Health Promotion International, Vol. 17, No. 4, 373-381,
December 2002
© Oxford University Press 2002
National environmental health planning in Vietnam: flying some kites
Centre of Environmental Health Development, WHO Collaborating Centre for Environmental Health, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW 1797, Australia and 1 Department of Preventative Medicine, Ministry of Health, 138A Giang Vo Street, Hanoi, Vietnam
Address for correspondence: Brent Powis Centre of Environmental Health Development WHO Collaborating Centre for Environmental Health University of Western Sydney Locked Bag 1797 Penrith South DC NSW 1797 Australia E-mail: b.powis{at}uws.edu.au
SUMMARY
The link between environment and health has been well established, as has the need to develop strategies to manage the environment to protect health. The response of many governments to the emergence of environment as a leading concern of public health policy has been to fragment environment and health functions across many agencies, without effective coordination or communication systems, resulting in poor planning frameworks. There is a deepening awareness by many in government and international agencies of the need to develop ‘national environmental health plans’ (NEHAPS) to build and integrate environment and health policy and practice. To date, however, experience in the development of these and similar plans indicates that prescriptive ‘top-down’ approaches to plan development may yield limited success. This paper describes an ongoing project in Vietnam to develop a process for a national environmental health plan that provides a strong link between policies and practice, and utilizes a learning model for plan development. As environmental health is a new concept in Vietnam, significant attention has been given to the development of both national and local visions. The lessons learnt to date indicate that the use of a learning framework may provide a strong basis for the emergence of environmental health policy and its management. Facilitation of this process has required the use of a variety of change management tools and has placed an emphasis on using them in culturally sensitive ways. It is hoped that the emerging model, which gives environmental health its first expression at both national and provincial levels, will be of value to others undertaking similar policy and planning initiatives.
Key words: environmental health; NEHAP; planning; policy
INTRODUCTION
Government responses to the emergence of environment as a leading concern of public health policy have in many cases been to fragment environment and health functions across many agencies, without effective coordination or communication systems (Kreisal, 1990
). Attempts to overcome such separations and to develop implementation networks between government agencies are often impeded by interorganizational issues, including threats to autonomy and lack of consensus (Brinkerhoff, 1991).
Against this backdrop and the increasing concern regarding the international and national threats to health, the United Nations Conference on Environment and Development held in Rio de Janerio in 1992 endorsed Agenda 21. As a blueprint for socially, economically and environmentally sustainable development, Agenda 21 has provided the endorsement for new approaches to the development and implementation of environmental health policy [World Health Organization, (WHO, 1997)].
As the international community emerges from the ‘Rio plus Ten’ conference in Johannesburg in 2002, it is vitally important not only to document, but to continue to critically reflect on the development of any such new approaches. The WHO developed its global strategy on health and environment as a framework to guide its action in response to Agenda 21 (WHO, 1993). As a result, many governments began developing more strategic approaches to the management of environmental health through the production of ‘National Environmental Health Action Plans’ (NEHAPs). However, governments face considerable difficulties with the development of such plans. The process in Europe was to pilot the development of NEHAPs in six countries (Bulgaria, Hungary, Italy, Latvia, the United Kingdom and Uzbekistan) and to share experiences. Potential problems identified in effecting plan development included:
- lack of clear and high level support;
- lack of cooperation between ministries;
- lack of experience in preparing plans;
- obtaining appropriate public participation;
- trans-boundary issues needing agreed solutions; and
- parallel processes occurring in government leading to duplication (European Environment and Health Committee, 1995).
The United Kingdom’s first draft of their NEHAP was distributed for public comment in 1995. Criticism by the UK Chartered Institute for Environmental Health claimed that the plan had succeeded in doing no more than re-state and re-package existing policies and programs (Chartered Institute of Environmental Health, 1995). The institute questioned the use of a prescribed planning approach and format, claiming that the opportunity to develop strategies that reflected individual systems and cultures was lost within the process. Other concerns included a:
- lack of visionary perspective;
- lack of specific detail on ‘what’, ‘how’ and ‘when’; and
- failure to engage people at the local level to inform national policy development.
). This may explain why many countries have been slow to adopt more comprehensive environmental health policies and strategies [(Anon, 1996), p. 139]. THE VIETNAM NEHAP
This paper describes the process led by the WHO since 1994 and supported by the authors to develop a national environmental health plan in Vietnam. The planning process has sought to address the challenges faced by developing countries in ways that provide for an adaptable framework and long-term sustainability.
