Urban Planning for Healthy Cities

The purpose of this paper is to evaluate the progress made by European cities in relation to Healthy Urban Planning (HUP) during Phase IV of the World Health Organization's Healthy Cities programme (2003–2008). The introduction sets out the general principle of HUP, identifying three levels or phases of health and planning integration. This leads on to a more specific analysis of the processes and substance of HUP, which provide criteria for assessment of progress. The assessment itself relies on two sources of data provided by the municipalities: the Annual Review Templates (ARTs) 2008 and the response to the Phase IV General Evaluation Questionnaire. The findings indicate that the evidence from different sources and questions in different sections are encouragingly consistent. The number of cities achieving a good level of understanding and activity in HUP has risen very substantially over the period. In particular, those achieving effective strategic integration of health and planning have increased. A key challenge for the future will be to develop planning frameworks which advance public health concerns in a spatial policy context driven often by market forces. A health in all policies approach could be valuable.     

Age-Friendly Cities of Europe

This article summarizes how members of the European Healthy Cities Network have applied the ‘healthy ageing’ approach developed by the World Health Organization in their influential report on Active Ageing. Network Cities can be regarded as social laboratories testing how municipal strategies and interventions can help maintain the health and independence which characterise older people of the third age. Evidence of the orientation and scope of city interventions is derived from a series of Healthy Ageing Sub-Network symposia but principally from responses by 59 member cities to a General Evaluation Questionnaire covering Phase IV (2003–2008) of the Network. Cities elaborated four aspects of healthy ageing (a) raising awareness of older people as a resource to society (b) personal and community empowerment (c) access to the full range of services, and (d) supportive physical and social environments. In conclusion, the key message is that by applying healthy ageing strategies to programmes and plans in many sectors, city governments can potentially compress the fourth age of ‘decrepitude and dependence’ and expand the third age of ‘achievement and independence’ with more older people contributing to the social and economic life of a city.     

City Leadership for Health and Well-being: Back to the Future

The new European Health Policy Framework and Strategy: Health 2020 of the World Health Organization, draws upon the experience and insights of five phases, spanning 25 years, of the WHO European Healthy Cities Network (WHO-EHCN). Applying the 2020 health lens to Healthy Cities, equity in health and human-centered sustainable development are core values and cities have a profound influence on the wider determinants of health in the European population. “Making it Happen” relies on four action elements applied and tested by municipalities and their formal and informal partners: political commitment, vision and strategy, institutional change, and networking. In turn, the renewed commitment by member states of the WHO Regional Committee to work with all spheres and tiers of government is a new dawn for city governance, encouraging cities to redouble their investment in health and health equity in all policies, even in a period of austerity. For phase VI, the WHO-EHCN is being positioned as a strategic vehicle for implementing Health 2020 at the local level. Healthy Cities' leadership is more relevant than ever.     

Health Impact Assessment in a Network of European Cities

The methodology of health impact assessment (HIA) was introduced as one of four core themes for Phase IV (2003–2008) of the World Health Organization European Healthy Cities Network (WHO-EHCN). Four objectives for HIA were set at the beginning of the phase. We report on the results of the evaluation of introducing and implementing this methodology in cities from countries across Europe with widely differing economies and sociopolitical contexts. Two main sources of data were used: a general questionnaire designed for the Phase IV evaluation and the annual reporting template for 2007–2008. Sources of bias included the proportion of non-responders and the requirement to communicate in English. Main barriers to the introduction and implementation of HIA were a lack of skill, knowledge and experience of HIA, the newness of the concept, the lack of a legal basis for implementation and a lack of political support. Main facilitating factors were political support, training in HIA, collaboration with an academic/public health institution or local health agency, a pre-existing culture of intersectoral working, a supportive national policy context, access to WHO materials about or expertise in HIA and membership of the WHO-EHCN, HIA Sub-Network or a National Network. The majority of respondents did not feel that they had had the resources, knowledge or experience to achieve all of the objectives set for HIA in Phase IV. The cities that appear to have been most successful at introducing and implementing HIA had pre-existing experience of HIA, came from a country with a history of applying HIA, were HIA Sub-Network members or had made a commitment to implementing HIA during successive years of Phase IV. Although HIA was recognised as an important component of Healthy Cities’ work, the experience in the WHO-EHCN underscores the need for political buy-in, capacity building and adequate resourcing for the introduction and implementation of HIA to be successful.     

