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.     

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.     

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 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.     

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.     

Urban Health Challenges in Europe

This article synthesizes diverse official reports, statistics, and scientific papers that present demographic, economic, environmental, and social trends impacting on the health and quality of life of citizens living in European cities. A literature review led to the identification of some key challenges including an aging society, migration flows, inequalities in health, global change, and risk behaviors that should be addressed in order to promote urban health. Other challenges, such as food production and consumption, are also relevant, but not included. Cities that have participated in one or more of the phases of the WHO European Healthy Cities Network have implemented a number of policies, programs, and measures to deal with the challenges discussed in this article. Some contributions are presented to illustrate how health and quality of life in urban areas can be promoted by local authorities.     

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 -- 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: 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.     

Comparative study on objective-setting public health policy--historical background and path dependence

The historical background and the path dependence of objective-setting public health policy are described in this review. The New Public Health movement appeared in the 1980s and was inspired by the Ottawa Charter on Health Promotion. This movement is based on the idea that public health is mostly promoted by creating a supportive environment for health as well as by individual efforts toward a healthy life style. The first objective-setting public health policy called Healthy People was proposed in USA, 1979, under the influence of The Lalonde Report published in Canada, 1974. Goals and targets were set in order to reduce the mortality of American people. This project led to Healthy People 2000 and Healthy People 2010. In the 1990s, objective-setting public health policies prevailed in Western countries, such as United Kingdom, Australia, New Zealand, and also in Japan. The objective-setting public health policy is the application of the management by objectives in the health policy domain. This policy is especially accepted in Anglo-Saxon countries where public sector reform was conducted on the basis of the New Public Management theory in the 1980s, which is when the WHO Regional Office for Europe started the Healthy Cities project that emphasized a network of project cities. The Health 21 in 1999 is another model of object-setting public health policy. A comparative study of four different objective-setting public health policies (USA, United Kingdom, WHO Regional Office for Europe, and Japan) was conducted regarding the goals and domains of the targets, methods of targeting, and evaluation of the project. The goals were almost identical in the four public health policies, while the domains of the targets were different. These differences were explained by the past experience of public health policy development in each country.     

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.     

Geographical inequalities in healthcare utilisation and the contribution of compositional factors: A multilevel analysis of 497 districts in Indonesia

Substantial inequalities in healthcare utilisation are reported in Indonesia. To develop appropriate health policies and interventions, we need to better understand geographical patterns in inequalities and any contributing factors. This study investigates geographical inequalities in healthcare utilisation across 497 districts in Indonesia and whether compositional factors – wealth, education, health insurance – contribute to such inequalities. Using data from a nationally representative Basic Health Research survey, from 2013 (N = 694,625), we applied multilevel logistic regressions, adjusted for need, to estimate associations of compositional factors with outpatient and inpatient care utilisation and to assess variability at province and district levels. We observed large variation of healthcare utilisation at district level and smaller variations at province level. Cities had higher utilisation rates than rural districts. Compositional factors contributed only modestly to geographical inequalities in healthcare utilisation. The effect of compositional factors on individual healthcare utilisation was stronger in rural areas as compared to cities and other areas with higher population densities. Unexplained district variation was substantial, comparable to that associated with health insurance. In policies to tackle inequalities in healthcare utilisation, addressing geographical factors such as service availability and infrastructures may be as important as improving compositional factors like health insurance.     

Community involvement at what cost?--local appraisal of a pan-European nutrition promotion programme in low-income neighbourhoods

In the UK, government has committed itself to improving health and reducing inequalities in health. For the first time, issues such as food poverty will be addressed by tackling the causes of poverty and wider determinants of ill health. The time has never been better, therefore, for health and local authorities to work collaboratively to promote and improve health. Community involvement is also paramount to sustainable programmes. However, such a dramatic shift in policy and greater emphasis on public health requires health professionals themselves to adopt a different approach. The World Health Organization (WHO) recommends a health promotion approach as a framework for action. But despite the existence of this framework there is little evidence that a wider understanding of health promotion and the necessary practical experience has been achieved. This has weakened the potential impact of health promotion and has possibly encouraged inappropriate use of health promotion principles in practice. The European Food and Shopping Research Project (SUPER project) was established under the WHO European network of Healthy Cities to help local projects implement the principles of health promotion (WHO, 1986). This paper describes the SUPER project and its implementation in Liverpool (1989-1997), where levels of unemployment, deprivation and ill health are amongst the highest in the UK. Participation in SUPER is appraised to identify the various benefits and obstacles involved and to identify links with progress at the local level. This appraisal is discussed and the use, and potential misuse, of participatory appraisal techniques to elicit information and mobilize communities is examined.     

