City Leadership for Health

City leadership for health

Summary evaluation of Phase IV of the WHO European Healthy Cities Network City leadership for health Summary evaluation of Phase IV of the WHO European Healthy Cities Network

Edited by Geoff Green & Agis Tsouros Keywords Abstract

CITIES The report is a summary evaluation of Phase IV of the WHO URBAN HEALTH European Healthy Cities Network. It reviews the organization LOCAL GOVERNMENT of healthy cities, their enduring values and the core themes of LEADERSHIP health impact assessment, healthy ageing, healthy urban plan- PROGRAM DEVELOPMENT ning and active living. There are 23 key messages for city deci- PROGRAM EVALUATION sion-makers and the international public health community. EUROPE

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Key messages 1 1. Introduction 3 2. Assessing the impact of Healthy Cities 4 3. Partnerships 6 4. City health profiles 8 5. City health development plans 10 6. Active participation by and empowerment of communities 12 7. Equity and determinants of health 14 8. Health impact assessment 16 9. Healthy ageing 18 10. Healthy urban planning in European cities 20 11. Active living 22 12. National Healthy Cities networks in Europe 24 References 26 Key messages

1. Introduction 7. Equity and determinants of health Healthy cities comprise a true laboratory of cutting-edge public Healthy cities have raised equity higher on their political health ideas and concepts. This knowledge and experience are agenda, changing emphasis to address the wider determinants intended to benefit all cities in Europe and beyond. of inequality in health. 1 2. Assessing the impact of Healthy Cities Although targeting poverty and exclusion removes some forms of inequality, policies for equity in health should also address The work of healthy city projects was evaluated using a long- the full social gradient in health, which runs from the top to term perspective and cutting-edge methods. the bottom of the socioeconomic spectrum. The purpose of the evaluation was to generate a synthesized knowledge base for dissemination to city governments and to 8. Health impact assessment the international public health community. In a few years, many healthy cities have developed capacity for planning and performing health impact assessment, 3. Partnerships encouraging decision-makers in all sectors to improve the Healthy city partnerships encompass more sectors than in health of their citizens by using health impact assessment. previous phases, achieving a greater degree of collaborative Cities have innovated in health impact assessment methods planning and implementation. and practice in Phase IV, and this should be developed further The WHO European Healthy Cities Network is well regarded in Phase V to optimize policies and other local government both as a source of technical expertise and as a powerful force proposals. for engaging politicians and organizations from many sectors. 9. Healthy ageing 4. City health profiles Membership of the WHO European Healthy Cities Network has Over 15 years, city health profiles have evolved as an encouraged nearly every city to adopt a healthy ageing indispensable tool for informing citizens, policy-makers and approach. politicians about health and as an evidence base for city By applying healthy ageing strategies in many sectors, city health planning. governments can compress the age of dependence and Although most cities understand the concept of a city health expand the age of achievement and independence. profile, effective intervention strategies require systematically analysing the local links between population health and its 10. Healthy urban planning in European cities wider determinants to identify where the problems lie and to Healthy cities catalyse intersectoral cooperation between monitor progress towards outcomes. planning departments and health agencies. 5. City health development plans Most WHO Network cities have implemented projects and programmes that enhance the health dimension of urban City health development plans are essential strategic development, but many struggle to fully integrate health into documents in many cities, encompassing the contribution of the urban planning system. many sectors and using the skills and commitment of many actors. 11. Active living Cutting-edge cities are developing city health development Healthy cities have moved beyond a traditional focus on plans to optimize resource allocation using health impact dedicated exercise towards active living as a routine part of assessment and cost–benefit analysis. everyday life. 6. Active participation by and empowerment of An integrated model of urban development encourages communities tougher choices in urban investment to optimize the health benefits of physical activity. Healthy cities are characterized by a strong commitment to community participation and empowerment. 12. National Healthy Cities networks in Europe Cities demonstrate inspiring activity across the four quadrants Of the 25 active national Healthy Cities networks in Europe, of Davidson’s wheel of participation – informing citizens, most significantly influence public health policy at the city, consulting with local people, enabling participation in regional and national levels. decision-making and empowering communities. National networks are now better organized than before, with clear strategies and annual plans. More than 70% now have a formal strategy document. 1 Introduction

