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1995
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ABSTRACT
In international public health and other disciplines there is a debate about the
use of process versus impact (sometimes referred to as outcome) indicators
in project evaluations. With growing international and national support for
Healthy City Projects in developing countries it is timely to address the
issue of how to evaluate such projects. This paper briefly describes process
and impact indicators, considers the importance of process indicators given
the role of institutional strengthening and capacity building in Healthy City
Projects and discusses the balance between locally and internationally generated
indicators. A case study of the first Healthy City Project in a developing country
in Asia (Chittagong, Bangladesh) illustrates how the project is linked with
urban management and can enhance co-operation, co-ordination, motivation,
internal organisation, decentralisation and community participation. Finally,
some institutional indicators for evaluation are suggested.
INTRODUCTION
WE ts:w 629
630 Edmund0 Werna and Trudy Harpham
Projects and discusses the balance between locally and internationally generated
indicators. A case study of the first Healthy City Project in a developing country
in Asia (Chittagong, Bangladesh) illustrates how the project is linked with
urban management and can enhance co-operation, co-ordination, motivation,
internal organisation, decentralisation and community participation. Finally,
some institutional indicators for evaluation are suggested.
ELEMENTS OF EVALUATION
many cases, this will be longer than the life span of a project. There
is considerable uncertainty about the time-lags for many public health-
oriented interventions.
?? Impact evaluation requires adequate control groups - A comparison
between the situation before and after the intervention may not be
appropriate, because changes may be due to factors outside the programme.
On the other hand, it is difficult to find suitable control groups. Problems
involve ethical considerations, the spill-over of effects, and the doubling
of costs.
?? Impact indicators are not sensitive - Summary indicators do not make
allowance for inequalities in health, risks and access to services.9
Most of the arguments for impact evaluation rest on the political power of the
data.10 WHO argues that countries may wish to define health for all in terms
of general objectives, such as the improvement in the health status of all their
citizens. WHO continues:
Increasingly, development planners and economists are looking for social
indicators such as health status measurements to guide decisions on economic
development strategies . . . it is particularly important to select a small
number of national indicators that have social and political punch in the
sense that people and policy makers will be incited to action by them.11
There is little debate as to whether such indicators should be internationally
generated (to be comparable across countries) or be locally produced.
The debate about impact versus process indicators has quickly entered
discussions about evaluation of Healthy City Projects and is considered in the
next section.
will depend on the local circumstances (see next subsection) as well as the timing
of the evaluation (i.e. some indicators may measure change after 2 years, others
will need 5 years). A thorough impact evaluation of HCP requires an extensive
inventory of indicators, whose elaboration is beyond the scope of this paper.
Collin23 provides a good inventory.
In order to define specific indicators to evaluate HCP, it is also important to
review a debate encountered in the HCP literature: whether to use international
indicators, or to generate them locally.
However, due to the reasons noted above, it is important to evaluate HCP even
during the process of local capacity building.
In short, both types of indicators analysed have a role in the evaluation of
HCP, and can be effectively used in conjunction. As already noted, many
communities in developing countries are not prepared for such a task. Therefore,
HCP should take this into account in its plan of action, i.e. the Project should
include in its agenda the development of local indicators along with the local
communities. The design of international indicators for HCPs in developing
countries, in its turn, is still incipient. WHO has been working on the design
of such indicators, with contributions from HCP experiences in industrialised
countries, and with comments/criticisms from the donor agencies which are
due to finance HCPs in developing countries. The research community with
expertise in developing countries should be more active in the design of such
indicators, and the present paper constitutes an effort in this direction.
In any case, whether indicators are designed locally or internationally, there
should be an emphasis on processes related to the institutional aspects of the
Project. The next section will present a case study to highlight the importance
of the linkages between urban management and the Project. This reinforces the
need to focus on institutional aspects as a main component of evaluation.
First, this section will show how HCP in general is linked with urban management.
Second, it will illustrate this point with the case of the first HCP implemented
in a developing country in Asia. Finally, the section concludes by presenting
institutional indicators which might be included in a HCP evaluation.
campaigns such as sensitising the private sector and special authorities which
have space capacity to provide given services.
The third issue is motivation. Cases of public officials with little interest in
(and even with little knowledge about) their duties have been frequent in
Chittagong. According to statements gathered in interviews, the work carried
out in the first phase of HCP has succeeded in raising the motivation of the
participants towards the fulfilment of its goals. Considering that HCP goals are
intertwined with the day-to-day activities of the participants, such motivation
is likely to have multiplier effects. Thus, it is important to devise ways of
keeping the momentum which was generated by the implementation of the
Chittagong HCP.
The fourth issue is internal management of the public authorities. Problems
include weak inter-departmental co-ordination, lack of performance monitoring
and reporting systems, wide variation of managerial structures for analogous
kinds of services, weak tradition of team work, among others. One of the basic
premises of HCP is to generate institutional change.48 In a speech given at
a 1993 Workshop, Greg Goldstein (from WHO) identified the Project with
a new form of local government. Indeed, the implementation of HCP is
based on institutional arrangements which are innovative to Chittagong. This
may not change the institutional organisation of its authorities. However, it may
introduce fresh managerial ideas for the participants.
