Can health and health equity be advanced by urban planning strategies designed to advance global competitiveness? Lessons from two Australian case studies

Can health and health equity be advanced by urban planning strategies designed to advance global competitiveness? Lessons from two Australian case studies

Social Science & Medicine 242 (2019) 112594 Contents lists available at ScienceDirect Social Science & Medicine journal homepage:

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Social Science & Medicine 242 (2019) 112594

Contents lists available at ScienceDirect

Social Science & Medicine journal homepage:

Can health and health equity be advanced by urban planning strategies designed to advance global competitiveness? Lessons from two Australian case studies


Michael McGreevya,∗, Patrick Harrisb, Toni Delany-Crowea, Matt Fishera, Peter Sainsburyc, Fran Bauma a b c

Southgate Institute for Health, Society and Equity Flinders University, Health Sciences Building, Sturt Road Bedford Park, South Australia, 5042, Australia University of Sydney Level 6 the Hub, Charles Perkins Centre D17, The University of Sydney, NSW, 2006, Australia University of Sydney, Australia



Keywords: Health equity Healthy public policy Health in all policies City image Liveable cities Healthy urban planning Sustainable cities Strategic planning Productivity Global competitiveness

Background: The purpose of this article is to investigate whether the neo-liberal goal of global economic competitiveness when included alongside image-inspired social goals such as liveability and environmental goals such as sustainability can lead to policies that impact positively on health and health equity. The paper presents an analysis of the content and intent of strategic planning and transport plans from two Australian state governments. Methods: The analysis was undertaken using a thematic document analysis of each plan and interviews with agents (n = 21) directly involved in the preparation of each document. Findings: Key strategic documents formulated under a neo-liberal hegemony simultaneously provided and reduced opportunities to promote and advance health. The policies viewed goals like liveability and sustainability as means of enhancing their cities’ image in global competition for exogenous capital flows. Although liveability has many definitions, one definition was able to be used in one jurisdiction as an avenue to include a broad array of social determinants of health into urban planning policy. However, a productivity or a narrowly focussed image narrative can undermine the social determinants of health credentials of liveability. Overemphasising immediate city problems like road congestion as mechanisms to enhance global competitiveness can undermine necessary long-term strategies for city planning that are known to improve liveability and human health. Even where liveability is at the fore, there is a high risk of exacerbating spatial inequities through liveability investments for competitive advantage because they tend to flow to parts of cities with the greatest connections to the global economy, not those with the greatest social need. Conclusions: A neo-liberal-inspired competitive city paradigm provides opportunities for the advancement of health in urban development. However, when driven by the goals of productivity and/or liveability as image enhancement it can potentially exacerbate health inequities.

1. Background Research shows that the form and function of urban environments powerfully determine the health of individuals and populations (Barton and Tsourou, 2013; Frumkin et al., 2004; Giles-Corti et al., 2016). However, health as a policy objective regularly finds itself subordinated to commercial imperatives in the planning of individual developments,

and lost within economic, environmental or social goals that tend to underpin city planning (Barton and Tsourou, 2013). The aim of this paper is to ascertain and investigate empirically the extent to which the goal of global competitiveness when included alongside social goals, such as liveability and sustainability, can lead to policies that have a positive impact on social determinants of health and health equity. The social determinants of health that are the focus of the research are:

Corresponding author. E-mail addresses: [email protected] (M. McGreevy), [email protected] (P. Harris), [email protected] (T. Delany-Crowe), [email protected] (M. Fisher), [email protected] (P. Sainsbury), [email protected] (F. Baum). ∗ Received 26 March 2019; Received in revised form 1 August 2019; Accepted 8 October 2019 Available online 09 October 2019 0277-9536/ © 2019 Elsevier Ltd. All rights reserved.

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M. McGreevy, et al. systems • Welfare • Transport and discrimina• Stigma tion relationships • Social exclusion • Social • Safety

environment • Natural or country connec• Land tion • Income • Housing systems • Health • Gender