Equity and the Social Determinants of Health in European Cities

Equity in health has been the underlying value of the World Health Organization’s (WHO) Health for All policy for 30 years. This article examines how cities have translated this principle into action. Using information designed to help evaluate phase IV (2003–2008) of the WHO European Healthy Cities Network (WHO-EHCN) plus documentation from city programs and websites, an attempt is made to assess how far the concept of equity in health is understood, the political will to tackle the issue, and types of action taken. Results show that although cities continue to focus considerable support on vulnerable groups, rather than the full social gradient, most are now making the necessary shift towards more upstream policies to tackle determinants of health such as poverty, unemployment, education, housing, and the environment, without neglecting access to care. Although local level data reflecting inequalities in health is improving, there is still a long way to go in some cities. The Healthy Cities Project is becoming an integral part of structures for long-term planning and intersectoral action for health in cities, and Health Impact Assessment is gradually being developed. Participation in the WHO-EHCN appears to allow new members to leap-frog ahead established cities. However, this evaluation also exposes barriers to effective local policies and processes to reduce health inequalities. Armed with locally generated evidence of critical success factors, the WHO-EHCN has embarked on a more rigorous and determined effort to achieve the prerequisites for equity in health. More attention will be given to evaluating the effectiveness of action taken and to dealing not only with the most vulnerable but a greater part of the gradient in socioeconomic health inequalities.     

Do Healthy Cities Work? A Logic of Method for Assessing Impact and Outcome of Healthy Cities

In this article, we discuss an appropriate methodology for assessing complex urban programs such as the WHO European Healthy Cities Network. The basic tenets and parameters for this project are reviewed, and situated in the broader urban health tradition. This leads to a delineation of the types of questions researchers can address when looking at a complex urban health program. Such questions reach appropriately beyond traditional public health concepts involving proximal and distal determinants of health (and associated upstream, midstream, and downstream rhetoric). Espousing a multi-level, reciprocal pathways perspective on Healthy Cities research, we also adopt a distinction between impacts and outcomes of Healthy Cities. The former are value-driven, the latter intervention-driven. These approaches lead to the acknowledgment of a logic of method that includes situational and contextual appreciation of unique Healthy City experiences in a Realist Evaluation paradigm. The article concludes with a reflection of evaluation and assessment procedures applied to Phase IV (2003-2008) of the WHO European Healthy Cities Network and an interpretation of response rates to the range of methods that have been adopted.     

Evaluation of Partnership Working in Cities in Phase IV of the WHO <Emphasis Type="Italic">Healthy Cities</Emphasis> Network

An intersectoral partnership for health improvement is a requirement of the WHO European Healthy Cities Network of municipalities. A review was undertaken in 59 cities based on responses to a structured questionnaire covering phase IV of the network (2003–2008). Cities usually combined formal and informal working partnerships in a pattern seen in previous phases. However, these encompassed more sectors than previously and achieved greater degrees of collaborative planning and implementation. Additional WHO technical support and networking in phase IV significantly enhanced collaboration with the urban planning sector. Critical success factors were high-level political commitment and a well-organized Healthy City office. Partnerships remain a successful component of Healthy City working. The core principles, purpose and intellectual rationale for intersectoral partnerships remain valid and fit for purpose. This applied to long-established phase III cities as well as newcomers to phase IV. The network, and in particular the WHO brand, is well regarded and encourages political and organizational engagement and is a source of support and technical expertise. A key challenge is to apply a more rigorous analytical framework and theory-informed approach to reviewing partnership and collaboration parameters.     