City leadership is a red thread running through 20 years sustainability in the urban environment. The report of and 4 phases of the WHO European Healthy Cities the Commission on Social Determinants of Health (1) Network, celebrated at the 2008 International Healthy adds greatly to our knowledge. The evidence base for Cities Conference in Zagreb, Croatia. Courage and the work of healthy cities has become much more 3 vision are required of city mayors whose remit does not robust over the past 20 years. Healthy cities comprise a extend to formal responsibility for health services. true laboratory of cutting-edge public health ideas and Health is the business of every sector, and mayors have concepts. The diverse socioeconomic and organizational a key role in orchestrating the contribution of many profile of the diverse members provides a vast and actors. unique seeding ground to test new ideas and harvest precious knowledge. Commitment Evaluation The challenge is to sustain a long-term commitment to the goal of health for every citizen, with effective inter- The evaluation of Phase IV of the WHO European Healthy ventions supported by stronger evidence and better Cities Network offers insights and lessons from WHO understanding of the determinants of health and the Network cities and national Healthy Cities networks quality of life. Decision-makers cannot turn their institu- active in 25 European countries. This report summarizes tions and policies upside down every time an interna- city partnerships (Chapter 3), health profiles (Chapter 4) tional declaration calls for change, and many calls to and city health development plans (Chapter 5) as organi- adapt to new realities have been made during the past zational features of healthy cities. Community participa- 20 years. Healthy cities provide a compass, promoting tion (Chapter 6) and equity (Chapter 7) are core values. health as an enduring core value in city policies and The core themes of Phase IV are health impact assess- development plans and serving as a beacon of social ment (Chapter 8), healthy ageing (Chapter 9), healthy justice and participatory governance. Cities in the fore- urban planning (Chapter 10) and physical activity and front of development today must possess the energy, active living (Chapter 11). Finally, Chapter 12 analyses leadership, skills and expertise to respond to new ways national Healthy Cities networks. The report reflects of thinking and doing and to take advantage of new underlying coherence in the Healthy Cities approach and opportunities. potential for change and innovation. The Healthy Cities movement has sustained its relevance for city govern- Evidence ments and offers a specific basis for local commitment and partnership across Europe. Evidence is critical for successful interventions. Many governments took more than 10 years to develop poli- Agis D. Tsouros cies based on the proven link between poverty and Unit Head, Noncommunicable Diseases and health. Cities are taking as long (Chapter 2) to respond Environment, Division of Health Programmes, systematically to the many determinants of health and WHO Regional Office for Europe 2 Assessing the impact of Healthy Cities Geoff Green & Evelyne de Leeuw

Key message 1 The work of healthy city projects was evaluated using a long-term perspective and cutting-edge methods. 4 Key message 2 The purpose of the evaluation was to generate a synthesized knowledge base for dissemination to city governments and to the international public health community.

The inspirational report of the Commission on Social WHO in evaluating impact. Reviewing Phase I Determinants of Health (1) does not merely review the (1988–1992), Ron Draper (2) focused on healthy city evidence on cause and effect. The focus is primarily on projects as catalysts for change, presenting a ten-year action to close the health gap within a generation. perspective from inception to significant health gains Good city governance will signifi- Fig. 2.1. Ron Draper’s ten-year perspective (Fig. 2.1). His model underpins cantly contribute to this. on how healthy city projects affect the current evaluation of Phase IV processes and structures (2003–2008). City potential Project Methodological approval European cities and partners have 5–10 years? 1–2 years? considerations formal competence or a guiding Health Strategies hand on the living and working gains and action Our cutting-edge approach to conditions that mediate How long generating knowledge goes between the distal structures of does it take? beyond traditional epidemio- society and proximal lifestyle logical paradigms. First, we Structures Healthy determinants such as exercise and build in context. Realist fourth- settings and diet.Their capital investment processes generation evaluation techniques Healthy programmes and urban planning 4–8 years? public 2–4 years? are appropriate for gauging the regimes may erode, sustain or policies performance of healthy city pro- enhance the health effects of jects. Second, we account for 3–6 years? transport, housing, working envi- multiple interventions. Practical ronments, sanitation, food distribution and education. city politics means simultaneous investment across many sectors, including those in which effects on health Long-term impact are not the primary concern of the decision-makers. Third, we account for the complex ways health is deter- Over 20 years and 4 phases of the WHO European mined by reviewing different levels of planning, policy Healthy Cities Network, member cities have joined and action. City leadership for health

Rationale Methods

Evaluation of Phase IV focuses on the wealth of knowl- The annual reporting template has become a core tool edge accumulated by the healthy city movement in in evaluating recent phases, compiling information on Europe. The purpose is to generate a knowledge base cities’ organization and activities. The general evalua- for dissemination to city governments and to the inter- tion questionnaire evolved from the evaluation of Phase national public health community. A team of experts III. These and other instruments were used for evaluat- 5 has conducted the research, which will be published in ing the work of the 79 member cities of the WHO the Journal of Urban Health. This booklet summarizes Network and the 25 active national networks. the key findings. Fig. 2.2. Phases and themes of the WHO European The annual reporting Scope Healthy Cities Network, 1988–2008 template and general Phase I Phase II Phase III Phase IV evaluation questionnaire We encompass 2003– 1988–1992 1993–1997 1998–2002 2003–2008 were sent to cities in

2008 and address four Setting the February 2008; 60 of 79 CHP CHDP CHDP main questions. agenda (77%) responded online. Data were supplemented I How did cities use by reports from the HUP HUP their membership subnetworks on the core in the WHO Net- themes and from 190 EU HIA work to strengthen project HIA case studies prepared by their public health June 2008 for the 2008 agenda? HA International Healthy Cities Conference in I How did cities work Zagreb. Ten experts were AL AL on partnerships for recruited to analyse the health, participa- 15 35 45 79 data and prepare tion, equity and the Number of cities in the WHO Network scientific papers. This social determinants report summarizes their CHP: city health plan. CHDP: city health development plan. HUP: healthy urban planning. of health? HIA: health impact assessment. EU: European Union. HA: healthy ageing. AL: active living. findings.