offices, the total and proportional size of the producer-service sector which services them, and the number of people employed in creative professions (Ichikawa et al., 2017; Sassen, 2018; GAWC, 2018). Currently at the top of the hierarchy are around 20 alpha ‘global’ cities such as London, New York, and Tokyo, and ‘sub-global’ cities such as Sydney, Shanghai and Berlin. These cities attract exogenous capital and highly skilled professionals and creatives by virtue of their position within the hierarchy (Ichikawa et al., 2017; Sassen, 2016, 2018). Below them are the ‘secondary cities’, comprising the vast bulk of the world's cities. Secondary cities exist in a sphere of hyper-competition with each other to lure exogenous corporate capital willing to invest in or move some operations beyond global and sub-global cities (Harvey, 1989; Krueger and Buckingham, 2012; Kaufmann and Arnold, 2017; Sassen, 2018). Central to competing for exogenous flows of capital is global image. Having a competitive global image is viewed as vital for a city to attract global businesses to set up subsidiary operations, as well as luring migrants, tourists and foreign students to choose a city as a place of consumption (Caragliu et al., 2011; Harvey, 1989; Kaufmann and Arnold, 2017). In particular, attracting and retaining ‘creative classes’ has risen in importance because of their associations with the new economy of information technology, innovation and creative service industries (Caragliu et al., 2011; Tranos and Gertner, 2012; Florida, 2005; Albino et al., 2015). These wider conditions have potential consequences for a ‘healthy planning’ agenda. The importance of global image justifies government investments into the quality of urban form and function within hegemonic neo-liberal ideals because they are seen to contribute to the economic competitiveness of the city. In particular, the purported attractiveness of liveable neighbourhoods (and cities that have them in abundance) to creative classes makes liveable neighbourhoods and their health-providing attributes worthy of preservation, restoration, and emulation on economic grounds (Florida, 2005; Zukin, 2009). There are currently numerous definitions of liveability, one of the most notable being the Economist magazine's citywide Global Liveability Index (EIU, 2017). However, the liveable neighbourhood definition most commonly referred to in planning and health literature dates back to Appleyard’s (1980) definition. This definition attempts to encapsulate in a single word the traits humanist urban theorists and practitioners argue make a place complete (Arundel et al., 2017; Appleyard, 1980; Hooper et al., 2015; Lowe et al., 2015). Lowe et al. (2015, p. 138) defined a liveable place as one that is:

• Food • Employment • Education • Culture change • Climate environment • Built • Open space

The urban environment and consequently the way urban planning shapes cities effects multiple social determinants of health and health equity. Increasingly over the past decades, neo-liberalism has provided the philosophical underpinnings of urban planning (Allmendinger and Houghton, 2010; Harvey, 2007; Olesen, 2013). Neo-liberalism owes its philosophical roots to 19th century liberalism and classical economics and 20th century philosophers such as Hayek (2014). Its philosophical underpinnings of the primacy of negative liberty or individual freedom from interference by the state, minimalist government, and faith in the equilibrium-seeking invisible hand of the free market contrasted to the interventionist Keynesian economics and Fordism that dominated the post World War 2 western political economy until the 1970s (Harvey, 2007). As Fordism and Keynesian economics encountered problems in the 1970s, neo-liberalism rose to supplant them as ‘the central guiding principle of economic thought and management’ (Harvey, 2007, p. 2). Initially neo-liberalism came in the form of ‘roll back’ action where the role of the state was wound back in favour of markets and private businesses via free trade, deregulation, privatisation, outsourcing and a reduction in government services and taxes. Over the ensuing decades, neo-liberalism evolved from prescription to hegemony instilling the primacy of economic growth into every sector (Allmendinger and Houghton, 2010; Harvey, 2007; Olesen, 2013). As the hegemonic idea of the era, neo-liberalism has added ‘roll out’ to ‘roll back’, where the state routinely intervenes to facilitate competitiveness and productivity via public investments which often entail a redistribution of funds from citizens to business (Krueger and Buckingham, 2012; Olesen, 2013; Searle and Bunker, 2010; Scott and Storper, 2015). The rise of neo-liberalism corresponded with the expansion of globalisation and transnational corporations as the major facilitating mechanisms for capital flows within national and international economies, and of cities as the preeminent spatial entity and polity for attracting those flows (Sassen, 2018; Olesen, 2013). Harvey (1989, p. 11) argued that all city governments regardless of ideology have little choice but to partake in and succumb to the dictates of global economic competition ‘‘to lure highly mobile and flexible production, financial, and consumption flows into its space’. Adherence to neo-liberalism as a hegemonic ideal has however rarely resulted in the withdrawal of government from urban planning. Instead, government intervention has required justification within the boundaries of the neo-liberal hegemonic ideal; i.e. policy settings have needed to prove their worthiness via their ability to contribute to a city's global competitiveness (Harvey, 2007; Olesen, 2013; Logan and Molotch, 2007). This has involved roll back interventions via deregulation, privatisation, private-public partnerships, and outsourcing (Allmendinger and Tewdwr-Jones, 2005; Harvey, 2007) and roll out interventions such as strategic investments into infrastructure, real estate and educational and recreational facilities (Harvey, 1989; Logan and Molotch, 2007). Since Harvey (1989) first made his observations, the nature of global competition has become more intense and the desire to lure exogenous capital has increased (Kaufmann and Arnold, 2017; Krueger and Buckingham, 2012; Sassen, 2018). The ability to attract exogenous capital flows is not a level playing field but subject to a city region's position within an international global hierarchy. Its global positioning will, in turn, have important impacts on its population's health. A city's position within the hierarchy is determined by its global influence measured by indices such as the number of transnational corporate headquarters or regional head

