HEALTHY CITIES

EFFECTIVE APPROACH TO
A RAPIDLY CHANGING WORLD
 ACKNOWLEDGEMENTS

This resource was developed for the World Health Organization by Agis Tsouros with contributions from Faten Ben Abdelaziz, Scarlett Storr,
Gerry Eijkemans, Monika Kosinska, Samar Elfeky, Tushara Fernando, Suvajee Good, Riitaa Hamalainen, Ruediger Krech and Tim France.

Healthy cities effective approach to a rapidly changing world

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HEALTHY CITIES
EFFECTIVE APPROACH TO
A RAPIDLY CHANGING WORLD
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . 3

Healthy Cities: Core attributes, values and principles 4

From goals to domains of action . . . . . . . . . . . 8

Organizing and implementing Healthy Cities . . . . 10

Conclusions . . . . . . . . . . . . . . . . . . . . . . 14

References . . . . . . . . . . . . . . . . . . . . . . . 15
Introduction

Healthy Cities is a thriving and dynamic movement around the world with a rich 30-year history.
Its evolution and implementation during that time have been deeply innovative and diverse.
It is more relevant today than ever in addressing the established and emerging public health
challenges of the 21st century.

The Healthy Cities initiative was conceived with the goal of placing health high on the social
and political agenda of cities by promoting health, equity and sustainable development through
innovation and multisectoral change (1). Its creation was based on recognition of the importance
of action at the local, urban level and of the key role of local governments. It thrives at the cutting
edge of public health, and this is one of the factors that contributed to its success. Healthy Cities
and local governments have gained new attention and significant prominence in the context
of the implementation of the Sustainable Development Goals (SDGs) and health promotion
agendas, as well as during development of the World Health Organization (WHO) Thirteenth
general programme of work 2019−2023 (GPW13). Healthy Cities is a strategic vehicle for health
development and well-being in urban settings, and actions taken at the city level have a cross-
cutting relevance to the majority of technical areas of WHO’s work.

The need for a consistent WHO approach to the Healthy Cities movement was introduced and
discussed during a health promotion technical focal points meeting that took place in Geneva on
25–26 February 2019. A two-part rapid survey was undertaken to inform that discussion:

Part 1 focused on three issues related to the positioning of Healthy Cities in each WHO
region, namely: its location in the organization; its connection with relevant regional
political statements, strategies and plans; and the main operational features, themes and
priorities of these programmes.

Part 2 addressed the question of the main features and themes of Healthy Cities, and the
role of WHO headquarters in supporting the global movement.

The results highlighted similarities – and significant variations – between the regions as well as
issues and perspectives of priority and contextual relevance to each region.

HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD 3

 Healthy Cities: Core attributes,
values and principles

Healthy Cities is a values- and partnership-based political project and multi-level movement. It
provides a platform and mechanism for engaging and working with local/municipal governments
and communities on issues impacting health and well-being. It is widely regarded as one of the
key health promotion, settings-based approaches, along with other initiatives such as healthy
workplaces, health-promoting schools, universities and hospitals, as well as healthy markets.
More importantly, however, Healthy Cities is considered as being well-positioned and recognized
as an effective strategic vehicle for reaching out to local and municipal governments and local
leaders and community stakeholders across multiple sectors. The active involvement of mayors,
and other local political and community leaders, in all aspects of Healthy Cities is crucial.

Various definitions have been proposed as to what constitutes a healthy city. Experience has
shown that descriptive definitions are generally easier to explain and communicate to the diverse
audiences and stakeholders the initiative works with. The following definition offers such an
example:

A healthy city is one that puts health, social well-being, equity and sustainable development
at the centre of local policies, strategies and programmes based on core values of the right
to health and well-being, peace, social justice, gender equality, solidarity, social inclusion
and sustainable development and guided by the principles of health for all, universal
health coverage, intersectoral governance for health, health-in-all-policies, community
participation, social cohesion and innovation.