The Vietnamese Government recognized the need to develop appropriate policy, legislation and management approaches to integrate environment and health into planning for sustainable development. The government’s ‘National Plan for Environment and Sustainable Development’ (State Committee For Sciences, 1991) called for the development of an integrated environmental health plan for urban development with the participation of all relevant sectors. The plan recognized the impact of poor environmental management on national mortality and morbidity rates, stating that ‘...in urban areas the threat to human health lies principally in effects of industrial pollution, vehicle emissions, overcrowded living conditions, poor sanitation infrastructures such as drinking water, toilet facilities, sewage disposal and waste management as a whole’ [(State Committee for Sciences, 1991), p. 72]. Historically, approaches may have been directed at massive engineering schemes; however, today it is recognized that any such scheme must be backed by adequate national environmental health policies and an effective local administration.
STRATEGIC MANAGEMENT LEARNING MODEL
The approach undertaken in Vietnam was influenced by lessons from recent work relating to the application of strategic management learning models to the environmental management field. Many have identified the limitations of past practice in developing countries (Rondinelli, 1983; Brinkerhoff and Goldsmith, 1990; Goldsmith, 1996; Peters, 1996), where plans of a prescriptive nature, delivered in a top down manner, have failed to facilitate long-term change.
The search for more effective management frameworks has led several workers to advocate processes that are learning based (Mintzberg, 1995a; Mintzberg, 1995b). For example, in search of an appropriate strategic framework for coastal management in Australia, Davis and Weller advocate the use of the ‘learning school’ of strategic management, where strategy is seen as an emergent process, taking shape as participants reflect on, and learn from, their experiences (Davis and Weller, 1993). This approach appears to be in line with the increasing government recognition of the need for more participatory approaches to development planning and the associated reorientation of government bureaucracy necessary for this to occur (Thompson, 1995).
A strategic development tool successfully used in the development of environmental health policy and management is the ‘ABCD’ strategic questioning model (Ireland, 1997). While the model’s success spreads across a number of settings, it has been particularly well suited to industry, where it has served to provide a framework for cultural change and continuous improvement (Ireland, 1997). As outlined by Ireland, the process incorporates all stages of strategic management in an overall management model. Figure 1 shows that the components of ‘ABCD’ do not exist in a sequential line, but move from the process of ‘A’ (Where are we now?) to ‘B’ (Where do we want to be?). In ‘C’, the process moves to asking how to move from ‘A’ to ‘B’, while ‘D’ asks who connects these tasks to make them yield benefit.
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In the development of ‘A’ and ‘B’, personal and shared mind maps as well as metaphor are often used as the facilitator’s tools. Often the sheer complexity of the problem is itself a barrier, and so techniques such as mind mapping and the use of metaphor have proven useful in developing a shared understanding and meaning (Seror, 1996
; Ireland, 1997). The power of metaphor can also be harnessed to provide an image that is powerful in communicating meaning. In the area of qualitative research, they have been used as data-reducing and pattern-making devices as well as to force the viewer to see the larger picture (Burns and Grove, 1993). The use of these techniques allows the participants to explore mental models by establishing dialectical tension between different viewpoints. As pointed out by Eden, an important part of dealing with cultural transformation is helping decision makers conceptualize and categorize aspects of their situation, and recognize the deeper structure of their assumptions (Eden, 1993). A LEARNING APPROACH FOR VIETNAM
The approach adopted in Vietnam was to utilize a learning model of strategic management that draws strongly on the ‘ABCD’ model in managing the learning process. As shown in Figure 2, the process involves initial inputs from three pilot study areas, followed by a series of learning cycles at both national and provincial levels.
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The process commenced in 1994 with the three pilot management areas; the city province of Hai Phong, Dong Hoi Town within Quang Binh Province, and Baria Vung Tau Province (Figure 3
). Participants were drawn from the provincial departments of environment and health, the Provincial Peoples Committee and a number of other government agencies. The WHO provided a methodological framework drawn from their experiences of ‘Healthy City’ programs (WHO, 1995). This included giving seminars to participants, outlining the relationship between environment and health, and the possible strategies employed to achieve greater collaboration both within and between government and community.
