Healthy City Concept

 1.        Healthy City Definition

 Various definitions on healthy city are expressed by scholars. However, definition explained by Hancock and Duhl is most frequently used by health officers and professionals.

Hancock and Duhl in Barton and Tsouros (2000) define healthy city as:

“A 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” (Hancock & Duhl in Barton & Tsouros, 2000, p.29).

This argument is supported and strengthened by other scholars and organisations such as Kickbusch and Goldstein (1996, p.4); WHO (1998, p, 13); WHO in WHO Western Pacific Region (2004, p.9); Froding, Eriksson and Elander (2008, p. 321); Hancock (2009, p. 7); Hancock and Duhl (1988); Department of Health, Hong Kong (2007, p. 34); Chu (2009, p.59).

However, around the period of 1987-1992, the beginning of WHO healthy city project introduced around European countries, this definition was then completed by the following definitions according to the authors’ perspectives and viewpoint.

“A healthy city is defined by a process and not just an outcome. A healthy city is not one that has achieved a particular health status level; it is conscious of health and striving to improve it. Thus, any city can be a healthy city, regardless of its current health status; what is required is a commitment to health and a structure and process to achieve it” (Tsourou & Barton, 2000, p.29). 

 

“The concept of a healthy city is one that offers us an interesting new perspective on the city and an exciting opportunity to enhance health and well-being. We believe that the city is the vital centre of our industrialized civilisation, that health is a result of the complex interactions of people with each other and their physical and social environments and that the city has a crucial role to play in the health and survival of humanity” (Hancock & Duhl, 1986:7 in Chu, 1997).

Based on the above definition it can be said that to create healthy cities and to obtain its benefit it takes time. Clark (2000) mentions that healthy cities impact takes efforts, time, cultural changes and constancy of purpose from the manager and a shift values both by the council and by the municipal organisations. It is difficult for government and healthy city’s decision makers to obtain healthy cities impact in short term. WHO even emphases that healthy city project is a long term development. To achieve this it needs a strong political commitment to put and place health issues at the top level of decision making process at all levels (WHO, 1998).

2.        Healthy City Objectives

The aims of this WHO healthy city project are to bring a partnership mechanism among public sectors, private sectors, and voluntary and community agencies to solve urban problems in order to create a health-supportive environment, to improve the recognition on holistic nature of health, to address health problems in integrated approaches, to mobilise resources from various sectors. The healthy city program aims to achieve a good quality of life, to provide basic sanitation and hygiene needs and to supply access to health care (WHO, 2002; Ashton, 2002; WHO 2007).

Harpham, Burton and Blue (2001) stated the healthy city objectives are to mobilize political and community participation in developing planning and implementation urban health; to increase awareness on health issues by governments from national level to local level and non-health departments and agencies; to create increased capacity of municipal government to manage urban problems and to format partnership with communities and CBOs; to create a network of cities which can provide information exchanges, skill, knowledge and technology transfers (Harpham, et.al, 2001).

3.        Qualities of Healthy Cities

According to WHO and scholars (Hancock & Duhl in Barton & Tsourou, 2000, p.31; WHO, 1992:4 in Chu, 1997; WHO, 1997a in Werna et al., 1998; Anderson & Hodson, 2002, p. 3; Hancock, 2009, p. 9; Butterworth, n.d.; Gannon, 2003) that the qualities of a healthy city should strive to achieve the following qualities:

• A clean, safe physical environment of high quality including housing quality
• An ecosystem that is stable now and sustainable in the long term
• A strong, mutually supportive and non exploitative community
• A high degree of participation and control by the public over the decisions affecting their lives, health and wellbeing
• The meeting of basic needs (food, water, shelter, income, safety and work) for all the city’s people
• Access to a wide variety of experiences and resources, with the chance for a wide variety of contact, interaction and communication
• A diverse, vital and innovative city economy
• The encouragement of connectedness with the past, with the cultural and biological heritage of city dwellers and with other groups and individuals
• A form that is compatible with and enhances the preceding characteristics.
• An optimum level of appropriate public health and sick care services accessible to all
• High health status (high levels of positive health and low levels of disease)

Qualities of healthy cities as mentioned above are general indicators. Healthy city has international indicators as offered by World Health Organization. There has different viewpoint about healthy city indicators either international or local indicators. Werna, Harpham, Blue, and Goldstein (1998) argued that it is important for healthy cities to refer to the international indicators as introduced by the World Health Organization (Werna et al., 1998). However, other scholars argue that different countries have different circumstances. Thus, even though WHO has provided a number of international indicators to measure healthy city program, it also requires to consider the local indicators. Healthy city concept and implementation in one country differs from others. It can be caused by the difference of local needs and environmental conditions (Davies & Kelly, 19993 in Werna et al., 1998).