The dynamic concept of Healthy Cities continuously evolves: integrating state-of-the-art scientific
evidence; addressing emerging public health challenges; aligning with global and regional
strategies for health and sustainable development; integrating knowledge from experience; and
grounding itself on local priorities and concerns.

One important example demonstrates the indisputable requirement for the dynamic Healthy
Cities concept: the response to emerged health crisis such as severe acute respiratory syndrome
(SARS) and COVID-19. The high population density, informal settlement settings, casual
employment, presence of low-income migrants and refugees, as well as inadequate access to
sanitation, all magnify cities’ vulnerability. This underlines the need for Healthy Cities to initiate
long-term urban resilience to health risks and crises.

Accordingly, GPW13 provides an opportunity to revitalize Healthy Cities, and explicitly recognizes
the important role of municipal governments in promoting the health-in-all-policies approach.

Political legitimacy to address challenging issues – such as equity, vulnerability, the determinants
of health and sustainability – comprise a key part of the initiative’s uniqueness. One of the
main strengths of the global Healthy Cities movement is the diversity of political, social and
organizational contexts within which it is being implemented within and across different regions.

4 HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD

Links to key global and regional strategies and plans
The legitimacy, potential impact and long-term sustainability of Healthy Cities depends on
how well and how explicitly it is aligned with political and strategic agendas at the global,
regional and country levels. These include: The United Nations (UN) Agenda 2030; global or
regional resolutions, strategies or action plans in the areas of health promotion, urban health
and governance for health; health-in-all-policies; social determinants of health (SDH) etc. In the
WHO European Region, for example, Healthy Cities was launched as a vehicle to strengthen
implementation of WHO strategies ‘Health for All’ and ‘Health 2020’, at the local level.

Countries increasingly include Healthy Cities approaches in national legislation, health policies
and plans. Political statements, charters and declarations have been adopted by mayors and other
local political leaders, expressing commitment to achieve the Healthy Cities values, principles and
goals. Such statements represent an essential aspect of the Healthy Cities approach. For example,
the 2016 Shanghai Mayors Consensus has been instrumental in renewing and legitimizing interest
in Healthy Cities across the WHO and in countries. Since 2016, several regions launched political
statements and declarations drawing on the Shanghai Mayors Consensus in order to reinforce
Healthy Cities developments in their respective areas.a

It is imperative that political leaders emphasize health as a core value in city vision statements,
policies and strategies, as well as acknowledging that they are well-placed to influence the
conditions that determine – or undermine – the health and well-being of citizens. They should
also acknowledge the link between health and sustainable development, and the role of local
governments in the implementation of Agenda 2030.

Key concepts, approaches and methods

Healthy Cities is continuously enriched with the best available concepts and methodologies
to address current and emerging public health challenges in urban settings. Their holistic use
is essential for implementing the Healthy Cities agenda and for creating the preconditions for
maximum impact and innovation. It is not only important what priorities a city wishes to address,
but how it plans to address them. Traditional approaches to public health can have limited
effect and scope in the context of cities. Established public health interventions are typically
‘downstream’ (focusing on proximal causes) rather than addressing the root causes of ill-health
and unhealthy behaviours.

Key issues, concepts and methods that should be addressed and employed by Healthy Cities are:
1. Explicit focus on both health and well-being.
2. Emphasis on the right to health for all and universal health coverage (UHC).
3. The Sustainable Development Goals (SDGs) and Healthy Cities (4, 5) go hand-in-hand, and
they are mutually reinforcing.