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Following the seminars, participants conducted studies into environmental and health issues in their province, and priorities for future action were identified. The studies involved representatives from the provincial departments of health, science technology and environment, construction, the police, and women’s and youth groups. Practitioner findings were shared with other provincial representatives and the national government at a national workshop held in June 1995. It was at this stage that the authors began documenting the process, becoming part of the WHO initiative to develop a NEHAP.
The three pilot studies highlighted that priority issues varied according to the history, location and level of development of the provinces. Dong Hoi is a rural town located in Quang Binh Province, near the centre of Vietnam, and has a population of 92 827. The study there focused its attention on improvements to sanitation, water supply and waste management, as well as community education and involvement. The Province of Baria-Vung Tau lies on the coast in the south of the country; it has a population of 
700 000 and is a major industrial and tourist area. Here the study focused on the management of water pollution, solid waste disposal and adequate sanitation, and the impact of oil pollution on health and tourism. Hai Phong, the third largest city in Vietnam is an industrial port city with a population of 1.6 million. Priority issues addressed in Hai Phong included the need to increase community awareness through improving understanding of the relationship between health and environment, food safety, and the control and management of air pollution from industry and vehicles.
The value of the pilot studies lay in raising awareness within government of the value of intersectoral collaboration and consultation, and of the interconnectedness of environment and health issues. Provincial participants at the national conference expressed a growing understanding and an interest in working towards shared solutions.
In June 1995, following the first national forum, the first stage of the process of transforming this early learning into a national approach to environmental health commenced, and involved working with a small team of local counterparts drawn from the key national ministries who agreed to participate in the change management process. More than 40 interviews were conducted with a range of national and provincial government officers, spanning provinces in the north (Hanoi, Hai Phong and Quang Ninh), the south (Vung Tau Baria and Ho Chi Minh) and the Central Province of Quang Binh. Mind mapping techniques, the use of metaphor and interviews were all utilized to develop a picture of ‘A’ (where environmental health was then) and ‘B’ (where it wanted to be).
In terms of ‘A’, the process revealed that environmental health as a field was widely dispersed across many government agencies, seldom collaborating and with strong feelings of separation between those in national government and those in the provinces. The local team used the metaphor ‘a sea of jellyfish’ to convey the feeling of entanglement, lack of structure and confusion. Likewise, other metaphors were used to unravel the complex organizational system and proved useful in establishing a ‘neutral’ base from which issues could arise. Issues of concern included confusion between government agencies regarding roles and the subsequent duplication of effort in many areas. The need for coordination and collaboration amongst these agencies, as well as a strong involvement of public health practitioners in the provinces, was recognized.
The team chose the symbol of the kite as a metaphor of what environmental health might look like at a national level. Kites in Vietnam are a symbol of everyone’s childhood, and are immediately recognized for their beauty and the skill of the flyer. The kite reflected the need for coordination and balance of all sectors at the national level, and the need for the provinces to take a dominant role in ‘flying the kite’. The connection between the national government and the provincial government was considered an essential link in the management process. The pathway to achieving this vision was articulated through an agreed hierarchy of goals as shown in Figure 4.
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Four themes were then identified as important strategic issues upon which actions should focus: (i) clarification of roles and rationalization of resources; (ii) building of environmental health awareness; (iii) human resource development; and (iv) building and unifying of a legislative framework. Problems began to emerge, however, when trying to develop further and implement the ‘C’ and ‘D’ components of the ‘ABCD’ approach. The sheer size and complexity of the system of governance and the new nature of the environmental health concept made it difficult to gain commitment to undertake major activities at the national level. The task of changing the entire organizational system responsible for the management of environment and health in Vietnam in a short time-frame was considered by the team to be too ambitious. It was realized that there was a need to develop more trust with the external facilitators and confidence with the concepts. At this stage, the WHO had provided much of the learning, with little transference of this learning ‘on the ground’. The situation appeared to favour what Mintzberg and Westley have identified as a focused approach to organizational change, where change is attempted in one representative part of a system (Mintzberg and Westley, 1992
). In utilizing this approach, the Province City of Hai Phong was selected by the government as the site for the further development of the national plan, with activities commencing in October 1996. WORKING IN THE PROVINCES
The process began in Hai Phong by gaining the support and involvement of the People’s Committee of Hai Phong, who agreed to take an active participatory role in future activities and, importantly, in the creation of new environmental health policies. This guaranteed the province the necessary political support to instigate changes to policies, legislation, structures and activities of the various provincial departments. Following this commitment, six staff selected from the Department of Health and Department of Science, Technology and Environment formed an Environmental Health Unit. The unit was given its own office and made administratively accountable to the People’s Committee Chairman. The committee also provided funding to the Environmental Health Unit, covering salaries and minor costs. The WHO continued to provide a variety of types of support, including training programs focusing on environmental health issues in Hai Phong, and financial support for a range of projects.