The next issue is decentrulisution. Although decentralisation has been adopted
as a key item in the public policy agenda in Bangladesh,@ its implementation
is still far from true devolution to local governments. As already noted, many
services in Chittagong are still outside the realm of the City Corporation, and
are controlled by agencies directly linked to central ministries. However, on the
one hand, the Chittagong HCP is co-ordinated by the City Corporation. On the
other hand, the Project includes areas of action which are outside the realm of
that authority. Therefore, the intervention of the Chittagong City Corporation in
the overall management of urban development is likely to increase with HCP.
Finally, HCP might boost community participation in Chittagong. This is
one of the basic propositions of the Healthy Cities Movement.50 Popular
participation has been regarded as fundamental for a sound urban management
process. However, although with some rhetoric and tentative actions from the
government, popular participation in Chittagong (as well as in the rest of
Bangladesh) is far from satisfactory .si Thus, HCP may also make a substantial
contribution on this issue.
In short, HCP has potential to ameliorate the major problems found in
the structure of urban management in Chittagong. It is worth noting that
the Chittagong HCP has its own problems, which need to be addressed if
the potential contribution of the Project is to be fully realised.52 At any
rate, the above analysis has confirmed the links between HCP and urban
management. This reinforces the case for designing institutional indicators for
a process evaluation of HCPs.
Existing institutions. The evaluation should cover all the institutions active
in urban development: the public, private and voluntary sectors, community
organisations and international agencies.
638 Edmundo Werna and Trudy Harpham
Institutional aspects of HCP. Although the achievement of the HCP aims via
the actors analysed above is more sustainable in the long run, the institutions set
up by the Project (i.e. the local and partnership task forces, steering committees
and working groups) are important to reach short-term and/or partial objectives
(which generate multiplier effects), and also to influence the above actors. The
evaluation should assess the implementation and development of the HCP
institutions. It is likely to overlap with many points of the previous set of
evaluation, because the key persons involved in HCP are all members of existing
institutions. Thus, each one of the two sets of evaluation can be used to cross-
check a number of points of the other.
CONCLUSION
This paper reviewed the debate about process and impact indicators both in
general terms and particularly in relation to the evaluation of Healthy City
Projects. It stressed the importance of the former set of indicators, and the
need to focus on the institutional aspects of the Project.
A central point of the paper, illustrated both in conceptual terms and with
the Chittagong case, is that WHOs Healthy Cities Project has evolved from an
initial and specific approach to public health to an integrated approach to urban
management - which, in its turn, has a broader/longer-term impact on health.
However, such a change has not been fully grasped yet (e.g. most papers written
about the HCP still have a public health rhetoric). Therefore, it is important
to clarify the current connection with urban management. Otherwise, Healthy
Cities may not be able to realise its broad potential (e.g. if the people involved do
not understand its extended scope). Consequently, the set of indicators suggested
in the paper aim at assessing such a broad approach of the Project.
Finally, it is important to note that the evaluation of the first HCP experiences in
developing countries has detected problems of implementation. The Healthy Cities
Movement originated and evolved conceptually and empirically in industrialised
countries. These countries differ from developing countries in many respects,
and the implementation of HCPs in the latter still needs refinement - for
instance, WHO has to take into account the specific difficulties of the local
institutions and communities in each city to implement the Project. The training
of a local team to co-ordinate the Project and the preparation of the local actors
to fully participate might require more time and resources than in industrialised
countries. Considering its present financial limitations, WHO needs to find
partners to implement Healthy City Projects in developing countries, and/or to
adapt the aims of the Project, taking into account the existing constraints. This
paper noted the importance of setting up a scheme to compare the development
of HCPs in cities in developing countries. This could help each Project to address
its problems based on similar experiences.
NOTES
1. In this paper, the terms HCP and Project are used interchangeably to refer to the Healthy Cities
Project.
640 Edmund0 Werna and Trudy Harpham
2. A. Tsouros (ed.), World Health Organization Heahhy Cities Project: A Project Becomes a Movement,
Review of Progress 1987 to 1990 (WHO, Copenhagen, 1990), p. 11.
3. Y. Von Schirnding and N. Padayachee, Healthy Cities for a Future South Africa, South African
Medical Journal 83 (1993), pp. 718-719.
4. Tsouros (1990), see note 2.
5. A. Elzinga, Evaluating the Evaluation Game: on the Methodology of Project Evaluation, with
Special Reference to Development Co-operation, Sarec Report, Stockholm (1981).
6. See A. Shrettenbrunner and T. Harpham, A Different Approach to Evaluating PHC Projects in
Developing Countries: How Acceptable is it to Aid Agencies ? Health Policy and Planning 9, 2
(1993), pp. 128-135.
7. B. Van Norren, J.T. Boerma and E.K.N. Sempebwa, Simplifying the Evaluation of Primary Health
Care Programmes, Social Science and Medicine 26(1989), pp. 1091-1097.