The SDGs offer a global framework of political responsibility and accountability, providing
powerful political support nationally and locally to those who argue for more inclusive and
sustainable economic, social and environmental policies. Addressing the SDGs at the local
level is a valuable exercise of scrutinizing and re-thinking and adapting local policies and
strategies about all aspects of development.

a For example, the Copenhagen Consensus of Mayors, WHO Regional Office for Europe, 2018 and Santiago de Cuba Statement, WHO
Regional Office for the Americas, 2018

HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD 5

 4. Addressing the social determinants of health (SDH) and health inequalities. Under the SDH
umbrella term several determinants have gained special attention in recent years including
commercial, political, ecological and cultural determinants of health.
5. An explicit grounding in health promotion and in particular the Ottawa Charter for Health
Promotion and its principles, including Creating supportive environments for health for all;
Investing in creating healthy places; and Making the healthy choices the easy choices.
6. Understanding the specificity of the urban and built environment and its positive and
negative impacts on health and well-being. Figure 1 illustrates the determinants of health in
the urban context.

Figure 1. The determinants of health and well-being in the urban context (6)

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6 HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD

7. Applying the life-course approach (7): Supporting good health and its social determinants,
throughout the life-course, increases healthy life expectancy and yields important economic,
societal and individual benefits. There is an accumulation of advantage and disadvantage
across the life stages.
8. Promoting population-based approaches (8): A population-based approach to health
focuses on improving the health status of the overall population.
9. Promoting health literacy (9), surpassing the narrow concept of health education. It is
influenced by the sociocultural context within which people live, and applies to individuals,
communities and institutions.
10. Creating conditions for community resilience (10–12), the ability to anticipate risk, limit
impact, and bounce back rapidly through survival, adaptability, evolution and growth in the
face of hardships and emergencies.
11. Local level governance for health and well-being: An intersectoral and multisectoral
approach to health development has been one of the cornerstones of the Healthy Cities
movement. The various approaches of modern governance for health at the local level can
be effectively employed to address and resolve complex urban health issues, address health
inequalities and take forward the local SDG agenda.
– Health-in-all-policies is an approach to public policy across sectors that systematically
accounts for the health implications of decisions (13); seeks synergies; and avoids harmful
health impacts in order to improve population health, reduce risk and improve health
equity.
– Whole-of-government approach (8, 14): addresses complex public health issues
through upstream action in interconnected ways to achieve shared goals and clear lines
of shared accountability.
– Whole-of-society approach to health: extends beyond institutions, to a wide range
of stakeholders, including: individuals, families and communities; intergovernmental
organizations; religious institutions; civil society; academia; the media; voluntary
associations; and, as appropriate, the private sector and industry, in support of health
development.

HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD 7

 From goals to domains of action

From its inception, Healthy Cities has been rooted in a firm set of values: the right to health
and well-being; equity and social justice; gender equality; solidarity; social inclusion; and
sustainable development. The Healthy Cities approach is founded on the overarching principles
of intersectoral collaboration, community participation and empowerment. These values and
principles are more relevant than ever, although over the years, their meaning, content and
evidence base have evolved significantly (2).

In translating Healthy Cities to the 21st century context, the main goals of the initiative are
extensive and can be articulated as follows:
1. Promoting health and equity in all local policies impacting social determinants of health (SDH)
and fully aligning with the Sustainable Development Goals (SDGs).
2. Creating environments that support health, well-being, healthy choices and healthy lifestyles.
3. Providing UHC, and social services that are accessible and sensitive to the needs of all citizens.
4. Investing in health promotion and health literacy.
5. Investing in a healthy start in life for children, and providing support to disadvantaged groups
such as migrants, the unemployed, and people living in poverty.
6. Strengthening disease prevention programmes, with special focus on obesity, smoking,
unhealthy nutrition and active living.
7. Promoting healthy urban planning and design (3).
8. Investing in green policies, clean air and water, as well as child- and age-friendly city
environments, and addressing climate change-related issues such as by lowering emissions
and identifying climate-resilient pathways.
9. Supporting community empowerment, participation and resilience, and promoting social
integration, peace, inclusion and community-based initiatives.
10. Strengthening the city’s public health services and capacity to respond to public health
emergencies.

Healthy Cities will lose its potential for positive health impact if it is limited to conventional health
initiatives and practices – which represent the day-to-day work of existing public health and
environmental services – or if it mainly focuses on organizing health education campaigns and
competitions.