Using local indicators has several reasons and benefit in particular community participation. Davies and Kelly (1993) argued that involving community has value in itself in designing indicators. In addition, local indicators can counterbalance biases of international indicators (Davies & Kelly, 1993). However, the international indicators do not mean totally different from the local indicators. It might be some international indicators are similar to the local indicators.

To achieve both these established international and local indicators, healthy cities program have be built in some important dimensions. Healthy cities have a number of characteristics which distinguish between healthy city approach and other health programs. WHO (1997; 2002) explains six characteristics of healthy cities project. They are commitment to health; political decision making; intersectoral action; community participation; innovation and healthy public policy. This argument is also explained and supported by Chu (2009) and other scholars such as Duhl and Sanchez (1999); Duhl and Sanchez in Butterworth, (n.d.).

4.         Healthy Cities’ Principles, Strategies and Approaches

Healthy city program has a number of principles, strategies and approaches to achieve the goals of healthy city.  These are “health should be an integral part of settlement management and development, health can be improved by modification of the physical, social and economic environment, conditions at places where people live and work have profound influence on health status of the people” (WHO, n.d.). Healthy cities program provides a framework for action based on the Ottawa Charter’s framework: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and re-orienting health services. The process of healthy city planning is both top-down and bottom up planning process.

WHO regional office for Western Pacific region noted the important ingredients of healthy cities projects. They are healthy cities project facilitates the health sector to take a important part to encourage health sector as valuable considerations into urban development and management (health advocacy), A healthy cities builds an effective coordination and integrate efforts among different parties within and outside the health sectors (intersectoral coordination), a healthy cities project encourages and mobilises community participation  at all level of healthy city processes from planning to implementation to get better health and quality of life (community participation), a healthy cities project respects the local culture and value of community and develops vision based on consensus (vision development), a healthy cities project needs strong political will from local government to implement the programs (political commitment), and a healthy cities project develops programs in different elemental settings such as schools, hospitals, markets, workplaces and communities (setting approach).

International healthy cities conference held on 15-18 October 2008 in Zagreb on Zagreb declaration for healthy cities also noted healthy cities principles and values. They are equity, participation and empowerment, working in partnership, solidarity and friendship and sustainable development (WHO, 2009). Another author explains that the principles of healthy cities are sustainability, innovation, adaptability, inclusiveness, equity, leadership and partnership (the government is committed to working together with local government, Non Government Organisations and private sectors and the community (cited from melbourne2030.vic.gov.au).

In conclusion, based on a variety of sources, the healthy city’s principles cover health advocacy, intersectoral coordination, community participation, vision development, political commitment, setting approach, equity, empowerment, solidarity and friendship, sustainability, innovation, adaptability, inclusiveness, leadership and partnership

However, to achieve the aims of healthy city there are a number of key strategies. These facilitate the healthy city achievement. The strategies consist of inter-sectoral coordination, coordination with multiple stakeholders within and outside the health sectors, coordination with local government and governmental agencies, coordination between public and private sectors, coordination with Non Government Organisations (NGOs); Community participation, their participations are needed from planning, implementation and evaluation; capacity building and mobilisation of local resources, decentralisation and good governance and leadership development (WHO, 2007).

5.        Barriers and Challenges in  Healthy Cities implementation

To implement healthy city program there are a lot of barriers and challenges occur in almost all countries, regions where healthy city projects are being developed. Based on literature review, writers note a number of barriers and challenges. These are lack of healthy city understanding; low advocacy; poverty; funding dependency from donor agencies; government attitude from national to the local government, poor infrastructure; low capacity for intersectoral collaboration; high illiteracy; political support and mobilization; low community participation; organisational and personal change; lack of time; low capacity building; limited resources (human, fund and material); bad governance; lack of coordination among sector; low health awareness (municipal and national authorities, non health ministries and agencies); low network (promoting information exchange and technology transfer); decentralization; and working mechanism (information system, monitoring, social marketing etc.)   

All problems, barriers and challenges as mentioned above happen in all regions. However, the first 11 problems mostly occur in Asia and Africa regions (Green & Tsourous, 2008; WHO, 2000; WHO, 2003; Harpham, et.al, 2001). Problems such as low political support from local government, low capacity building at all levels, lack of collaboration/partnerships with stakeholders, project oriented (high independence from donor agencies) and poverty are the main problems in South-East Asia regions. These problems are also similar in Eastern Mediterranean and Africa regions and generally in developing countries. However, these problems need to explore more to understand and explain them further. It is because healthy city implementation differs from national level to local level or among local level. 

Therefore, in order to help these problems, countries in South East Asia region agreed to seek external support for sharing resources, experience and skills to strengthen healthy cities implementation. Further, the countries also agreed that to keep sustainability of the program fundraising mechanism such as from private sectors, fee for services, donations and charity, micro-credit, and voluntarism and should be sought to decrease the dependency healthy cities officers from the donor agencies (WHO, 2000).