‘safe, attractive, socially cohesive and inclusive, and environmentally sustainable; with affordable and diverse housing linked by convenient public transport, walking and cycling infrastructure to employment, education, public open space, local shops, health and community services, and leisure and cultural opportunities’. Global image enhancement also provides an economic justification for other actions that advance social determinants of health, such as preserving and restoring natural environments, reducing car use and pollution by investing in bike, pedestrian and public transport infrastructure, investing in education, arts and recreation facilities, and maintaining quality public places (Barton and Tsourou, 2013; Florida, 2005). On the other hand, many of the products of the automobile city such as single use dormitory suburbs, shopping centres, hypermarkets, and freeways are detrimental to a city's image and therefore economic competitiveness as well as multiple social determinants of health (Frumkin et al., 2004; Florida, 2005; Talen, 2006; Zukin, 2009). Therefore, global image enhancement has the potential to direct policy initiatives into the creation of liveable neighbourhoods and away from unhealthy suburban sprawl (Frumkin et al., 2004). However, compounding risks for inequality, it also holds out the prospect of government expenditure being redirected from efforts to redistribute income and advance social inclusion and social justice towards image 2

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enhancement to attract and retain already privileged creative classes and/or facilitate entrepreneurial and urban development as profit making activity (Caragliu et al., 2011; Grengs, 2005). Despite its challenges to health, sustainability and image, suburban sprawl has long had and continues to have influential supporters. In particular some urbanists have championed the post-war automobile city of freeways, houses in suburbs, shopping centres, office parks and campuses as the spatial manifestations of free people operating in free markets and the most efficient means of reducing cost for both businesses and consumers (Garreau, 1992; Gordon and Richardson, 1997; Cox et al., 2017). Neo-liberalism as a theory has been highly influential in Australian federal and state public policy development in general, and urban planning in particular, for over thirty years (Albrechts, 2006; Badcock, 2014; Gleeson and Low, 2000; Miller and Orchard, 2014). Australian cities have also had a long history of comprehensive spatial planning with normative goals (Searle and Bunker, 2010). Using two case studies from Australia this article looks at the potential for spatial planning with normative goals under a neo-liberal hegemony to advance social determinants of health and health equity. This type of theorising has yet to be tested in the healthy planning literature. This article analyses Australian urban planning documents from two state jurisdictions, the New South Wales Long Term Transport Master Plan (Transport for Newman and Kenworthy, 2015) from the Australian state of New South Wales (NSW) and the Thirty Year Plan for Greater Adelaide (DPTI, 2017) from state of South Australia (SA). The capital and largest city in NSW is Sydney. Sydney is Australia's largest city with a population of almost 5 million and is a top ten Alpha + ranked global city (GAWC, 2018). Adelaide is the capital and largest city in the state of South Australia. South Australia is the fifth largest state in Australia by population and Adelaide with a population of approximately 1.3 million is the fifth largest city. Although wealthy by global standards, Adelaide is a Gamma + secondary city with a global ranking outside the top one hundred (GAWC, 2018). Both jurisdictions have a long history of comprehensive city planning for their capitals (Searle and Bunker, 2010). The documents analysed from both jurisdictions are long term comprehensive strategic plans, one has a focus on land use which includes transport, the other transport which includes land use. Both documents have goals of economic competitiveness, liveability and sustainability and large numbers of subsidiary objectives that seek to realise these goals. Both documents refer to image as being an important factor for their respective jurisdiction's global competitiveness and claim that their sector has a major role in enhancing global image. The Thirty Year Plan for Greater Adelaide also makes overt links between liveable urban form and multiple social determinates of health; the New South Wales Long Term Transport Master Plan much less so. The analysis examines connections between the two plans and aspects of liveability that have direct benefits for social determinants of health. It also considers whether the content of the plans overtly or implicitly links the work of the government departments responsible for the plans to liveability and the social determinants of health and whether they are pursued with this in mind. The paper explicitly examines whether social determinants are included in pursuit of, or complementary to, some other virtue such as competitiveness, sustainability or social justice, or alternatively, whether they exist as window dressing to other overriding and potentially contradictory priorities.

108 urban planning policy documents and selected legislation from all Australian state and territory jurisdictions for their ability to progress social determinants of health and health equity. 2.1. Document selection Based upon this analysis the research team identified the Thirty Year Plan for Greater Adelaide 2017 (TYPGA) and the New South Wales Long Term Transport Master Plan 2012 (NSWLTMP) as examples of good practice in urban planning policy addressing social determinants of health, because both refer to and are inclusive of multiple social determinants of health in objectives and strategies. The plans were compared as case studies following Yin (2011), whereby the findings from two exemplary but different cases yielded important insights about the phenomenon under investigation – here the influence of neo-liberalism on the inclusion of health in urban planning. The analysis of the priority intent of the plans was undertaken using two research methods. The first was thematic document analysis. The second comprised 21 semi-structured qualitative interviews with agents directly involved in the preparation of one or other document. The interviews ran for between 40 and 60 min each and were conducted face to face and via phone/Skype. The interviews were used to examine in further depth both the intent of the document and the relationship between priority goals and social determinants of health and health equity. Lists of informants used in the interviews and their associations are provided in Tables 1 and 2. 2.2. Data analysis The aim of the research was to test the theoretical assumptions in the wider planning and neoliberalism literature against the data in the documents and from the interviews. To this end, data analysis occurred concurrently with data collection, i.e. while documents and interviews were coded, connections were also made to the theoretical literature (Baum et al., 2018). This social scientific methodology, termed ‘retroduction’, mixes inductive (data driven) and abductive (theory-testing) reasoning (Bhaskar, 1978; Sayer, 2000). The final connections and resulting narrative were made during the drafting of this paper, with input from all authors. 3. Findings In this section, we analyse the TYPGA and NSWLTMP documents and interview data to determine the extent to which neo-liberal goals of global economic competitiveness refer to image enhancement. We then look at the links between notions of image enhancement and health enhancing objectives related to liveability and sustainability. In particular, whether liveability and sustainability objectives are potentially undermined by other explicit or implicit political priorities. Table 1 South Australian informants. Department of Planning, Transport and Infrastructure (DPTI) 2 senior public servants from the urban planning area 1 public servant from the urban planning area 1 public servant from the transport area Department of Health 1 senior public servant from public health 5 public servants from public health Active living coalition (a health focussed organisation with a broad membership from state and local government departments and agencies, and non-government organisations). 1 member