I How successful were they in promoting action on Expert authors used Ron Draper’s framework and drew the core themes of healthy urban planning, health on theoretical perspectives related to their domain. impact assessment, healthy ageing and active Empirical data came primarily from questionnaire living? responses marshalled by each healthy city coordinator and approved by a politician or politically responsible I What evidence is there on the impact and results of officer. Although cities provided information in good healthy city work at the local, national and interna- faith and with professional integrity, evaluators endeav- tional levels? oured to account for any bias. 3 Partnerships Alistair Lipp & Tim Winters

Key message 1 Healthy city partnerships encompass more sectors than in previous phases, achieving a greater degree of collaborative planning and implementation. 6 Key message 2 The WHO European Healthy Cities Network is well regarded both as a source of technical expertise and as a powerful force for engaging politicians and organizations from many sectors.

Concept and context Partnership structures

In 1985, Targets for Health for All (1) highlighted social The political commitment of city mayors is essential to determinants of health beyond the scope of tradi- ensure the cooperation of municipal departments. tional health services. The pre- Most healthy cities have both formal polit- requisites for health ical structures and informal enshrined in this policy working relationships with made health every- Community statutory, voluntary, body’s business. Action private and public agencies. r r o o r r r t r t

to improve population r In Phase IV, 94% of city part- o c o o c o t o t t e t e t c c c s c health required the cooper- s nerships have agreed on joint c

e e

e l e e s t s s a

ation of all sectors. t working and only 12% have c c n s i r e y o o s r o i s t m m

e t not yet implemented joint p s o n n a & s i

u c n o s n h d From the launch of the r plans. u o t i a u l n c r d v I a B T E E n WHO European Healthy e E Cities Network in 1988, H Technical cooperation is cities have imple- Local policies and legislation necessary both to under- mented this policy at take collaborative projects National policies and legislation the local level. Cities and produce the strate- applying for Health for All policy framework gic city health (develop- membership were ment) plans within required to establish an Fig. 3.1. Key sectors for healthy city collaboration Phases II–IV. Fig. 3.1 shows intersectoral committee the iconic Parthenon high- for health, and this structure has remained a key feature lighting the key sectors and levels of collaboration (2): throughout all the phases. Stakeholders must cooperate 78% of city partnerships plan strategically, with 19% both politically and technically. having this as their main focus; 81% supervise collaborative projects, with 22% as their main focus. City leadership for health

Engaging key sectors Success factors and obstacles

Partnerships within the health and social service sectors For many cities, political support is critical to success, dominated earlier phases of the WHO Network and typically “the enormous and unanimous political drive account for most collaborative partnerships in Phase IV. to make this project succeed” and “endurance, tenacity, At the most engaged level, 76% of city partnerships are leadership and optimism”. Another key factor is a implementing collaborative plans, strategically located office 7 Fig. 3.2. Partnerships with the urban projects or programmes. A further planning sector and well-organized team 15% have agreed strategies and 50 with good management and plans, and only 9% remain at the 45 communication skills. One basic level of merely agreeing to city cited “the importance of 40 23 collaborate. cities negotiating objectives and

s 35 e i establishing goals with t 19 i c

30 f cities

However, compared with Phase III, o reasonably high standards”.

g 25 more cities in Phase IV are engaging a t n

e 20 c

with other sectors: 64% at the high- r Obstacles to success include

e 11 est level with the education sector, P 15 cities organizational and person- 46% with the voluntary sector, 42% 10 2 nel change, for some “a fairly with urban planning and 28% with 5 cities constant change in the the transport sector. Cities recorded 0 health service structures in the greatest increase in collaboration Share Agree to Agreed Implementation the city, which has often led information collaborate plans with urban planning, reflecting a core to planning blight”. Others theme of Phase IV. Relatively few cities engage with the cited lack of time and money: “Funding is allocated economic sector; 21% have agreed strategies, but only according to the sector silos and, given the lack of 15% operate at the highest level. resources, everyone protects their own piece of the cake”. Although the concept of intersectoral working is Achievement central to the Healthy Cities approach, implementing a global strategic focus can be difficult. Partners have agreed to work together in the vast majority of cities (98%), although in a very few cities, Membership of the WHO Network predominantly in eastern Europe, partnerships have struggled to achieve the most basic level of partnership The WHO connection is important to most cities. work. Fig. 3.2 shows how cities rate their partnership Although 82% said that they would continue without with healthy urban planning on a spectrum ranging it, many cities said that membership of the WHO from “No contact” through “Implementation of collab- Network had persuaded local governments of the bene- orative plans, projects or programmes”. Compared with fits of intersectoral collaboration. It provides leverage, Phase III, cities have scaled up. Then the largest group confers “significant public status and recognition” and (43%) agreed on plans and strategies. Now many is “important for leadership, inspiration and motivation (42%) are moving on to implementation. of politicians and decision-makers”. 4 City health profiles Premila Webster

Key message 1 Over 15 years, city health profiles have evolved as an indispensable tool for informing citizens, policy-makers and politicians about health and as an 8 evidence base for city health planning. Key message 2 Although most cities understand the concept of a city health profile, effective intervention strategies require systematically analysing the local links between population health and its wider determinants to identify where the problems lie and to monitor progress towards outcomes.