On the meeting participants discussed and noted five policy challenges in implementing healthy settings which are being faced by those countries. The policy challenges are political commitment and decentralization. In some countries central government probably has strong supports and policies to implement healthy cities programs. However, healthy cities implementations at the local levels are very low. This can be seen from the poor collaboration among stakeholders both government agencies and non government agencies and its difficult for them to make integrated planning process. This is due to poor leadership of local government particularly. Hence, healthy cities implementation needs strong political will from the national level to the local level from the Mayor.

In terms of decentralisation some countries in South East Asia region have followed decentralisation system. Some authorities and responsibilities have already been at the local government’ hand. Decentralisation ideally facilitates local government to build collaboration with local institutions. However in reality, this is also not easy to build it because interest groups often have different understanding even misunderstanding and conception about healthy cities both national level and local level or within among local level instititutions.

Another challenge is partnerships. Partnership is very important factors which contribute to healthy cities program. Governmental agencies involvement and other stakeholders such as Non Government Organisations (NGOs), private sectors, and community leaders are poor. Most local governments especially in the countries of South East Asia region are lack of resources to effectively implement healthy cities program. Building partnerships with universities, research institutions, and donor agencies is an effective way to solve this problem by exchanging resources, experts, skills, materials, funding, and others. Other challenges are information systems, system for monitoring and evaluation, networking, capacity building, mobilizing resources and social marketing.       

6.        Success Factors for Healthy Cities implementation

The successful healthy city programs are not easy. They are determined by several factors including commitment of local community members, a clear vision, the ownership of policies, a wide array of stakeholders and a process for institutionalizing the program (Types of healthy settings, n.d.). However, to implement healthy cities programs Mayors are key factors because they can encourage and involve all governmental agencies and departments, including private sectors, universities and NGOs in formulating and adopting a ‘municipal health plan’ or city health plan (Werna et al., 1998). WHO even recognised a number of major lessons learnt which contribute to successful healthy cities implementation. They are strong political support from government, coordinating healthy cities structure and an effective secretariat, community engagement, effective leadership, external support and the needs of healthy cities program in short term achievement (WHO, 2000).

Healthy cities implementation has showed that strong political support from local leaders is essential to develop and maintain sustainable healthy cities project. Without strong political commitment from Mayors, healthy cities program will face various difficulties to achieve the organisational change, to build coordination across sectors, and to mobilise resources. A strong political leadership will bring healthy cities program easier to implement. This is also key success factors of healthy cities program. Mayors from cities in Western Pacific Region have often been invited to attend the international conference and international visits, give award carry out study tour to know more healthy cities within the regions or between the regions. This is a means to keep sustainable program for long time. Healthy cities program will obtain strong support if healthy cities program is headed by Mayors. This happens in a lot of the Japanese healthy cities projects across the metropolitan area in Tokyo, Japan (WHO, 2000).

A strong political support further is recognised that this also relates to other aspects of healthy cities implementation such as the needs of effective leadership and active community involvement. Strong political leaders will reflect in engaging community and recognise the importance of community involvement. Effective leadership is a success factor of healthy cities. Attributes needed as an effective leader are inspirational and facilitating style of leadership. These also include flexibility, good communication skills, vision, and enthusiasm, willingness to question current practice, entrepreneurship skills, willingness to take risks and willingness to walk around bureaucratic blocks. Furthermore, it stated that the success of intersectoral collaboration is dependent upon not only on establishing structure, but also on the skills of the people involved (WHO, 2000)

Healthy city support is not only from internal factors. It is important as well to obtain the external factor support. The external factors can be from the national level, WHO and international agencies. They are needed to coordinate, integrate and synchronise healthy cities activities; and to give funding and share experts, resources and experiences among healthy cities officers. Another lesson learnt of healthy cities which is obtained from this region is willingness to achieve healthy cities program in short time. This aims to encourage local government and community member’s political commitment to the project. Thus, some programs have to be able to show the achievement in short time while others are being developed in which the outcome will be achieved in longer term   (WHO, 2000).

Countries in South-East Asia region in report and documentation of the technical discussions held in junction with the 37^th meeting of CCPDM in New Delhi, August 31, 2000 agreed that political commitment and building partnership with stakeholders (government sectors, non government sectors and community participation are very important for the success of healthy settings including healthy cities program (WHO, 2000).

Achieving a healthy city is not easy, very complex task which involve various actors, agents, interest groups with different backgrounds, aspirations, potentials and cultures (Landry, 2002 in Gannon, 2003). Therefore, Gannon (2003) noted a number of preconditions for achieving a healthy city as presented by Landry (2002). They are personal qualities, will and leadership, human diversity and access to varied talent, organisational culture, local identity, urban spaces and facilities and networking dynamics.

In conclusion, healthy cities implementation will be success if a range of barriers and challenges are addressed.