2. Research method The research undertaken for this article is part of a wider Australian Research Council funded project (DP100244) (Baum et al., 2018). This article reports selected findings from the component of the broader research that has involved analysing urban planning policies. In the urban planning sector, the researchers thematically coded and analysed 3

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facilitating economic development which accords with a roll back neoliberal deregulation agenda. However, the goals of liveability and sustainability were not viewed as conflicting with the third goal of economic competitiveness but rather fundamental to it. Aligned with notions of the ‘smart city’, sustainability and liveability are seen as economically desirable because of their ability to enhance the image of the city and attract and retain creative classes. For example, the TYPGA states.

Table 2 New South Wales informants. Transport for NSW 5 senior public servants 2 public servants Consultant Organisation (involved in the plan's preparation) 1 senior consultant Business Advocacy Organisation (involved in the plan's preparation) 1 member Transport minister's office 1 public servant

Creating liveable, vibrant, sustainable and accessible places is a key competitive advantage for attracting and retaining talented people and investment (DPTI, 2017, p. 47).

3.1. Balancing economic, environmental and social goals under the hegemony of neo-liberalism

To illustrate further the importance of image enhancement, ‘liveable’ was mentioned 37 times, ‘sustainable’ 31 times and ‘health’ 32 times in the TYPGA. However, there were only two references to ‘productivity’, one related to ‘peri-urban agriculture’, and one to the ‘clustering of services in activity centres’. Central to the realisation of all three goals is the embracing of a ‘new urban form’ for urban development. This is articulated as medium to high density mixed use developments along and in walking distance of major transit corridors and around activity centres attached to rapid transit, reflecting the ‘smart growth’ principles advocated by Calthorpe (1993) and Newman and Kenworthy (2015). These principles conform to those for a liveable place and therefore have the ability to advance social determinants of health correspondingly (Lowe et al., 2015). Thus, while the TYPGA on the one hand advocated a ‘roll back’ agenda of reducing ‘red tape’ for business, it also looks to government intervention as a means of facilitating liveability via smart growth. As such, the TYPGA has more a reregulation rather than deregulation agenda. A major obstacle to the new urban form argued in the TYPGA is current land use regulations administered by local governments. Consequently, there is a reregulation strategy outlined in the plan for a new planning act and a new planning system with land use regulations designed to halt urban sprawl and facilitate the ‘new urban form’ in targeted areas (DPTI, 2017).

Both the TYPGA and NSWLTMP have economic goals alongside those with an environmental or social focus capable of addressing multiple social determinants of health. The three major goals of the TYPGA are:

• Maintain and Improve Liveability • Increase Competitiveness • Drive Sustainability and Resilience to Climate Change (DPTI, 2017, p. 11).

The goal of increasing competitiveness within a traditional ‘roll back’ neo-liberal framework has the potential to clash with the other two goals of liveability and sustainability. The NSWLTMP has eight major goals referred to in the document as transport objectives: 1. 2. 3. 4. 5. 6. 7. 8.

Improve quality of service Improve liveability Support economic growth and productivity Support regional development Improve safety and security Reduce social disadvantage Improve sustainability Strengthen transport planning processes (Transport for Newman and Kenworthy, 2015, p. 22).

3.1.2. Economic competition and productivity as drivers in the NSWLTMP The length of the New South Wales Long Term Transport Master Plan (440 pages) enables it to provide comprehensive assessments of all transport modes (walking, cycling, heavy rail, light rail, buses, ferries, and roads), as well as their relationships with each other and land uses. The document emphasises mode integration in order to form a single complementary network as the desired outcome. The long-term intent is to create a networked polycentric city. This involves moving more services and employment opportunities to outer suburbs.

These objectives are a balance between 1, 5 and 8 that pertain to the planning and day to day management of the system, 3 and 4 which are economically focussed and include a direct reference to productivity, and 2, 6 and 7 which are largely social and environmental and have numerous direct and indirect correlations with social determinants of health. Goal 6 signifies a potential commitment to equity.