Health in the Urban Environment: A Qualitative Review of the Brighton and Hove WHO Healthy City Program

Phase IV of the WHO European Region’s Healthy Cities Program ended in December 2008. This article presents the findings from a recently completed review of Brighton and Hove’s Healthy City Program which aimed to scope whether added value had accrued from the city’s role as a WHO Healthy City during phase IV. In contrast to most other evaluations of healthy cities, this review adopted a qualitative approach representing an appraisal of the Brighton and Hove Healthy City Program from the internal viewpoint of its local stakeholders. In addition to documentary analysis and a facilitated workshop, a series of in-depth interviews (N = 27) were conducted with stakeholders from the Brighton and Hove Healthy City Partnership representing each of the sectors reflected in the Local Strategic Partnership (public, statutory, elected, community and voluntary, neighborhood and communities, business). The key findings of the review are presented in a way which reflects the three key areas of the review including (1) the healthy cities approach, (2) participation in phase IV of the WHO Healthy Cities Program, and (3) the Brighton and Hove Healthy City Partnership. These findings are discussed, and recommendations for action at local, national, and European levels are proposed. In particular, we argue that there is an urgent need to develop a suitable monitoring and evaluation system for the WHO Healthy Cities Program with appropriate indicators that are meaningful and relevant to local stakeholders. Moreover, it would be important for any such system to capitalize on the benefits that qualitative methodologies can offer alongside more traditional quantitative indicators.     

Promoting Active Living in Healthy Cities of Europe

Local governments in Europe have a vital role in promoting physical activity in the daily life of citizens. However, explicit investment in active living has been limited. One of the four core themes for Phase IV (2003–2008) of the World Health Organization (WHO) European Healthy Cities Network (WHO-EHCN) was to encourage local governments and their partners to implement programs in favor of active living. This study analyzes the performance of network cities during this period. Responses to a general evaluation questionnaire are analyzed by content according to a checklist, and categorized into themes and dimensions. Most cities viewed “active living” as an important issue for urban planning; to improve visual appeal, enhance social cohesion, create a more sustainable transport system to promote walkability and cyclability and to reduce inequalities in public health. Almost all member cities reported on existing policies that support the promotion of active living. However, only eight (of the 59) responding cities mentioned an integrated framework specific for active living. Many efforts to promote active living are nested in programs to prevent obesity among adults or children. Future challenges include establishing integrated policies specifically for active living, introducing a larger range of actions, as well as increasing funding and capacity to make a difference at the population level.     

The Valencian Community Healthy Cities Network: assessment of the implementation process

In 1986 WHO-Euro began to develop the Healthy Cities projectwhich was later extended to Spain, in this paper the factorsrelated to the initial development of the Healthy Cities Projectin the member towns and cities of the Valencian Community HealthyCities Network, and the level of their development will be described. The project began in 1987 and the Network, at the time of thisstudy (March 1991), was made up of 48 towns and cities. Theinstrument used to assess the process of the project developmentwas a questionnaire administered by personal interview withthe three people responsible for the project in each city: theMayor, Health Councillor and Health Officer. A score was establishedto measure the level of development of the project in each citywhich included performance of the health diagnosis and plan,the existence of intersectoral committees and the creation ofchannels of community participation. A large proportion of the cities (72%) have carried out theHealth Diagnosis; 26% of the cities have intersectoral committeesand community participation is as yet in the initial stages.Political parties' support of their city's membership in theNetwork, has been almost unanimous with only three exceptions.Resources allocated to the project are not yet constant, althoughthere is important support from different levels, and on thepart of local and autonomous institutions. Differences can beobserved in the level of development of the cities which makeup the Network, related partly to length of time of membership,to the size of the city and to other factors difficult to assess.     

Why urban health cannot be ignored: the way forward

Urban health is an increasingly relevant and challenging field of action for the European region, and indeed the whole world. Urban health and action at the local level represent a high priority for the European Office of the World Health Organization. The success and appeal of the Healthy Cities concept to politicians, to professionals, and to community activists has resulted in a continuing growth of the movement both within and outside Europe. More than 1200 cities and towns are now involved in the 26 national Healthy Cities networks and several regional networks in Europe. Working directly and closely with a relatively small network of selected fully committed cities (over two 5-year phases: 1988 to 1992 and 1993 to 1997) has proved to be a valuable tool for strategic growth and a source of know-how, legitimacy, and continuous learning. No plan or strategy for health can be serious without systematically addressing poverty, vulnerability, and access to care. The WHO Healthy Cities programme gives emphasis on addressing equity and the social determinants of health through explicit political commitment and integrative policy making and planning.     