8 HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD

Advocacy and communication are vital to the Healthy Cities initiative. Explaining its unique goals
and approaches to the wider public and non-specialist audiences should be clear and compelling.
A politician, for example, could say that Healthy Cities is about:

making the health and well-being of our people a top priority;

working together – public sectors and communities – for the health of our city;

caring for all our people and promoting equity and social support and inclusion;

creating city environments, where people live, work and play, that support health and
encourage healthy choices;

making high-quality services available to all who need them;

making the city clean, safe, attractive and sustainable;

giving our people a say, as well as knowledge and skills for health and well-being.

Table 1 outlines the eight critical areas that together form the framework for organizing and
implementing Healthy Cities initiatives and movements.

Table 1. Essential Healthy Cities action domains

Improve city Reduce/minimize Promote health-in-all-

governance for health health inequalities policies approach
and well-being

Promote community Create physical and Improve the quality

development and built environments of and access to local
empowerment, that are supportive health and social
and create social to health and healthy services
environments that choices
support health

Consider and plan for Strengthen local Plan for urban

all people in the city public health services preparedness,
and prioritize those and capacity to deal readiness and response
most in need with health-related in public health
emergencies emergencies

HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD 9

 Organizing and implementing
Healthy Cities

There are a host of initiatives in different regions that fall under the Healthy Cities rubric,
including healthy municipalities, healthy villages, healthy territories, healthy islands and healthy
communities.

The most common organizational form of Healthy Cities in the regions are the National Healthy
Cities Networks. National networks play key strategic roles in promoting the Healthy Cities
principles and approaches, supporting their member cities, organizing training and learning
events, as well as working with different national and international partners. National networks
may be led, coordinated or supported by ministries of health to varying extents. National
networks can also be run as legal entities (e.g. nongovernmental organizations) with political
and technical secretariats.

Working directly with cities is less common. The WHO Regional Office for Europe runs a network
of designated cities based on explicit requirements and commitments, and it also supports
national networks as well as a Network of National Healthy Cities in Europe.

The Regional Office for the Eastern Mediterranean has a system of awarding Healthy Cities status
to cities in the countries of the region, based on a local self-assessment and evaluation.

Healthy Cities in the Western Pacific Region is supported by the Western Pacific Alliance of
Healthy Cities, a nongovernmental organization run by the Tokyo Medical School, and includes
a system of presenting awards to successful cities at their meetings. The political presence in
Healthy Cities meetings varies widely, both between and within individual regions. Some regions
regularly convene mayors meetings and issue statements in support of Healthy Cities.

The new support for Healthy Cities within WHO provides an excellent opportunity to re-visit
the configuration of Healthy Cities within regions. A number of factors of significant influence
include: the position and resource base of Healthy Cities within WHO regional offices; the role and
views of ministries of health; the function of Healthy Cities associations and national networks;
and the part played by other support structures, such as WHO collaborating centres.

Support and coordination of Healthy Cities in WHO regional offices is resource intensive.
Supporting national networks and providing a regular platform for sharing experiences and
dialogue is probably the minimum regional offices can offer. The WHO Regional Office for Europe
has a fee-pay system for all member cities of the WHO European Network, which has secured the
sustainability of Healthy Cities programme for many years.

10 HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD

 Figure 2. Overview of Healthy Cities strategic approach

Developing inclusive surveillance practices

Providing information and evidence-based

actions that leave no one behind Forging local partnerships for health
Understanding and acting on vulnerabilities Promoting accountability
(immediate and longer-term care)
Completing a city health profile
Working on community introducing an integrated city health
strengthening and response development plan

Planning for emergency Health in all local Policies

measures that leave no one
Investing in population-based and
behind City diplomacy
community-based health promotion
and disease prevention programmes Explaining the meaning and the root
ban causes of inequalities and their
Addressing obesity in the young and r ur Impro
n fo , negative impact on society
Pla d ness govern ve city
in adults
e pa re ss a nd a
r
p ine
d ublic hea lt nce fo Measuring inequalities
Improving capacity to deal with rea nse in pencies well-bh and r
p o e r g eing
emergencies related to climate res lth em
heal y to d es a blic