In the next 20 years, the Long Term Transport Master Plan will support the development of Greater Sydney as a network of centres with strong connectivity between growth centres and economic centres such as Parramatta, Penrith, Liverpool, Macquarie Park, the Port Botany and Sydney Airport precinct and North Sydney. The priority will be to develop a more integrated transport system across Greater Sydney to attract businesses and investment, improve liveability and support efficient freight movements (Transport for Newman and Kenworthy, 2015, p. 194).

3.1.1. Liveability as a competitive virtue in the TYPGA In South Australia, the potential hegemony of neo-liberalism and globalization and the importance given to ‘smart city’ principles are all touched upon in the following objective. For Adelaide to be competitive in a global economy we must stimulate this new economy by removing unnecessary red tape to business growth, accelerating approvals processes and ensuring that regulations support opportunity (DPTI, 2017, p. 75).

Despite having a comprehensive array of social and environmental goals and objectives, a public servant claimed the NSWLTMP nevertheless has an economic priority.

A public servant from Health also described the pre-eminence of economic growth when they stated:

… it [health] was never going to be what primarily drove the plan which was broadly an economic development and economic development-supporting agenda (NSW Public Servant, Transport 4).

… the thinking of the time was that the role of the planning strategy is to be an enabler of economic development. That is still a strongly held view within Planning. I think it was quite strongly held by the Minister of the time and by his Chief Executive (SA Public Servant, Health 1).

Many interviewees claimed the main objective of the NSWLTMP is overcoming a perceived economic problem not directly mentioned in the goals but repeatedly mentioned throughout the document, traffic congestion. All interviewees referred to addressing congestion as the

Crucial to both the objective and the comment is the intent of the government to use the TYPGA and the planning system as a means of 4

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overriding priority of the plan. For example:

outcomes by which success, or otherwise, in moving towards goals is ultimately determined. They are therefore the principal mechanisms by which activities and projects are prioritised (Bevan and Hood, 2006).

the biggest issue of the day was congestion. […] the notion of the walkable city, the thirty minute city, the transit oriented development, all of these things were about freeing up congestion, getting people out of cars, and giving, and options about where people could live and work and that's been an enduring theme with us, to government right through the period (NSW Senior Public Servant, Transport 5).

3.2.1. Liveability and the targets of the TYPGA Liveability is one of the three goals of the TYPGA (DPTI, 2017, p. 11, p. 11). Although no definition of liveability is provided, ‘the new urban form’ envisaged for the city corresponds to the humanist definition provided by Lowe et al. (2015). Under this definition liveability provides a potential avenue by which social determinants of health can be brought into the planning of urban environments (Arundel et al., 2017; Corburn, 2004; Frumkin et al., 2004). This appears to have been the case in regard to the TYPGA. Liveability as a goal was able to give health officials, who were early collaborators during development of the TYPGA, an avenue to advocate for the incorporation of broad social determinants of health.

The priority of reducing congestion and its relationship with productivity is emphasised by the number of times both are mentioned compared to other goals or objectives; congestion is mentioned 332 times, productivity 216 times, sustainable or sustainability 66 times, health or healthy 43 times, liveability or liveable 25 times, disadvantage 24 times, and equity 3 times. The perceived links between congestion, productivity and economic competitiveness that drove formulation are exemplified by the following quote.

What we ended up doing was trying to find a phrase that meant roughly the same thing [health] but which was more palatable and more acceptable in the planning profession. Liveability was starting to be used a bit, so we jumped on that and used that (SA Public Servant, Health 1).

I think you need a productive economy to support all of the social outcomes that you have. To have a productive economy you need to be able to get services to people quickly, people want the goods that they wish to consume or sell most efficiently, and they also want to move themselves most efficiently. Business to business movements, people driving around to sell real estate and things like that are equally important to the economy than moving a big truck full of widgets from China (NSW Senior Public Servant, Transport 6).

Our focus was broad, and we were really pleased when they expanded the liveability bit to include a focus on healthy neighbourhoods. That was a really big shift. In the beginning it was all about liveability, and they really increased the health focus (SA Public Servant, Health 2). Furthermore, all the KPIs in the TYPGA directly benefit liveability and health via social determinants, as well as sustainability (Table 3). In comparison there are no targets directly linked to competitiveness. The relationship between the KPI targets and liveability, and liveability with health, is also unambiguously clear throughout the document. There is a chapter, for instance, entitled “Healthy neighbourhoods” (DPTI, 2017, pp 71–4). In addition, most other chapters touch upon multiple social determinants. For example, the housing chapter addresses aspects of affordability related to rental or purchase price, as well as location and the variable costs of mechanical heating and cooling.

Although not the primary focus, there are chapters in the NSWLTMP that draw attention to the perceived relationship between global competitiveness for investment, consumption, image and liveability particularly in regard to the inner city. For example: The CBD is economically and culturally the heart of global Sydney and is nationally important. A highly efficient transport network will maintain and improve Sydney's global status and amenity […] The CBD has to maintain a high level of amenity, liveability and vitality to attract international firms and workers (Transport for Newman and Kenworthy, 2015, p 62, 106). Walking, cycling and public transport in Sydney's inner city and inner suburbs are seen in the NSWLTMP as a means of improving liveability with a positive effect upon global image. Furthermore, a major strategic project to enhance both liveability and global image is to construct new light rail infrastructure to replace bus services. Nevertheless, a business advocate who collaborated on the NSWLTMP noted the difficulty modelling for indirect economic benefits such as global ‘image’ enhancement.

