| BackgroundThough urbanization has brought a large number of benefits, its implications for urban environment and society has posed great threats to our health, even become the main contributors of diseases. After the economic reform, our country has been seeing a rapid development. At the same time, a big crowd of social, economic, environmental and ecological concerns were raised like income inequity, heavy traffic, air pollution, etc. These problems has generally become crucial factors challenging urban residents’health status.In conformance with the requirement of the State Council, the National Patriotic Health Committee initiated the China Healthy Cities movement in 1989 with the objective to improve cities’appearance as well as people’s health. During the past 25 years, a total of 178 cities have been named as "China Healthy City/District" by the National Patriotic Health Committee, including 149 China Healthy Cities (CHC), and 29 China Healthy Districts. Lots of questions merit further exploration such as follows:How effective the operation mechanism of this movement and what characteristics this movement embrace? What implications of this movement on urban environment, urban residents’wellbeing and cities’ socioeconomic development. In addition, what are similarities and differences compared with WHO healthy cities projects? If this is necessary to continue this movement and what is the future pathway?To date, gaps exit in literature concerning comprehensive evaluation of both WHO healthy cities project and CHC. Current studies mainly focused on either experience of CHC activities or evaluation research about effects of certain policy implementation. There is a lack of comprehensive evaluation of the overall movement as well as the introduction of working mechanism of this movement, especially the casual pathways and methods research. Through a comprehensive evaluation of CHC, it would be helpful to push this movement forward, and provide scientific evidences for establishing sustainable healthy cities tailoring our country and each city.ObjectivesEvaluate the effects of CHC on urban environment, population health and socioeconomic development. Analysis the strategy, policy and measures of CHC. Additionally, it also aimed to present policy-making evidences for promoting the movement and future Healthy City planning. Specifically, the objectives of this movement includes:1) policy analysis of CHC movement; 2) analysis of assessment mechanism of CHC movement; 3) evaluate the movement’s implications in terms of environment, health and society; 4) propose policy recommendations for the future development of CHC movement.Sampling and DataConsidering limits of selecting control cities, study population of this research was the 77 general prefecture-level cities that have already been named as CHC. A stratified and systematic sampling method was used in this study.77 CHC as general prefecture-level cities were classified into 3 groups.For each group,5 cities were randomly selected based on a systematic sampling method, producing 15 cities in total.One paired non-CHC city within its local province was purposively matched based on GDP per capita and demographic characteristics.Retrospective case-control study design was adopted in this research to construct the CHC group and the control group.Besides aforementioned sampled cities,4 cities were selected for typical case study, among which Baoji city and Zhuzhou city has already been included in the sample.This study formulated an indicator system for the purpose of evaluation, based on indicators of CHC and WHO healthy cities projects, including 71 indicators categorized in 7 parts. Data were collected from CHC cities and control cities respectively. Data were then analyzed indicator-by-indicator, especially before-and-after comparison and comparative analysis with control groups.As for quantitative data, those related to characteristics of cities and current materials available from National Patriotic Health Campaign Office were also collected besides information of designed indicators. In addition, residents’ satisfaction survey were conducted.Qualitative data came from interviews of 13 key informants from 11 institutions, and focus group interview of residents in each CHC city.MethodsTaking into account the complexities and wide-reach of CHC, Mixed methods were applied. Qualitative analysis and quantitative analysis were conducted simultaneously. In the process of analysis, results from both qualitative and quantitative analysis were integrated; specifically, how themes raised from qualitative study support or refuse results of quantitative study were deeply discussed.Quantitative data analysis:firstly, we integrated each indicator data in CHC group and control group, separately, in every year and conducted before- and -after comparison. Also, these data were analyzed by stratified analysis to control the baseline level in CHC and non-CHC groups.For health indicators like infectious diseases mobility were standardized for comparison. Repeated measures mixed model was applied to test temporal change of indicators. Qualitative data were analyzed manually using thematic analysis.The field reseach were from Dec.2013 to Feb.2014.Results1. Process Evaluation of CHC Movement1.1 CHCs are mainly located at east coastal areas. Almost every year, there are cities that gain the CHC title. In particular, the number of CHC cities dramatically increased since 2006.1.2 Policies adopted in CHC movement meet characteristics of public policy. Various policy tools were applied in the process of CHC movement, with mandatory policy tools as the core. But the appearance and usage of voluntary policy tools and mixed policy tools served as the foundation for widely social participation and sustainable development.1.3 CHC movement promoted the change and innovation of governments, ensuring sustainable development after CHC movement from the institutional level. In the process of CHC movement, all cities established a steering group led by major leaders in the city and with multi-sectors’wide participation. Patriotic Campaign Office were strengthened in areas like personnel and finance. Some cities completed the reform of sanitation institutions and health promotion departments.1.4 Huge investments were made in terms of not only infrastructures to improve cities image but also software strengthening of city regulation. This study also revealed that CHC movement among western cities was largely lagged behind those in eastern areas due to economic restrictions.1.5 CHC movement raised a unique assessment mechanism. "China Healthy Cities Criterion" and "Methods for Assessment and Naming of China Healthy Cities" are the main basis for evaluation. Though the