The newly formed Environmental Health Unit and the WHO then developed a vision for environmental health in Hai Phong with staff from the new office. In an early workshop, one of the authors found that the search for common understanding could be effectively reached through the metaphor of poetry, with groups or individuals asked to write poetry on their vision for Hai Phong. The process of poetry unlocked many from the structures of formality and began a process of awakening in the staff the belief that they had the capacity to create shared vision. The following poem was selected as one that reflected the sentiments of all involved:
Hai Phong is the place we loveWhere people will live in peace and in good health
Hai Phong is the cradle feeding its people
Its clean environment is a fairy
It is green, civilized, rich and beautiful
This is the third city in Vietnam
The translation of the visionary process to one of goal setting then began. Departures from direct use of the ‘ABCD’ model continued, as the authors found an increasing need to adapt various tools to the situation. Mind maps were used in small groups to develop a picture of the issues confronting Hai Phong and converted into goals for the Environmental Health Unit. The development of a local vision and set of goals by the team served to provide a strong sense of ownership of the process.
‘HEALTHY CITIES’ EMERGES AS PART OF A NATIONAL PLAN
The next phase began in mid 1997, with the development of a plan of action by Environmental Health Unit staff. This plan included a number of specific projects that were considered to require a strong collaborative approach. Of particular significance was the decision to devolve the management of environmental health further, to levels closer to the community. This was achieved by selecting an urban district within the city to serve as the base for implementing specific environmental health projects. Community involvement and intersectoral collaboration led to the formation of a ‘Healthy District’ committee that was supported by Environmental Health Unit staff. The committee identified priority environmental health issues and sought ways to address problems. A priority ‘setting’ identified previously was the central market. Strategies for creating a ‘Healthy Market’ included training of the environmental health staff, liaison and negotiation with a range of provincial departments, market managers and the community, education of food handlers, identification of risk factors, structural improvements, and the formulation and adoption of new food safety policies by the province. Additional settings were subsequently identified with ‘Healthy Schools’, ‘Healthy Marketplaces’, ‘Healthy Work-places’, ‘Healthy Wards’ and ‘Healthy Communities’, all being initiated by the ‘Healthy District’ committee. The People’s Committee agreed to implement any new ‘legislative’ policies arising from that process.
The use of a wide range of ‘settings’ to drive change in environmental health policy and practice at the provincial level was soon presented by those at the provincial level as the Hai Phong Healthy Cities program. Together with similar approaches adopted in the city of Hue, the success of the program prompted the Ministry of Health to establish a national Healthy Cities Management Committee in 1999, with the Vice Minister for Health as Chair of the Committee.
The ‘Healthy Cities’ approach in Hai Phong and Hue subsequently involved a wide range of intersectoral representatives, including the WHO, the Departments of Health Services, Science Technology and Environment, Agriculture and Rural Development, the Urban Environmental Company, and community and social organizations such as the Women’s Union and Youth Union. These groups collaborated in initiating a project improving water quality in Quan Ngua Lake, and water supply and waste management in Ga market (Hai Phong) via drainage and sewerage improvements. The project also involved changes to food vendor regulation in the markets, the promotion of education on food hygiene and safety for consumers and vendors, and the construction of public toilets in the market. In Hue city, the government supported a resettlement program for >700 people who had been living on waterways in boats, and built hygienic latrines for disadvantaged households in suburban areas.
In the primary schools of Phu My (Hue) and Nguyen Dinh Chieu (Hai Phong), health protection activities were organized; sanitation was improved, toilets were rebuilt, and students were educated in hygiene practices such as hand-washing before meals and after defecation.
The use of ‘settings’ extended to other provinces outside of Hai Phong and Hue, with four new ‘Healthy Cities’ in Vietnam (Hanoi, Ha Dong, Can Tho and Thanh Hoa) being established in the past 3 years (1998–2001). ‘Healthy Cities’ has emerged as an important strategy in the development of a national environmental health plan, and the initiatives at the local level have been integral to driving the process.
