier, edited by Sergio Villamayor-Tomas and Roldan Muradian, 261–70. Cham: Springer International Publishing. https://doi.org/10.1007/978-3-031-22566-6_22. ## 6.2 [[Recommended reading]] Fraser, Evan D.G., Andrew J. Dougill, Warren E. Mabee, Mark Reed, and Patrick McAlpine. 2006. ‘Bottom up and Top down: Analysis of Participatory Processes for Sustainability Indicator Identification as a Pathway to Community Empowerment and Sustainable Environmental Management’. Journal of Environmental Management 78 (2): 114–27. https://doi.org/10.1016/j.jenvman.2005.04.009. Gignac, Florence, Valeria Righi, Raül Toran, Lucía Paz Errandonea, Rodney Ortiz, Mark Nieuwenhuijsen, Javier Creus, Xavier Basagaña, and Mara Balestrini. 2022. ‘Co-Creating a Local Environmental Epidemiology Study: The Case of Citizen Science for Investigating Air Pollution and Related Health Risks in Barcelona, Spain’. Environmental Health 21 (1): 11. https://doi.org/10.1186/s12940-021-00826-8. Mathpati, Mahesh, Unnikrishnan Payyappallimana, Darshan Shankar, and John Porter. 2020. ‘“Population Self-Reliance in Health” and COVID 19: The Need for a 4th Tier in the Health System’. Journal of Ayurveda and Integrative Medicine, September. https://doi.org/10.1016/j.jaim.2020.09.003. ## Other cited references and sources Abimbola, Seye, Leonard Baatiema, and Maryam Bigdeli. 2019. ‘The Impacts of Decentralization on Health System Equity, Efficiency and Resilience: A Realist Synthesis of the Evidence’. Health Policy and Planning 34 (8): 605–17. https://doi.org/10.1093/heapol/czz055.