criterion has been revised 5 times and the assessment method was disseminated 7 times, this study still shows defects in terms of equity of criterions, choice of indicators and ways for assessment.2. Outcome Evaluation of CHC Movement2.1 CHC movement has improved the urban environment and facilitated the infrastructure construction. In terms of garbage and sewage disposal rate, road seeping mechanically rate, green area per capita, and the percentage of standard agri-product markets, CHC increased significantly (p<0.1). The difference between the two groups became smaller when CHC’s baseline was initially lower, and grew larger, when CHC’s baseline was higher.1) Generally, sewage disposal rate has been improved after the movement, and performed better than that in control group; in 2012, the average sewage disposal rate in CHC group is 92.9% while 87.7% in the control group.2) The air condition in all sampled CHCs have been significantly improved and with more than 300 days with good air quality. However, this improvement is rarely seen in the control group. This improvement is more evident in typical CHCs like Pan Zhihuan city. There were only 51 days with good air condition in 2003. This figure was stepped up to 330 in 2008 when it gain the CHC name and to 343 in 2012.3) Green coverage rate in built-up areas has been steadily improved in CHC group around the named year and finally outstripped that in the control group.4) Almost all CHCs has newly established or upgraded the urban sewage disposal system, garbage disposal system, medical waste disposal system. Furthermore, water supply and drainage systems have been strengthened; water qualified rate in all sampled CHCs has been brought up to 100%.5) The proportion of agri-market that met the CHC requirements increased from 35.16% to 60.63%; while from 50.35% to 59.88%, a lower increase level.2.2 CHC movement improved health status of urban residents. Given the complexity of health determinants and limited available resources, this study still show positive impacts of CHC movement on population health.1) After the named year, the increasing speed of reported morbidity of infectious diseases in CHC has largely reduced and achieved a higher reduction compared with the control group. The average increase rate in CHC during the four years before is 16.71% and decreased to -2.75% four years after.2) The average maternal mortality rate of CHC group in the fifth year before is 33.4 per 100 thousands higher than 25.8 per thousands in the control group. In the fourth year after, both of the group reduced to around 17 per thousands. Most CHCs have the similar trend and level in terms of infant mortality rate and under-5 rate.3) Based on available resources, the life expectancy in CHC increase faster than that in the control group. Life expectancy of Jinhua city in 2009 is 76.6 while the control city, Taizhou city, is 79.2; in 2012, life expectancy of Jinhua city grow to 79.2 while Taizhou is 78.8 at the same time.4) CHC movement has effectively managed the density of rats, mosquitos and flies, as well as other health risk factors.2.3 CHC movement strengthened government regulation, improved the investment environment and raised people’s satisfaction about the society.1) One of the most effective achievement of CHC movement was to dramatically improve the concept of city development and regulation, formulate advanced social health awareness. With environment improvement as the core, CHC movement directly raised the whole society’s health awareness and displayed special impacts on health. The movement’s influence on health is a long-term and complicated process; most interviewees holds that entire health environment has been improved, especially with respect to living environment, food safety, quality of drinking water and health promotion.2) CHC movement help to raise investment in health and strengthen health systems. For example, in terms of infectious diseases prevention and control, there was a large investment of human resources, finance and equipment aiming to strengthen disease prevention and control system, improve the quality of disease information reported, which played a key role in reduce communicable diseases morbidity.3) CHC movement contributed to an improvement in investment environment and city appearance, accelerate the transition of economic structures. In this study, large number of interviewees expressed CHC movement’s positive influence on urban investment environment and development of tertiary industry like tourism. Though we found no significant difference of economic development between the two groups using GDP per capita as an indicator, we could at least believe that big investment during CHC movement does not negatively influence economic development but provide the necessary foundation for economic prosperity and improved the quality of economic development.4) CHC movement enhanced people’s satisfaction of urban living environment and happiness. Residents have showed a high satisfaction of CHC movement effects. Qualitative analysis results demonstrated that 98% of people consider CHC movement effects as good or very good. People’s satisfaction about living status present the highest increase rate to 76.1% after the named year, which is 5.9 times higher than that before.Conclusions and Policy Implications1. Conclusions 1) To create the CHC, the government used the authority and power to force departments and individuals to take action in order to implement policies and address problems.2) The CHC movement improves the system of patriotic health. In addition, the organization of the government was innovated and changed, and urban management and health education system were optimized.3) To create CHC, either the hardware on the image of the city, or the software on norms of urban governance invested enormous. The large number of investment in short-time induced image projects and resources waste. The large investment restricted the initiative of economically underdeveloped areas, such as the western region.4) CHC movement has positive effects on environmental improvement, public health and social development.5) There were big gaps between creating the CHC and WHO healthy cities in the areas of health services, social justice, etc.2. Policy Implications Based on study results, we proposed the following policy recommendations.1) Continuously improve the sustainable development mechanism of CHC movement with strengthening urban regulation capacity as basis; 2) Making clear of the relationship between CHC and WHO healthy cities, to transfer CHC to healthy cities as soon as possible; 3) To establish an information system for routine assessment, monitor and evaluation. |
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