Concept and context Purpose

City health profiles originated in Phase II to provide an The role of city health profiles in influencing health evidence base for health planning. They continued in policy is: Phases III and IV as an essential tool for informing citi- I to interest, inform and educate the public, health zens, policy-makers and politicians about health and its professionals, politicians and policy-makers and determinants in cities. WHO defines city health profiles stimulate them to action; as reports that I “identify in writ- Fig. 4.1. Content of a city to act as a source of information about health in the ing and graphs, health profile locality; health problems Statistics I to identify health problems, high-risk groups and and their solu- unmet needs; tions in a specific n C o I i to be a critical component of health planning, indi- i t t

city” (1). City i p z i e r Health profile cating health priorities, the preferred resource allo- c n

health profiles s e

D cation and direction of service development; and are the basis of city health devel- I to provide a focus for intersectoral action. opment plans, Experiences which set out Reviews strategies and intervention programmes to improve the health of a city’s population.The best city health profiles A 1999 review (2) highlighted lifestyles and inequality are not limited to indicators describing health status as the two main areas for development, with the chal- and the determinants of health but also incorporate an lenge of systematically connecting determinants to analysis of how these determinants influence health health outcomes. A second review in 2005 (3) reported outcomes. Fig. 4.1 summarizes the content of a city some success in providing an evidence base for health health profile. planning, although many cities had difficulty in making recommendations for target-setting. City leadership for health

The updating cycle working group including “sociologists, strategists, experts in all city spheres: town planning, education, A city health profile is an essential tool in the Healthy public health services, transport, culture, social care, Cities toolbox, adapting and evolving since first devel- physical training, housing and communal services”. oped in 1994 to become a sophisticated mechanism for gathering planning-relevant information. Most cities Intervention have produced a city health profile and have a three- to 9 five-year cycle for updating them. One third updated it The ultimate aim of city health profiles is to improve the in the past year and, of the remainder, health of the local population. Evidence from 84% planned to update within two years. Fig. 4.2. Example: profiles is used to inform appropriate percentage of interventions to improve health. An people 65+ years in Health ageing profiles districts of Udine example is the systematic collec- tion of mental health indicators Cities developed complementary healthy in Rijeka to enable mental ageing profiles in Phase IV, espe- health care and activities to cially in the Subnetwork on prevent mental disorders Healthy Ageing. Emphasizing and their effects. City health health outcomes rather than profiles also contribute to indicators of illness and disease, strategic development, healthy ageing profiles reach providing the evidence for beyond a traditional focus on city health development health and social care services plans. Victoria-Gasteiz, a city towards a life-course approach to that joined the WHO Network maintaining functional capacity. They in Phase IV, produced its first adopt a positive and dynamic model, city health profile in 2007, identifying wider indicators of well-being which helped “set the priorities and such as secure housing and accessi- determine the goals that constitute the ble transport. Fig. 4.2, extracted >60% (city) health development plan for from Udine’s city health profile, 40–60% 2007–2009”. shows the density of older people. 20–40% 0–20% Ideally, city health profiles should Intersectoral approach Source: Zamaro (4). explicitly be part of a cycle. Victoria- Gasteiz reported that “once the health Cities report how the production process brings plan concludes, a new city health together stakeholders from many influential sectors. For profile will be discussed and designed” to measure example, Dresden involved urban planners in addition changes in health status as a result of intervention to the Office for Social Affairs, with its traditional programmes. Over the years, a city’s health profile is responsibility for providing social services. In expected to become an influential part of public health Cherepovets, the health profile was developed by a policy and activity. 5 City health development plans Geoff Green

Key message 1 City health development plans are essential strategic documents in many cities, encompassing the contribution of many sectors and using the skills and 10 commitment of many actors. Key message 2 Cutting-edge cities are developing city health development plans to optimize resource allocation using health impact assessment and cost–benefit analysis.

Context education and disease prevention by the health sector. It was agreed that enhanced city health development City health development planning was initiated at a plans (1) would be required in Phase III. They would business meeting of the WHO European Healthy Cities advance city health plans by addressing the wider deter- Network in Belfast in minants of health and 1990. Until then, cities Fig. 5.1. City health development planning relating to social, environ- primarily focused on mental and economic 1 Sec demonstration projects or to aspects of city life. ct r e City 2 to place the new 2003 S 2008 Relationships health public health higher health health between health, on the agenda of development economy and envi- profile S profile e 3 c plan r municipal councils and to o ronment are reciprocal r ct their partners. In Belfast, 4 Se and mutually reinforcing. cities agreed that City health development Baseline Mechanism for change Outcome demonstration projects plans should harmonize alone were not suffi- strategic plans at the cient to fundamentally alter the direction of city devel- city level, with health sometimes in focus and sometimes opment. Missing but essential was an instrument for integrated into other plans for the city or sector. strategic city planning for health. According to Jostein Rovik, former Mayor of Sandnes, Concepts city health development plans should “tell us where we are going and how we get there”. They therefore Despite subsequent investment in city health plans require a vision and a mechanism for change. Health during Phase II, a series of WHO Network business meet- profiles provide a baseline and indicate progress ings concluded that many plans were too limited in (Fig. 5.1). scope and strategic direction, often focusing on health City leadership for health