3.2.2. Productivity and congestion and (KPIs) in the NSWLTMP In the NSWLTMP there were eight goals including liveability, however, most interviewees claimed the dominant goal was economic growth and productivity and there were two dominant KPIs used to indicate progress towards these goals. One was project initiation and completion. The other was improving congestion indexed as travel time savings. Using cost benefit analysis modelling, time was monetised and saving it (and therefore money) became the key performance indicator used to assess the value of any project or strategy. A public servant from Transport explained:

But no-one's got the right tool. And the wider economic benefit is just - it's incomplete and it doesn't capture everything […] You know, building a metro through the centre of Sydney, or building the CBD light rail through the centre of George Street, how on earth do you possibly capture the rise in Sydney's status as a global city that those projects will have? (NSW Business Advocate 1).

Everything comes back to what are the KPIs of the executives who make the decisions. So, the KPI of the chief executive of what was then RTA (Road and Traffic Authority) is now RMS (Roads and Maritime

Hence, despite some references to image, the major justification for the Sydney light rail came back to the priority objective of reducing congestion.

Table 3 Key Performance Indicator Targets TYPGA (DPTI, 2017, pp 36–7). 1 85% of all new housing in metropolitan Adelaide will be built in established urban areas by 2045 2 Increase the percentage of residents living in walkable neighbourhoods in Inner, Middle and Outer Metropolitan Adelaide by 25% by 2045 3 60% of all new housing in metropolitan Adelaide will be built within close proximity to current and proposed fixed line (rail, tram, O-Bahn and bus) and high frequency bus routes by 2045 4 Increase the share of work trips made by active transport modes by residents of Inner, Middle and Outer Adelaide by 30% by 2045 5 Urban green cover is increased by 20% in metropolitan Adelaide by 2045 6 Increase housing choice by 25% to meet changing household needs in Greater Adelaide by 2045.

Sydney's Light Rail Future will reduce buses in the CBD by 180 in the morning's busiest hour and when combined with bus network changes this will increase up to 220 (buses), helping to lower congestion caused by buses entering and travelling along CBD streets (Transport for Newman and Kenworthy, 2015, p. 156). 3.2. Goals and their relationship to key performance indicators (KPIs) While strategic goals are guiding, aspirational and usually unmeasurable, key performance indicators (KPIs) are the measurable 5

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Services) is that they must maintain the travel speed in the network […] travel time savings is what is the value per hour by the number of people by the number of minutes that you save with whatever you propose (NSW Public Servant, Transport 1).

Public Servant, Health 1). In the TYPGA's key performance indicator targets, it is not so much a case of giving up or ignoring outer suburbs but instead a case of treating unequals equally and therefore exacerbating inequality. For example, the walkability KPI target is to:

Reduced travel time as a KPI prioritises the fastest mobility option, which in the suburb to suburb trips that account for most metropolitan journeys, is the private motor vehicle. A public servant from Transport explained:

Increase the percentage of residents living in walkable neighbourhoods in Inner, Middle and Outer Metropolitan, Adelaide by 25% by 2045 (DPTI, 2017, 146).

… the priority is the movement of cars, and whatever will facilitate the movement of cars is the focus. And, what I've definitely learnt over time is that transport engineers are very good at solving problems, and that essentially that the problem that they're given, and have been given for a long time is how quickly can we move cars? As opposed to mobility.

According to the document, using a ‘multi-criteria GIS analysis’ 73% of residents in inner suburbs, 53% in middle suburbs, and 30% in outer suburbs currently live in walkable neighbourhoods (DPTI, 146). This means by 2045 the numbers of residents living in walkable neighbourhoods will rise to 91% in inner suburbs, 66% in middle suburbs, and just 38% in outer suburbs.

Q: Yeah, or as opposed to ensuring effective land use, or cutting emissions or anything like that.

3.3.2. Health equity problems evident in the NSWLTMP The equity concerns of the NSWLTMP pertain to the prioritising of transport modes. The objectives and strategies to create a networked public transport system and to increase employment and services in outer suburbs as a means of tackling congestion would also potentially improve liveability, equity and social inclusion. However, travel time savings as a productivity-enhancing KPI create inequity between travel modes as it values the speed of private motor vehicles most highly. Furthermore, while travel time savings can be used to justify investments in public transport, it tends to favour modes that are best able to clear traffic in specific areas at specific times of day by encouraging people with cars to take alternative means (Grengs, 2005; Mees, 2014). This fails to address evidence that addressing transport inequities requires a comprehensive, integrated public transport system to make it possible for those without cars to travel to and from multiple points in the city at any time (Grengs, 2005; Mees, 2009). Furthermore, the priority of getting motorists to use public transport as an alternative for long commutes prioritises ease of access and convenience to stations from buses and cars above the fine-grained detail and human scale required for pedestrian and cycling orientation (Mees, 2009). A public servant explained:

A: Oh, no, none of that (NSW Public Servant, Transport 3). There are circumstances where rapid public transport can reduce travel time, most notably trips from suburb to city or suburb to major activity centre. Nevertheless, reducing travel time as the priority has the effect of reversing the mode order of priority when it comes to realising social and environmental benefits such as liveability, health, equity, efficiency, or sustainability. The prioritised order to achieve any of these puts walking first, then cycling, then public transport with private motor vehicle use last (Ewing and Handy, 2009; Newman and Kenworthy, 2015; Frumkin et al., 2004). A public servant elaborated on the problem of prioritising walking and cycling modal choices over and above the car in relation to travel time savings KPIs. But they [walking and cycling] rate really poorly on travel time savings because every bicycle and every pedestrian is considered to be a cost as opposed to a benefit in travel time savings. […] And if you get more pedestrians and you widen a footpath and you take a traffic lane out and that slows traffic down and travel time savings (NSW Public Servant, Transport 1). The issues of health and wellbeing related to travel were rarely advanced as a major concern. However, a senior public servant did try to provide a post-hoc health rationalisation for the pursuit of travel time savings.

… that if there's not an issue with incorporating the health benefit or the health paradigm, then sure […] But then, if it gets in the way of the priority, we wouldn't necessarily put (bicycle facilities) where we're going to put some park and ride, which are for cars. Then when there's competing priorities, the agency will return back to its priorities (NSW Public Servant, Transport 3).

I don't think that [health and wellbeing] was considered explicitly in the development. […] But if you can reduce people's travel times to and from work so they've got more time at home with the family and all the rest of it, that in itself even if they're driving there and go by public transport or whatever, that still has certain benefits for their health and well-being (NSW Senior Public Servant, Transport 2).

Consequently, while the actual document does not discriminate between modes, the KPI of travel time savings does when it comes to funding. A senior public servant observed: If you look at the State Government's budgets for public transport, road infrastructure and then walking and cycling, it's like billions for this, billions for that, and a few hundred thousand for walking and cycling (NSW Senior Public Servant, Transport 2).

3.3. Health equity 3.3.1. Health equity problems evident in the TYPGA A major issue of the policy direction set out in the TYPGA from a social determinant of health and health equity perspective is its inequity. For example, targeted infill opportunities and associated redevelopments highlighted across the metropolitan area are heavily concentrated within 10 km of the CBD. This has the potential to increase social exclusion and inequity because, as pointed out in the plan itself, the least liveable areas of the metropolitan area are in the outer suburbs. A public servant from Health noted this as a flaw in the plan:

4. Discussion This analysis has shown how liveability and economic competitiveness acted as driving forces behind two comprehensive planning processes for Sydney and Adelaide and how both have implications for population health status. The findings have demonstrated how planning for the future transport needs of Sydney prioritised reducing road congestion over and above liveability, and with the often-explicit goal of facilitating the global competitiveness of the city. In contrast, Adelaide's urban plan emphasised liveability as a direct facilitator of competitiveness. The different purpose of each plan – one for transport and one for land use – does not alone account for these differences. A

if you look at the current version of the 30-Year Plan, its targets aim to increase the liveability of suburbs within a ten kilometre radius and pretty well ignores outer suburbs which have much lower health equity and much poorer liveability. Almost like they have just given up on them (SA 6

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deeper reading of the plans and the explanation of their development from interviews, when compared with the literature on neo-liberalism, offers much for understanding how and why public health issues such as liveability, health and equity are positioned in city policy and planning. Allmendinger and Haughton (2010) argue that plans such as the TYPGA and the NSWLTMP often promise a range of social and environmental goods as facades for neo-liberal agendas and economic power in order to co-opt multi-sector consensus. In post-industrial cities, urban development itself has become a major driver of economic activity as both a producer of consumables (e.g. purchases for dwellings and lifestyle), prestige and investment options and a provider of locations for consumption. In these scenarios, city planning focuses upon brokering and facilitation; essentially ensuring development-ready sites are available for actual, anticipated or hoped for market demand (Allmendinger and Tewdwr-Jones, 2005; Olesen, 2013; Leigh and Blakely, 2016). Consequently, intent is not simply demonstrable by inclusion in government planning documents. Policy intent is ultimately determined by concurrence with the political priorities of government ministers, agendas of senior bureaucrats, key performance indicators and the prioritization and funding which flows in support of these (Lewis, 2005; Bevan and Hood, 2006). In the case of the plans analysed, the problem is not their intent but rather the likely inequity flowing from their application. Global competitiveness as an economic imperative directs government funds towards globally connected and image enhancing parts of the city, not to areas of social or locational disadvantage (Caragliu et al., 2011; Krueger and Buckingham, 2012). In the case of the TYPGA, liveability improvements occur in conjunction with targeted infill in areas able to enhance the city's image and where market demand for property is high. Outer suburbs, which are disproportionally populated by people who are less well-off, have worse health status and would benefit most from more liveable suburbs, are not afforded the same attention or resource investments in liveability. In the case of the NSWLTMP, the goal of reducing congestion has led to planning for a polycentric metropolis connected and integrated by a networked transport system. The networked city approach is recognised as the best means of shortening journey length and inducing a transfer from private motor vehicles to public and active transport, and improving health as a result (Frank and Engelke, 2005; Handy and Clifton, 2001; Pucher et al., 2010; Newman and Kenworthy, 2015; Mees, 2014). It also holds out the prospect of improving social inclusion by improving access to services, social activities, employment and the breadth of the city for those without regular access to private motor vehicles, again with large benefits for health and health equity (GilesCorti et al., 2014; Grengs, 2005). However, the priority of tackling congestion and the dominant KPI of travel time savings have the potential to undermine these benefits as they favour car travel over other modes. There is little evidence that investing in roads overcomes congestion (Handy, 2005; Cervero and Hansen, 2002; Newman and Kenworthy, 2015). However, there is significant evidence that investing in roads, particularly urban freeways, reduces walking, cycling and public transport use and increases average vehicle kilometres travelled all of which affect health adversely (Ewing et al., 2015; Handy, 2005; Ewing and Handy, 2009; De Dios Ortuzar and Willumsen, 2011). Increases in average vehicle kilometres travelled cause more pollution, more road trauma, more time spent in cars, less physical activity and poorer population health (Frank and Engelke, 2005; Stevenson et al., 2016). In both the TYPGA and the NSWLTMP, the priority of improving global competitiveness via improvements in image is exemplified in the priority of inner-city public transport investments, particularly light rail. In global competition, light rail is considered modern, cosmopolitan, European, progressive, cool and sleek (Ferbrache and Knowles, 2017). On the other hand, buses are viewed as second rate and