CHANGE AT THE NATIONAL LEVEL
Established in 1999, the nationwide Healthy Cities Steering Committee now leads the Healthy Cities Project. The Healthy Cities Steering Committee has been aided by the Technical Advisory Group, an informal collective made up of members from a range of sectors that meet to discuss the progress of the ‘Healthy Cities’ implementation, and to give feedback and recommendations.
In July 2001, the Healthy Cities Steering Committee approved a National Master Plan on ‘Healthy Cities’. As a strategy within the NEHAP process, this plan will help the national government reflect on the experiences that are being shared by practitioners in the provinces, and at the same time build national capacity and policies.
MODEL FOR NATIONAL ENVIRONMENTAL HEALTH ACTION PLANNING
The emerging model for development of a national environmental health plan in Vietnam is one that is based on learning from experiences at both the national and provincial levels. As such, the plan is a process of learning; a process that includes the challenge of giving meaning to environmental health as a concept in Vietnam.
The underlying focus of national environmental health action plans is to link environmental and health policies. Environmental health in Vietnam is directed at the reunion of environment and health, fields that in many countries have been split (Kotchian, 1997). The NEHAP process in Vietnam thus hopes to provide the opportunity to link environmental and health policy and its implementation, at both the national and local levels.
The work to date in Vietnam has emphasized that the development of a national environmental health plan as a process has enabled the government to make major changes to the way people and organizations work together. An important part of this change process has been the development of meaningful visions of environmental health, which have derived from a combination of experiential learning and ‘imported learning’ from outside agencies. This approach overcomes the tendency for ‘mindless change processes’ (Mintzberg and Westley, 1992), where the process of visioning is bypassed, with the resultant planning tending to be dysfunctional. The visioning process in Hai Phong has been followed by the development of strategies and actions upon which the government and external support agencies have continued the learning process. The experience to date has also emphasized the need for long-term approaches, whilst also ensuring that short-term goals are established and met. The authors are convinced that the key to ongoing acceptance of the process relies on sustained and committed contact between government staff and external facilitators, both of whom are committed to building a trusting relationship.
In the context of experience in Vietnam, it is useful to reflect on the key ingredients of successful change, referred to by Senge and coworkers as ‘organizational architecture’, including guiding principles, infrastructure and tools (Senge et al., 1994). The guiding principles for environmental health have been solidly laid down at the international level through Agenda 21; however, there is still a need to articulate these principles at the local level. Focus on the development of a shared vision at both the national and provincial levels in Vietnam has served to articulate these principles in a form appropriate to the cultural setting, while providing a sense of ownership and pride to the national and provincial teams. The tools available in the change process are many, but the experience to date has emphasized the importance of adaptable and flexible application. The ‘ABCD’ strategic questioning model has proven to be useful in an environmental health change process, a process needing to work at the cultural level of organizations in order to be successful.
In terms of infrastructure, the Vietnam environmental health planning process to date has emphasized the need to address a range of issues, including human resource management, legislation and roles and responsibilities across government ministries. However, such transformations require considerable resources, political commitment and courage. There is also potential for such large-scale approaches to be ‘top down’, and therefore to be less effective. As highlighted by Thompson, such changes also need to address an entrenched, often cumbersome bureaucracy, and a culture averse to risk taking (Thompson, 1995). The experiences of provinces such as Hai Phong have given the national government the confidence to test new approaches in other provinces, as well as to begin the process of reshaping national policy and infrastructure. This ensures that the environmental health ‘kite’ flies in the right direction and is strongly connected to the community and issues on the ground.
CONCLUSIONS
The difficulty in developing and successfully implementing national environmental health action plans may be attributed to by the tendency to have prescribed approaches that are top down and that separate planning from implementation. The current approach developed in Vietnam has attempted to overcome these problems by adopting a ‘plan’, which is a process of learning and emerges over time. As such, it is a dynamic process that is better suited to the uncertainty and rapid change characteristic of countries like Vietnam.
In developing countries, donors continue to be very active in supporting the planning process by providing new knowledge and skills to key participants. The process to date has reinforced the value of experiential learning as a way to fully articulate this new knowledge into new understanding. While the ‘ABCD’ strategic questioning, used together with a suite of tools such as mind mapping and metaphor, have proven very useful in managing the change process, the need to adapt these approaches and to create new ones that reflect the needs of ‘people and place’ has also been emphasized.