Types of city health development plans Process

When Phase IV started, three types of city health devel- As Stoke-on-Trent reported at the start of Phase IV,“The opment plan were identified to reflect the practical poli- plan is not an end in itself but has to have a tics of each city (2). The classic model (type 1) contains purpose ... . The process of developing the plan is more the essential elements of vision, integrative strategy and important than the actual plan.” This is reflected now. operational sector plans. In a sectoral approach (type 2), Izhevsk says that the process of preparing a city health 11 the project team (or steering group) negotiates bilateral development plan “is an excellent school for specialists agreements with competent agencies to include a and heads of departments”, leading “to their under- health dimension in their plans. standing that the health of the Fig. 5.2. WHO Network cities by type of An integrated approach (type population is not a task for the city health development planning 3) seeks to embed a strong health sector only and that they 60 health dimension into a have an important role in public comprehensive city develop- health”. For Athens, “It was the 50 17 ment plan. cities right instrument to bring together experts from different sectors to s 40 e i t i

Of the 31 cities initially apply- c cooperate, think and plan

f o

ing for membership in the WHO e together.”

g 30

a 10 t

Network for Phase IV, 17 had n

e cities c r already developed a classical e P 20 Cutting edge city health development plan, 10 had adopted an integrated A few cities are developing a 10 4 strategy and only 4 were pursu- cities harder cutting edge to their city ing bilateral agreements (Fig. 0 health development plans. Their 5.2). Cities now report good Type I: Type II: Type III: decision-makers no longer merely classical sectoral integrated progress with reviewing their require evidence on intersectoral plans; 19% had updated their plans in the previous year determinants of health and summarize strategies for and 57% planned to do so. improving health. They want to optimize resource allocation. Montijo reports how the integrated city health Profile and plans development plan process overcame “scarce cooperation” that “multiplied interventions and consumed Udine says that city health profiles are the starting- excessive resources”. Lódz highlights how their city point in a virtuous circle of reviewing and updating the health development plan ensured “organized action city health development plan, allowing cities to contin- and the rational use of resources”. Helsingborg’s ually evaluate progress and health status. In Posnan, Department for Sustainable Development provides the every action for citizens is only taken after deep analy- knowledge needed to optimize resource allocation in sis of their health needs. Helsingborg has initiated a the annual budgeting process.Their ambition is compre- new monitoring system to reach further into the hensive economic impact assessment covering health, management levels of the city. social and environmental aspects. 6 Active participation by and empowerment of communities Mark Dooris & Zoë Heritage

Key message 1 Healthy cities are characterized by a strong commitment to community 12 participation and empowerment. Key message 2 Cities demonstrate inspiring activity across the four quadrants of Davidson’s wheel of participation – informing citizens, consulting with local people, enabling participation in decision-making and empowering communities.

Context variety of ways. However, its core is the notion of power, defined as “the ability to control the factors that deter- The core principles of community participation and mine one’s life” (2). In practice, this means that healthy empowerment underpin all phases of the WHO cities should promote “support for community-level European Healthy Cities Network. A series of interna- action and capacity-building; strengthening of infra- tional charters and declarations structures and networks; and Fig. 6.1. Davidson’s wheel of participation have guided the work of WHO meaningful organizational and provide a framework for development and change” (3). healthy city development. The Ottawa Charter for Health t I en nfo The famous ladder of parti- Promotion (1) declared “At rm Entrusted Minimal rm cipation, popularized by e control communication a the heart of this process w t Arnstein (4), puts o Limited i is the empowerment Independent o genuine empowerment p control information n of communities, their m on the top rung, parti- E ownership and con- Delegate Good-quality cipation midway and control information trol of their own consultation on the endeavours and dest- Limited decentralized Limited lower rungs. However,

decision-making consultation

inies.” C the WHO European

o Healthy Cities Network o

Partnership Customer s t

u prefers the non-hierar-

Concepts a care

Effective l

p t

i Genuine

advisory a chical model popularized c

consultation t t i

body o r n

Although it is generally a by Davidson’s wheel of agreed that participation P participation (Fig. 6.1) (5).In implies being involved, the reviewing Phase IV, cities have concept of empowerment is used in a described their action in each quadrant.