Healthy cities -- WHO's New Public Health initiative

The World Health Organization's European Office has initiateda major new project known as "Healthy Cities". As a laboratoryfor the lifestyle targets agreed for Europe, the time seemsright to support integrated approaches to health promotion atthe city level. The city is often the lowest administrativelevel which can marshal the resources and has the politicalmandate and authority to develop and implement intersectoralapproaches to health; because it is a place with which its citizensidentify, there are good prospects for participation harnessedto neighbourhood or civic pride. Throughout the European Regionat present there is evidence of a general renaissance of publichealth activity at this level and it seems appropriate for WHOto support and facilitate processes which are already underway. The project will initially bring together ten or twelve Europeancities to collaborate in the implementation of intersectoralcity health plans. In turn, these cities will take responsibilityfor supporting the development of further networks of citieswhich wish to participate in the project. WHO will provide technicalexpertise and generate a range of resource materials of valueto the cities involved. In addition there will be a major collaborativeEuropean television series on the healthy city. By concentrating on concrete examples of health promotion whichinclude a commitment to community participation and intersectoralcollaboration, it is expected that the Healthy Cities projectwill mark the point at which WHO philosophies and frameworksare taken off the shelves and into the streets of European cities     

Healthy Cities projects

This is a review article on "Healthy Cities". The Healthy Cities programme has been developed by the World Health Organization (WHO) to tackle urban health and environmental issues in a broad way. It is a kind of comprehensive policy package to carry out individual projects and activities effectively and efficiently. Its key aspects include healthy public policy, vision sharing, high political commitment, establishment of structural organization, strategic health planning, intersectoral collaboration, community participation, setting approach, development of supportive environment for health, formation of city health profile, national and international networking, participatory research, periodic monitoring and evaluation, and mechanisms for sustainability of projects. The present paper covered the Healthy Cities concept and approaches, rapid urbanization in the world, developments of WHO Healthy Cities, Healthy Cities developments in the Western Pacific Region, the health promotion viewpoint, and roles of research.     

Five years "Healthy Lower Rhine…Against Stroke": implementation of a regional,intersectoral and sustainable public health program

Aim  

Stroke is one of the leading causes of death worldwide. Optimizing health care according to the “time is brain” concept is recommended by the Local Health Conferences (KGK) in North Rhine-Westphalia. In 2001, KGK managers from six neighboring districts and municipalities founded the "Healthy Lower Rhine Network." In 2003 the network launched the program "Healthy Lower Rhine…Against Stroke." This initiative aims primarily at reducing pre-hospital time, i.e., delays from onset of symptoms to hospital presentation in order to optimize modern acute health care. Improving community knowledge of stroke is crucial in this context as well as training in the professional sector.     

From projects to policy: 'healthy cities' as a mechanism for policy change for health?

One of the aims of the European Healthy Cities project was to contribute to the development of healthy public policy. This paper examines the evidence from ten cities in the Netherlands and the United Kingdom which are either part of the World Health Organization (WHO) Healthy City Project or part of their respective National Networks. Five key issues are identified based on current thinking in political and administrative science concerning change and policy-making. These provide a framework for the analysis of key informant interviews undertaken in the ten case studies. It was concluded that, at the time of the research, a substantive policy change had not taken place and in most cases the Health city initiatives were still projects rather than policies and, where plans or strategies had been developed, they were still insufficient in their impact in raising health as opposed to health care up the policy agenda.     