Developing a step- by-step action

change, linked weather phenomena, h he a
cit ervic l pu
eme th-rela eal w nd

plan for the city

rge te it

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ca

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HEALTHY
CITIES
for all peo ple i tize
Consider and n the

Giving every child a healthy start in life Developing mechanisms and

city and prio need
those most in

in-al te he alth
ACTION
l-policies
capacity for integrating health and
Ensuring access to education for all,

ch
equity considerations within local
DOMAINS
approa
including pre-school for all children o policy-making
Prom
plan
ri

Addressing ageism and healthy ageing Ensuring policy coherence that is

beneficial to health and promoting
Mapping out the social landscape in related synergies
n d a n d it y
I m of a al

the city with attention to the needs of

ea e n ts e a t e
t un
pro nd

m
m

vulnerable and socially disadvantaged th co n

ve

Increasing capacity for health

m cr

a e o t e o p m e t, a
loc oci

people he cce quali m impact assessment

P r o e v el e n ro n
lt h
s

al alt s s t t y Create
se h a o physical and d e r m vi t h
w en r
rvi nd
ces
built en vironm e nts
e m p o o ci al u pp o
that are t i v e t o s ts
health suppor
ices
t ha
and healthy cho
Promoting health literacy
Ensuring universal health
coverage Promoting community resilience

Improving the quality of the Promoting social dialogue, participation and

services to address the needs Creating safe and clean inclusion
and expectations of diverse neighbourhoods
community groups Supporting local community-based projects and
Addressing poor sanitation, air and initiatives
Removing barriers (including noise pollution, hygiene and housing
cultural) that create underuse conditions Ensuring access to social support for the
of or interrupt the provision of most needy
Promoting cycling and walking and
health and support services
investing in healthy transport Encouraging physical activity and active
Improving coordination living for people in all age groups
Making the city child- and age-friendly
between primary health care
and other public health Creating smoke-free physical and social
Addressing climate change and environments
services
minimizing carbon footprints
Ensuring access to healthy food and
Ensuring access-to-all green spaces, sustainable nutrition and preventing young
areas for social interaction and good people from easy access to sugary foods
facilities are available for all and drinks
Investing in healthy urban planning and Addressing mental health issues and
design, closely working with urban well-being, and reducing stress in the
planners and architects community

HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD 11

 To be successful at the local level, Healthy Cities projects/initiatives require political support,
holistic strategic planning and the managerial means and resources to deliver results. There are
at least four prerequisites for sustainable and successful Healthy Cities projects (1):

• Strong political commitment to the values and goals of Healthy Cities must be demonstrable
and convincing. The aim is to secure the support of the mayor and the city council and ideally
support from across the political spectrum as well as local academic institutions, and voluntary,
public and community sectors.
• Institutional managerial mechanisms and structures to support intersectoral work and
community participation. The location of the project office in the city organizational
structure and the profile of the project coordinator are of critical importance. A Healthy
Cities project cannot reach its potential if it is reduced to a technical project far from the policy
and strategy locus of the city. As a political project, Healthy Cities must be steered by the
mayor or governor or another senior politician with delegated authority. The Healthy Cities
project office is expected to fulfil five main functions:
1. Advocacy, mediation, communication, coordination and advising.
2. Engagement in policy and strategic planning processes.
3. Project management and intersectoral cooperation and dialogue.
4. Community development and relations.
5. Collaboration with national counterparts and partners in local, national and/or
international agencies, networks or institutions.
• A city health profile is essential for prioritizing, monitoring and driving accountability for
health in the city. City health profiles should be produced regularly (e.g. at least every two years)
and provide information on the health of the population – including health inequalities – as
well as information on living and working conditions and lifestyles. City health development
planning must draw on the contributions of different sectors and stakeholders. There are
various approaches to city strategic and health development planning. For example, cities can
choose a single strategy and plan, or several thematic ones.
• Healthy Cities engages in formal and informal networking locally, national and internationally
and it creates platforms for dialogue, learning, sharing and consensus- building.