Source: adapted from Davidson (5). City leadership for health

Informing citizens Participation in decisions

Every city gives priority to informing their citizens about One third of cities in the WHO Network involve repre- health issues. Two thirds use the traditional mass media sentatives for nongovernmental organizations on their of television, radio or newspaper, with nearly as many healthy city steering groups. Another 18% highlight the using the Internet. For example, Belfast launched its importance of more general participation in strategic own new web site during processes and formulat- 13 Phase IV. Half of ing and delivering “At the strategic “A vivid example cities use special- programmes as level, the City of Kuopio has was the City Health Forum: ist newsletters an all-purpose decided that the Health Kuopio choosing the city’s priorities for and bulletins. municipal Programme and the WHO European health. Authoritative public venture. Healthy Cities Network are major organizations (pensioners, brands of the region. We inform our environmental organizations and citizens about health in all possible children’s and youth ways: via the Internet, media nongovernmental organizations) cooperation, leaflets, posters were involved.” Izhevsk, and events.” Russian Federation Kuopio, Finland

Consulting local people Empowering citizens

Some cities confine consultation to specific projects, Cities often regard consultation and participation as and others are committed to consult across the breadth steps towards empowerment. Others strongly empha- of their work. The most commonly used mechanism is size the enabling role of funded professionals and questionnaires (62% of cities) followed by meetings active participation, leadership and public events and management by (48%). Rennes has citizens. A priority developed large “We have learned is to equip citi- public events the importance of local zens with the “We produced a to compile accessible venues, providing the skills, confi- strategy for involving vulnerable residents’ basics (transport, child care and dence and groups in participatory budgeting: desires for interpreting), making it a good capability a feasible and tested method for the city of experience, giving and receiving to partici- local government to produce tomorrow. feedback and being pate in the maps of priorities.” accountable.” Newcastle, city’s deci- Tirana, Albania United Kingdom sion-making processes. 7 Equity and determinants of health Anna Ritsatakis

Key message 1 Healthy cities have raised equity higher on their political agenda, changing emphasis to address the wider determinants of inequality in health. 14 Key message 2 Although targeting poverty and exclusion removes some forms of inequality, policies for equity in health should also address the full social gradient in health, which runs from the top to the bottom of the socioeconomic spectrum.

Concept and context Whitehead & Dahlgren (5). ltural and ic, cu envir mon onm Lifestyles and health ser- eco en o- ving and workin ta Equity in health has been an ci Li g l c vices are important, but so conditions on l Work d underlying value of WHO’s ra it so are wider social, e environment Unemployment io n mmuni n Health for All policy for e d co ty n s economic and G an etw al o Water and three decades (1). ci rk environmental o lifestyl s sanitation Education S ual e f Defined as unjust and id ac determinants of iv to d r n s Health care avoidable differences Agriculture I health. Age, sex services in health status in the and food and hereditary production 1 early 1990s (2), equity 2 factors Housing Healthy city 4 3 is the core value in governments Closing the gap in a Fig. 7.1. A social model of health are well posi-

generation: health equity Source: adapted from Whitehead & Dahlgren (5). tioned to influence living through action on the social and working conditions. determinants of health, the 2008 report of the In Phase IV, progress has depended on whether: Commission on Social Determinants of Health (3). Promoting equity is not confined to alleviating poverty. I equity in health is on their political agenda; Like HEALTH21 (4), the Health for All policy framework for the WHO European Region, the Commission addresses I information is gathered to raise awareness and the full social gradient in health from the top to the monitor progress; bottom of the socioeconomic spectrum. I their emphasis has changed from health care to a The goal of equity is intimately linked to action on the wider spectrum of determinants; and social determinants of health – part of the title of the Commission’s report. Fig. 7.1 shows the famous social I interventions address the social determinants of model of health (and inequality in health) developed by health. City leadership for health

Highlighting equity between action within the health sector, targeting vulnerable groups and addressing wider determinants Although some city partners report difficulty in gaining of health. a common understanding of equity, more than two thirds refer to the broad concept embedded in WHO Traditional health sector interventions include health Health for All policy. Poverty and social exclusion are education, disease prevention and health care. high on the agenda of the European Union, providing Programmes often target high-risk or vulnerable 15 extra impetus to giving equity higher priority on the groups: for example, screening for tuberculosis in disad- agenda of the 40 cities in the vantaged areas of Barcelona and Fig. 7.2. City action to promote WHO European Healthy Cities providing primary health care for equity in health Network within European 50 uninsured people and disadvan- Union countries. Equity in taged regions in Çankaya. health is important for the 40 cities, with 71% saying “very 24 24 Cities in Denmark, Finland, Sweden s e

i cities cities t important” and 19% “moder- i 21 and the United Kingdom strongly c