Healthy Cities Evaluation: the co-ordinators perspective

The Healthy Cities Project is based on the development of healthypublic policies by local governments. The study aim of someproject teams in different countries has been to find out whatprocesses are involved in the development of these policies,how decisions are made, and who and what they are influencedby. The Valencian Community Healthy Cities Network conductedan evaluation process, part of which is presented in this paper.The aim was to find out the concepts and opinions of the projectco-ordinators concerning the opportunities and problems forhealthy municipal policies, and to analyse the municipal organizationwith a view to detecting structural opportunities for interdepartmentalwork. Interviews were conducted with the people responsiblefor the project in 13 cities and the relevant documents analysed.When discussing their health concept and actions for health,few of the co-ordinators mentioned the ideas contained in theOttawa Charter. The established health programmes were ratherbased on personal/ individual changes and topic approach thansetting-based strategies. The structural and strategic opportunitiesfor interdepartmental work, as well as the active participationof the community in the healthy policies decision-making processneed to be strengthened, as they are perceived to be insufficient.Personal relationships and political differences between thedifferent actors appear to play an important role in the opportunitiesfor the implementation of intersectoral policies.     

Introduction of health impact assessment and healthy cities as a tool for tackling health inequality]

In order to reduce the health inequalities within a society changes need to be made in broad health determinants and their distribution in the population. It has been expected that the Health impact assessment(HIA) and Healthy Cities can provide opportunities and useful means for changing social policy and environment related with the broad health determinants in developed countries. HIA is any combination of procedures or methods by which a proposed 4P(policy, plan, program, project) may be judged as to the effects it may have on the health of a population. Healthy city is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and in developing to their maximum potential. In Korea, social and academic interest regarding the HIA and Healthy Cities has been growing recently but the need of HIA and Healthy Cities in the perspective of reducing health inequality was not introduced adequately. So we reviewed the basic concepts and methods of the HIA and Healthy Cities, and its possible contribution to reducing health inequalities. We concluded that though the concepts and methods of the HIA and Healthy Cities are relatively new and still in need of improvement, they will be useful in approaching the issue of health inequality in Korea.     

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.     

Healthy Cities, local environmental action and climate change

This paper reports results of a study that explored the relationship between the local environmental actions of Healthy Cities programs and the adverse health impacts of climate change. The analysis is primarily based on a limited literature review of climate change and health, with particular attention to the relationships between Healthy Cities and climate change, and on documentary analysis of information from organization reports and website content associated with Healthy Cities programs in Europe and Australia. Four semi-structured interviews with key people in two Healthy Cities programs in Europe and Australia were conducted to provide information to supplement and complement the published information and to verify theme identification. The main findings of this study are that, although there is no explicit connection between the local activities of Healthy Cities programs and the potential (or actual) adverse health impacts of climate change, Healthy Cities programs are involved in many local environmental actions and some of these actions, for example, those relating to improving air quality and reducing pollution, are linked implicitly to the health impacts of climate change. Through their local relationships and their participation in regional networks, Healthy Cities are able to make connections between local environmental actions and the health impacts of climate change. Furthermore, expanding Healthy Cities to include eco-social sustainability as a central aim not only has the potential to strengthen the links between local environmental actions and climate change, but also presents a relevant health development setting for exploring the social and environmental sustainability of cities.     

The Commission on the Social Determinants of Health: reinventing health promotion for the twenty-first century?

This paper describes the work of the Commission on the Social Determinants of Health, established by WHO in 2005 and considers the potential for this Commission to contribute to a reinvention of health promotion for the twenty-first century. It argues that the Commission can do this by reinforcing the move that health promotion has been making since the 1980s to be less concerned with behaviour change and more concerned with creating the conditions in which health and well-being flourish. Specific contributions the Commission will make are: providing a vision of the moral importance and feasibility of a more equitable world; positioning health promotion as a task for the whole of the economy through action within the government sector and through assessment of the health equity impact of the corporate sector and neo-liberalism; through its Knowledge Networks, providing a much stronger evidence base than has previously been available on the social determinants of health and health equity including the actions and policies that are most likely to promote health and equity; providing a focus for the further growth of a global social movement advocating for health equity within and between countries; contributing to the reform of WHO and other international health agencies so that all programmes are built to take comprehensive action in communities and nationally to tackle the underlying causes of disease; adding legitimacy to moves to re-orientate health care systems to a focus on health promotion and population health.     

Empowerment for Healthy Cities and Communities in Korea

The Healthy Cities project started in 1998 in Korea. Around the world, public health and healthy cities are becoming bigger and bigger priorities. Capacity mapping is an important tool for improving a country’s health status. This study aims to review the initiation of the Korean “Healthy City” project. Korea follows a bottom-up approach for the development of Healthy City policies and has implemented plans accordingly. Korea has created a unique program through Healthy Cities; it has developed a Healthy City act, indicators for evaluating the program, a health impact assessment program, an award system, and a domestic networking system.     

Joint working and the production of a city health plan: the Liverpool experience

Several cities within the WHO Healthy Cities Project are developing City Health Plans, a broad strategy to improve health in the city. This paper examines the effectiveness of joint working during the production of the City Health Plan in Liverpool, from the point of view of the participants' perceptions. The results of the study were used to inform the reform of joint planning. The results suggested that joint working had been reasonably effective in developing the City Health Plan in Liverpool, but that more attention should be paid to the process of people working together, rather than an emphasis on formal interorganisational structures.