Figure 3 outlines the theory of change that underpins the transformative changes of Healthy
Cities.

12 HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD

Figure 3. Theory of change underpinning transformative changes of Health Cities

Theory of change
Transformative changes in the way cities, understand
and deal with health, equity and well-being

Active civic engagement

Policy
Political Addressing dialogue, Institutional Analysis and
engagement the urban Diplomacy evidence
inclusive capacity changes and
and determinants multi- innovation to support
commitment of health building action
stakeholder
platforms

Continuously adapting to emerging priorities, knowledge, needs

and sociopolitical contexts

Healthy Cities is a dynamic concept that evolves with time and the accumulation of new evidence
and experience, as well as the emergence of new priorities and political developments.

To be able to periodically review the Healthy Cities agenda it is advisable to consider introducing a
phased approach that could run over a three- to five-year period. The experience of the European
Healthy Cities programme, which evolved over the past 30 years in five-year phases, involved: the
regular renewal of its goals and requirements; integration of new global and regional strategies;
review of results and progress evaluation; and allowed participating member cities to leave the
project at the end of a given phase at no political cost.

Indicators, outputs and outcomes linked to WHO GPW13

Developing indicators that reflect the full spectrum of Healthy Cities goals and activities is
challenging. The WHO Regional Office for Europe uses a set of indicators under nine categories
– all aligned with SDH and SDG – that guide Healthy Cities implementation. They are also used as
the basis for assessing progress and evaluating the cities eligibility for relevant awards. The same
indicators were also used in the earlier phases of the project in the region. With the revitalization
of Healthy Cities there is scope to identify core indicators that could be used by all regions.

An opportunity also exists to define in more detail how Healthy Cities and GPW13 can best be
further aligned, and which should be the most appropriate and commonly defined outputs and
outcomes.

HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD 13

 Conclusions

The Healthy Cities movement represents a powerful platform for innovation and change. It would
benefit from a global strategic framework that captures and refines the initiative’s common
principles, methods of work and priorities globally, as well as performance and accountability
standards and indicators in key areas of action.

Such a framework will promote coherence and synergies between regional Healthy Cities
initiatives and help to strengthen political leadership (15) at the global level. Creating platforms for
inter-regional dialogue is also essential to enabling mutual learning and sharing of experiences,
and also offers opportunities for enhancing city diplomacy at the global level.

National governments should do more to support and use national Healthy Cities networks as
strategic vehicles for taking forward the health and SDG agenda at the local level. Furthermore,
scaling-up and strengthening the global Healthy Cities movement would also benefit from
expanding new and existing partnerships with agencies concerned with urban human, social
and sustainable development. Urban health should be recognized as an important cross-cutting
domain of WHO work, and the urban dimension should be systematically explored in all technical
and programmatic planning and implementation of the Organization. Healthy Cities and the
SDGs are mutually reinforcing and provide enormous opportunity and legitimacy for strong
leadership, partnership and action.

Public health crisis such as SARS and COVID-19 pandemic drew lessons on the role of healthy
cities in providing risk communication and preparedness not only within the crisis but beyond,
hence leveraging the response for long-term urban resilience to health risks and crises.

The timing is excellent to strengthen the Healthy Cities movement, and to more closely align it with
the global and regional agendas for health and sustainable development and with the WHO GPW13.

14 HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD

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HEALTHY CITIES: EFFECTIVE APPROACH TO A RAPIDLY CHANGING WORLD 15

It is timely to strengthen the Healthy Cities movement and align it with global and regional
agendas for health and sustainable development, including WHO’s Thirteenth general
programme of work 2019−2023. This overview reasserts the values, core agenda and
operational attributes of Healthy Cities.