f 30 cities o ately important”. address the wider determinants of e g a t

n health, often as part of comprehen-

e 20 c r

e sive regeneration strategies to

Healthy city catalyst P improve the environment, social 10 Healthy city project offices cohesion and job opportunities in significantly influence policies disadvantaged neighbourhoods. 0 and processes in most cities; Health Vulnerable Wider Twenty-four cities in the WHO 19% highlight their critical services groups determinants Network are acting to enhance the strategic role, indicating that equity would not be on the economy or reduce poverty, often by promoting educa- city agenda without their input. Evidence, either from tion and training to gain access to employment. local health profiles or via the wider WHO Network, helps persuade politicians that tackling inequality in Monitoring and checking health is a priority.The central location and intersectoral approach of healthy city projects also encourages agen- To varying degrees, promoting equity in health has cies and partners to include equity in formulating their entered the policy cycle of: awareness-building development plans. policy formulation implementation monitoring and evaluation reassessment revision. Compared Action with earlier phases, more cities are auditing policies, plans and programmes for how they affect equity, are City action to address the determinants of inequality in able to compare differences between neighbourhoods health has gradually changed (since Phase III) away and are targeting unhealthy citizens. However, targeting from downstream (proximal) determinants towards the poverty has a downside; the full social gradient in upstream (distal) determinants shown in the outer rings health runs from the top to the bottom of the socioeco- of Fig. 7.1. However, Fig. 7.2 reveals a fine balance nomic spectrum. 8 Health impact assessment Erica Ison

Key message 1 In a few years, many healthy cities have developed capacity for planning and performing health impact assessment, encouraging decision-makers in all 16 sectors to improve the health of their citizens by using health impact assessment. Key message 2 Cities have innovated in health impact assessment methods and practice in Phase IV, and this should be developed further in Phase V to optimize policies and other local government proposals.

Concept and context Implementation

The Gothenburg consensus paper published in 1999 (1) Health impact assessment was a core theme for Phase describes the concept of health impact assessment: a IV. A subnetwork of 10–15 cities led by Belfast was method used to assess the potential effects of a policy, created to provide training and to encourage cities to programme or project on the assess their own policies and other Fig. 8.1. The six stages of health health of a population using impact assessment proposals and had four objectives: a combination of procedures, Selecting proposals to be I Screening to raise the awareness of politicians methods and tools (Fig. 8.1). investigated using HIA and city administrators of the Establishing parameters for health potential for health impact assess- During the past decade, the impact assessment, the methods to Scoping be used and management ment to enhance policies and WHO European Healthy arrangements for the process plans; Cities Network has devel- Identifying the proposals’ potential effects on health and well-being and oped health impact assess- Appraisal how to address these effects I to provide leadership and to

ment as a tool for local deci- Writing a report for decision-makers strengthen capacity for health sion-makers. Progressive city with results and suggestions to impact assessment at the city level; Reporting change the proposal to improve governments are well placed health and reduce inequality in health I to disseminate the practice of cities, to assess how their non- Supporting If appropriate, liaising with decision- with evidence of how health impact health policies affect their decision-makers makers over suggestions to change the proposal assessment contributes to develop- citizens’ health. With their ing health and the potential for strong intersectoral approach Evaluating the health impact assess- Monitoring & ment process and effectiveness and, strengthening healthy urban plan- to influencing the socioeco- evaluation if possible, health outcomes after the proposal is implemented ning and healthy ageing; and nomic and environmental determinants of health, healthy cities have a unique I to help mainstream health impact assessment as a opportunity to use health impact assessment for the systematic framework for assessing all city policies integrated development of sustainable communities. and projects. City leadership for health

Challenges impact assessment in their local administration; in some cities this was linked to healthy urban planning or was There are many challenges to implementing health integrated into other methods of impact assessment. impact assessment and many barriers to grasping this relatively new and complex method even at the Success national level. The greatest problem for cities was lack of expertise or experience. Building capacity takes time. Cities found that the two most important factors facili- 17 Politicians and professionals resisted in some cities. If tating health impact assessment were political support health impact assessment was given low priority, no and training, followed by links to an academic or public resources were allocated to introducing and imple- health institution providing access to expertise. Previous menting it. experience is also important. Successful cities more likely operated within a pre-existing culture of intersec- Achievements toral work. Other factors critical to achieving the objectives were commitment to implementing health impact Cities succeeded best with the first objective (Fig. 8.2), assessment in successive years, a supportive national required for meeting the policy context and subnet- other more demanding Fig. 8.2. Achieving the objectives of work membership. health impact assessment objectives. Clarifying the 80 purpose and methods of Innovation health impact assessment 70 encourages cities to invest Phase IV has been innova- 60 in health impact assess- 28 tive. Some cities, mainly in s

e cities ment and gives politicians i Scandinavia and the United t 50 i c

courage to use the results. o Kingdom, have been at the

g 40

Nearly 40% of cities built a forefront of developing t

n 18 e capacity by training politi- c health impact assessment r

e 30 cities cians and professionals in P 14 and are exploring ways of cities health impact assessment. 20 redesigning it to make it fit for purpose in a local 10 7 Nearly 30% of cities under- cities government setting to opti- took one or more health 0 mize policy (2). With the Objective 1 Objective 2 Objective 3 Objective 4 impact assessment studies. Awareness Capacity Practice Mainstream overarching goal of health Cities lobbied governments and equity in health in all at the regional (Italy), federal (Switzerland) and national local policies, Phase V of the WHO Network (2009–2013) level (France and Lithuania) to adopt health impact provides an opportunity to use health impact assessment assessment. Only 15% of cities mainstreamed health systematically across all domains of city life. 9 Healthy ageing Geoff Green

Key message 1 Membership of the WHO European Healthy Cities Network has encouraged nearly every city to adopt a healthy ageing approach. 18 Key message 2 By applying healthy ageing strategies in many sectors, city governments can compress the age of dependence and expand the age of achievement and independence.