Healthy cities: overview of a WHO international program

Health is the outcome of all the factors and activities impinging upon the lives of individuals and communities. The last decade has seen an emerging understanding within development circles that living conditions are greatly affected by local action, by the work of local government, and by community groups and organizations. In addressing health and environmental issues and making interventions, an integrated approach, based on 'settings', exemplified in the Healthy Cities approach, has proved most effective. A Healthy City project can involve people and organizations in the programs and activities that are needed for better health, and enables a city or neighborhood to mobilize the human and financial resources required to address many health and quality of life issues. The WHO program involves implementating city projects and networks in all regions of the world and serves as a vehicle for many health programs, including major disease control initiatives. Healthy City projects allow Ministries of Health to develop stronger partnerships with local government organizations (such as the Union of Local Authorities and its members, "Local Agenda 21" initiatives, and others). One focus for the program is the development of 'multi-'multi-city action plans' for major global priority issues, including AIDS, sanitation, women's health, and violence, to ensure that major public health programs are strengthened by wider community participation. It is recognized that city networking--at national, regional, and international levels--now must be better exploited by individual cities and municipalities to solve local health problems.     

Healthy Cities: Facilitating the Active Participation and Empowerment of Local People

Community participation and empowerment are key values underpinning the European WHO Healthy Cities initiative, now in its fifth phase. This paper provides a brief overview of the history, policy context, and theory relating to community participation and empowerment. Drawing on Phase IV evaluation data, it presents the findings in relation to the four quadrants of Davidson’s Wheel of Participation—information, consultation, participation in decision making, and empowerment. The large majority of European Healthy Cities have mechanisms in place to provide information for and to consult with local people. Most also demonstrate a commitment to enabling community participation in decision-making and to empowering citizens. Within this context, the evaluation highlighted a diversity of approaches and revealed varied perspectives on how participation and empowerment can be integrated within city leadership and governance processes. The paper concludes by suggesting that there is a need to strengthen future evaluative research to better understand how and why the Healthy Cities approach makes a difference.     

What about healthy networks? An analysis of the national networks of healthy cities in Europe

The World Health Organization (WHO)/Euro Healthy Cities Projecthas received much attention since the first project cities wereselected in 1987 in fact many more cities than can participateshowed (and still show) their interest. Thus initiatives havebeen taken to establish activities similar to the Healthy CitiesProject, not only in Europe but all over the worl4 ‘nationalnetworks of Healthy Cities’ have developed The nationalnetworks in Europe call themselves ‘EURONET’, aEuropean network of national Healthy Cities networks. EURONETis not a formal association; how this initiative will developin the near future is under discussion. A national network is an example of a social network but becauseof its complexity and different leveLs of ‘networking’,is difficult to analyse. However analysis, and evaluation, isneeded to review the functioning and impact of the healthy citiesidea. To study and analyse the networks in Europe, which areas a whole rather large, a selection has been made to reducethe number of participants (n=14), number of resources (n=4)and (categories of) activities (n=9) which were examined Theanalysis provided information about the development of the network;among other things it looked at why they started who took theinitiative, what changes occurred during the period of development,who were the participants at a national level, what activitieswere undertaken, and the relationship between activities andparticipants. As expected the findings did not provide a uniformpicture of ‘what a national Healthy Cities network shouldlook like’ nor did they give the recipe of ‘howto become a Healthy Cities network’. However, the strengthof national networks is that they have the potential to continuethe Healthy Cities project aims and objectives, even if theWHO project ever ceases.     

Utility-driven evidence for healthy cities: problems with evidence generation and application

The question whether the WHO Healthy Cities project 'works' has been asked ever since a number of novel ideas and actions related to community health, health promotion and healthy public policy in the mid 1980s came together in the Healthy Cities Movement initiated by the World Health Organization. The question, however, has become more urgent since we have entered an era in which the drive for 'evidence' seems all-pervasive. The article explores the nature of evidence, review available evidence on Healthy Cities accomplishments, and discusses whether enough evidence has been accumulated on different performances within the realm of Healthy Cities. A main point of reference is the European Healthy Cities Project (E-HCP). Building on the information gathered through documentary research on the topic, it is concluded that there is fair evidence that Healthy Cities works. However, the future holds great challenges for further development and evidence-oriented evaluations of Healthy Cities. There are problems with (1) the communication of evidence, (2) the tension between the original intention of the Healthy Cities Movement and its current operations, and (3) the complex nature of Healthy Cities and the methodological tools currently available.