associated with lower order ‘secondary cities’ not global cities (Ferbrache and Knowles, 2017). Consequently, governments for the sake of image are prepared to spend significantly more funds on light rail than less expensive options such as designated bus lanes (Hensher and Mulley, 2015). As funds for public transport are limited and light rail expensive, this potentially diverts funds away from public transport that advances social inclusion and encourages healthy behaviours including walking and socialising. In recent years, the idea of the ‘smart city’ has been championed as the attractor of new industries and the creative classes that work within them (Caragliu et al., 2011; Tranos and Gertner, 2012). Smart cities are perceived as globally connected by information technology and transport infrastructure, and use technology to ameliorate urban problems and inefficiencies (Caragliu et al., 2011; Albino et al., 2015). In the South Australian TYPGA, there is a fundamental belief in the ‘smart city’ approach. In particular, no contradiction is seen between the three goals expressed of increasing global competitiveness, sustainability and liveability. Instead, as a plan for a secondary global city, the TYPGA sees enhancing liveability and sustainability as vital contributors to the city's image, and global economic competitiveness. Consequently, the public health advocates interviewed were able to use liveability as an avenue to include a broad array of social determinants of health into planning policy. As a result, the ‘new urban form’ envisaged in the TYPGA and the objectives in support of it are comprehensive in their support of liveability and multiple social determinants of health. The health advocates used a Health in All Policies approach in a way that has been previously evaluated as effective at persuading other sectors to consider health outcomes alongside their other goals (Baum et al, 2017). In conclusion, it would be easy to assume that the combination of hegemonic neo-liberal ideology, the influence of the development and building industries, and the ongoing love affair between Australians and their private cars would make opportunities to influence urban planning and transport policies to include elements that promote better public health rare. However, the desire of cities (and the jurisdictions they sit in) to maximise their global image and international competitiveness and hence the inflow of exogenous capital to them can present opportunities. The TYPGA demonstrates that in the right political climate liveability can provide an avenue for the advancement of policies in support of social determinants of health. However, the pursuit of liveability requires a note of caution as it has multiple definitions. Some definitions, such as that of Lowe et al. (2015), potentially advance multiple social determinants of health, whereas others, such as that of EIU (2017), focus on individual behaviour and/or the lifestyles of the privileged and therefore do not. While not wishing to present an overly optimistic picture of what can be achieved, this research demonstrates that such opportunities can be crafted and used to promote health by urban planners and public health advocates who: (1) prioritise public health and health equity as central to urban planning and design (along the lines of that argued by Barton and Tsourou (2013), and Corburn (2004). (2) understand the conditions surrounding how urban policies and plans are developed and implemented Harris et al., 2015, 2019. (3) Recognise that processes are essential, such as framing strategies and goals in language that is consistent with that used by urban planners to achieve their KPIs. We have, however, identified significant concerns that health advocates need to be vigilant about even when land use and transport planners begin to incorporate health promoting strategies. In particular, even when equity is professed as an organising principle for a plan, it can fall by the wayside during the development of strategies and targets. An emphasis on increasing liveability as means of enhancing global image can see public infrastructure investments diverted away 7

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from suburbs where they might do most to promote health towards more affluent suburbs with the best global connections. This trend will increase health inequities in long term. Similarly, an emphasis on transport investments to reduce congestion may see infrastructure funds diverted away from those that facilitate equitable access to those which reduce travel times.

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