We need to learn how both to create and fly kites and, much like environmental health itself, this is both an art and a science. While the ‘kite’ in Vietnam will take time to build, there has already been much important learning that is potentially valuable to others embarking on a similar journey.
ACKNOWLEDGEMENTS
The authors wish to express their gratitude to the WHO Western Pacific Region for supporting the initiative described in this paper. In particular we wish to acknowledge the vision and support of Mr Steve Tamplin, the then Regional Advisor in Environmental Health. We would also like to thank the national counterparts throughout Vietnam for their enthusiasm and commitment throughout this process. We wish to express that the ideas and views contained in this research paper are solely the views of the authors and do not necessarily reflect the ideas or views of the WHO or any organizations or persons connected to it.
REFERENCES
Anon (1996) Greening our health. Lancet, 348, 139.[Medline]
Brinkerhoff, D. W. (1991) Improving Development Program Performance: Guidelines for Managers. Lynne Rienner, Boulder, CO.
Brinkerhoff, D. W. and Goldsmith, A. A. (eds) (1990) Institutional Sustainability in Agriculture and Rural Development: a Global Perspective. Praeger, New York, NY.
Burns, S. and Grove, S. (1993) The Practice of Nursing Research: Conduct, Critique and Utilization. W. B. Saunders, Sydney, Australia.
Chartered Institute of Environmental Health (1995) The UK Environmental Health Action Plan. The Chartered Institute of Health, London, UK.
Davis, G. and Weller, P. (1993) Strategic Management in the Public Sector: Managing the Coastal Zone. Report to the Resource Assessment Commission. Canberra, Australia.
Eden, C. (1993) Strategy development and implementation: cognitive mapping for group support. In Hendry, J., Johnson, G. and Newton, J. (eds) Strategic Thinking—Leadership and the Management of Change. John Wiley and Sons, Chichester, UK.
European Environment and Health Committee (1995) European Programme to Support the Development of National Environmental Action Plans. WHO Regional Office for Europe, Copenhagen, Denmark.
Goldsmith, A. A. (1996) Strategic thinking in international development: using management tools to see the big picture. World Development, 24, 1431–1439.
Ireland, J. A. (1997) Managing the mind while managing the environment—tools for thinking strategically. In Brown, V. (ed.) Managing for Local Sustainability. University of Western Sydney Hawkesbury, Sydney, pp. 151–166.
Kotchian, S. (1997) Perspectives on the place of environmental health and public health and public health agencies. Annual Review of Public Health, 18, 245–259.[Web of Science][Medline]
Kreisal, W. (1990) Environmental health in the 1990s. World Health, Jan–Feb, 5–7.
Mintzberg, H. (1995a) The Five Ps for Strategy. In Mintzbergh, H., Quinn, J. and Voyer, J. (eds) The Strategy Process. Collegiate Edition.
Mintzberg, H. (1995b) Crafting Strategy. In Mintzbergh, H., Quinn, J. and Voyer, J. (eds) The Strategy Process. Collegiate Edition.
Mintzberg, H. and Westley, F. (1992) Cycles of organizational change. Strategic Management Journal, 13, 39–59.
Peters, B. G. (1996) The policy process in developed and less developed political systems. International Journal of Public Administration, 19, 1639–1668.
Rondinelli, D. (1983) Development Projects as Policy Experiments. Methuen, London.
Senge, P. M., Roberts, C., Ross, R., Smith, B. and Kleiner, A. (1994) The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. Doubleday, New York, NY.
Seror, A. C. (1996) Action research for international information technology transfer: a methodology and network model. Technovation, 16, 421–429.
State Committee For Sciences (1991) Vietnam National Plan for Environment and Sustainable Development: 1991–2000. Hanoi, Vietnam.
Thompson, J. (1995) Participatory approaches in government bureaucracies: facilitating the process of institutional change. World Development, 23, 1521–1554.
WHO (1993) WHO Global Strategy for Health and Environment. WHO, Geneva, Switzerland.
WHO (1995) Building a Healthy City: a Practitioners Guide. A Step-by-step Approach to Implementing Healthy City Projects in Low-income Countries. WHO, Geneva, Switzerland.
WHO (1997) Health and Environment in Sustainable Development—Five Years after the Earth Summit. WHO, Geneva, Switzerland.
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