8. Van Norren et al. (1989) see note 7.
9. D.R. Gwatkin, J.R. Wilcox and J.D. Wray, The Policy Implications of Field Experiments in Primary
Health and Nutrition Care. Social Science and Medicine 4. C (1980). DD. 121-128.
10. See, for instance, Schrettenbrunner and Harpham (1993), note6. n*
11. WHO, Development of Indicators for Monitoring Progress Towards Health for all by the Year 2000,
Health For All Series No. 4 (WHO, Geneva, 1981).
12. e.g. A. Blankers, Accra Healthy Cities Project/Urban Primary Health Care - One Year After its
Initiation, Research Report, Faculty of Health Sciences, University of Limburg, The Netherlands
(July 1993); J.K. Davies and M.P. Kelly, (eds), Healthy Cities - Research and Practice (Routledge,
London, 1993); E. de Leeuw and M. Goumans, Current Research and Evaluation on Healthy
Cities Programs - A Focus on Community Research Priorities and the Producers and Users of
this Research, paper presented at the International Healthy Cities and Communities Conference,
San Francisco, December, 1993.
13. e.g. F. Baum, Healthy Cities and Change: Social Movement or Bureaucratic Tool? Health
Promotion International 8, 1 (1993), pp. 266-285; F. Baum and R. Cooke, Healthy Cities
Australia: the Evaluation of the Pilot Project in Noarlunga, South Australia, Health Promotion
International 7, 3 (1992), pp. 181-193; F. Baum, R. Cooke, K. Crowe, M. Traynor and B. Clarke,
Healthy Cities Noarlunga Pilot Project Evaluation, Southern Community Health Research Unit,
Noarlunga (1990).
14. R. Draper, L. Curtice, J. Hooper and M. Goumans, WHO Healthy Cities Project: Review of the
First Five Years (1987-1992) - A Working Tool and a Reference Framework for Evaluating the
Project (World Health Organization, Regional Office in Europe, 1993); WHO, Building a Healthy
City: A Practitionerss Guide, a manual prepared by the Unit of Urban Environmental Health, Office
of Operational Support (WHO, Geneva, Draft dated 19 July 1994).
15. J.F. Collin, (coordinator), Guide Notes for the Healrhy-Cities Indicators (WHO, Copenhagen, 1992);
Working Group on Indicators of Healthy Cities, Summary Report (WHO: Copenhagen, 1990).
16. See Collin (1992), note 15.
17. See Collin (1992), note 15.
18. See N. Harris, (ed.), Cities in the 2990s - The Challenge for Developing Countries (UCL Press,
London, 1992); E. Werna, United Nations Agencies Urban Policies and Health, paper presented
at the Conference Urban Health Research: Implications for Policy, London School of Hygiene and
Tropical Medicine, December 1994.
19. E. Werna, Urban Management, Provision of Health-related Services and the Healthy City Project
in Chittagong, Bangladesh, Research Report, Urban Health Programme, London School of Hygiene
and Tropical Medicine, 1994.
20. e.g. WHO, Twenty Steps for developing a Healthy Cities Project, WHO Regional Office for Europe
(WHO, Copenhagen, 1992); WHO (1994), see note 13.
21. See UN (United Nations), Agenda 21 - Rio Declaration, Proceedings of the United Nations
Conference on Environment and Development, Rio de Janeiro, 3-14 June, 1992; UNCHS, Global
Shelter for the Year 2000 (UNCHS, Nairobi, 1988); UNCHS-World Bank-UNDP, Urban Management
Programme Annual Report 1993 (World Bank, Washington, 1994); UNDP, Cities, People and Poverty:
Urban Development Co-operation for the 1990s. Strategy Paper (UNDP, New York, 1991); UNICEF,
UNICEF Programmes for the Urban Poor, Policy Paper (UNICEF, New York, 1993); World Bank,
Urban Policy and Economic Development - An Agenda for the 1990s. World Bank Policy Paper
(World Bank, Washington, 1991).
22. See Harris (1992) and Werna (1994), note 18. Five of the most active agencies in the urban field
are the following: UNCHS (United Nations Centre for Human Settlements), the World Bank, UNDP
(United Nations Development Programme), UNICEF (United Nations Childrens Fund), and WHO
(World Health Organisation).
23. Collin (1992), see note 15.
24. Collin (1992), see note 15; Draper et al. (1992) see note 14; WHO (1994) see note 13; Working
Group on Indicators of Healthy Cities (1990), see note 15.
See note 12.
;:. This is analogous to John Turners approach to community involvement in housing provision, which
has been widely applied in developing countries - see J. Turner, Introduction, in B. Turner (ed.),
Building Community - A Third World Case Book (Building Community Books, London, 1988),
pp. 13-18; J. Turner and R. Fitcher (eds), Freedom to Build: Dweller Control of the Housing Prices
(Macmillan, New York, 1972).
27 Baum (1993), see note 13; Baum and Cooke (1992), see note 13; Baum et al. (1990), see note 13;
de Leeuw and Goumans (1993), see note 12.
28. See note 12.
The Evaluation of Healthy City Projects in Developing Countries 641