Concept and context survived into the third age in many countries, with major policy implications. Older people are an increas- Active ageing: a policy framework (1) inspired the core ing resource to the economy and society. theme of healthy ageing. Fig. 9.1. A life-course approach to ageing This challenged orthodox City action perspectives of global Early life Adult life Older age Growth and Maintaining highest Maintaining ageing as a “demo- development possible level of independence and City governments have a key y t i

c function preventing disability

graphic time bomb” likely a role in promoting independ- p a

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l g to adversely affect both e of ence and empowering older

a in func n indiv tion o idu sustainable economic i als people as a resource. t a c Disability threshold n

development and demand u Traditionally responsible for F for health and social Rehabilitation and ensuring social services and for regulat- support services. Central the quality of life ing living and working condi- Age to our alternative concept a Sources in the environment can lower the disability threshold, thus decreasing the number of tions in most European coun- of active or healthy disabled people in a given community. tries, cities and their partners Source: Kalache A, Kickbusch I. A global strategy for healthy ageing. World Health, 1997, 50(4):4–5. ageing is a life-course can also shape a social and approach maintaining that interventions in the early physical environment that encourages healthy lifestyles. and middle life-course will reduce levels of disability in later life (Fig. 9.1). Core theme of the WHO Network

The third age This was the rationale for selecting healthy ageing as one of the core themes of Phase IV of the WHO Equally important is the concept of a third age of European Healthy Cities Network. The four objectives personal achievement and independence after with- were (a) to raise awareness, (b) to empower, (c) to drawing from the labour market but before the onset of develop supportive environments and (d) to improve “dependence and decrepitude” (2). Only in the last 50 access. Nineteen cities were recruited to a Subnetwork years has a significant proportion of older people on Healthy Ageing to lead the way. City leadership for health

Raising awareness Supportive environments

Raising awareness of the status and role of older people The work of the WHO European Healthy Cities is a prerequisite to strategies and plans to enhance their Subnetwork on Healthy Urban Planning has positively lives. The Subnetwork on Healthy Ageing committed to influenced cities. More than half report specific a “positive and dynamic” model for healthy ageing programmes or projects to enhance their urban environ- profiles at its first meeting in Stockholm in 2005. ment. Brighton & Hove, Györ and partners have devel- 19 Traditional indicators of population health and local oped a European good practice guide to housing design health care systems are balanced by those describing that promotes independence and quality of life (3). the determinants of health and empowerment. Most cities have removed architectural barriers to walkability in their streets and parks. Others have improved Nearly all Subnetwork cities and many other WHO road traffic management systems to help older pedestri- Network cities have produced healthy ageing profiles ans cross roads safely. Udine and Vienna have a (Fig. 9.2). One quarter comprehensive approach to neighbour- also refer to policies or Fig. 9.2. Healthy ageing achievements hood development emphasizing age- strategies that raise in four domains friendly environments to promote social- awareness. Brno, 60 ization and intergenerational solidarity. Posnan and Sandnes 50 43 Thirteen cities take a strategic approach, s 40 e

i cities t i have given older people c 40 cities incorporating age-friendly environments

o 32

higher priority in updat- e into overarching transport programmes

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ing their overarching n and city development plans.

e cities c 20 r city development plans. e P 10 Access 0 Empowerment Ageing Empowered Age-friendly Access to profiles communities environment social life Cities do not usually report on the Although literature on rationing of health and social care services, health promotion tends to focus on personal empower- which disproportionately affects older people. They ment, most city responses refer to collective forms of focus instead on two main types of intervention by serv- empowerment by communities representing the inter- ice providers. The first type enhances social networks ests of older people. These range from small mutual and improves mental health. Many older people receive groups, such as the clubs in Athens, Liverpool, formal help to accomplish basic activities in their own Novocheboksarsk and Rennes, to city-wide organiza- homes but may feel isolated and lonely. Cities report a tions such the veterans’ organizations in Russian variety of innovative projects to integrate them into the Federation cities or the elders’ councils in Györ and wider community, such as the “sympathy houses” in Newcastle. Many receive funding from the city. One Aydin. The second type is the provision of either cultural third of cities describe how the municipality and its or physical activities. Sunderland’s sport and leisure partner agencies hear and act on the voice of older facilities, libraries, arts centres and community venues people. offer a wide range of activities for the physical and emotional well-being of older residents. 10 Healthy urban planning in European cities Hugh Barton & Marcus Grant

Key message 1 Healthy cities catalyse intersectoral cooperation between planning departments 20 and health agencies. Key message 2 Most WHO Network cities have implemented projects and programmes that enhance the health dimension of urban development, but many struggle to fully integrate health into the urban planning system.

Context Healthy urban planning influences health The WHO European Healthy Cities Network has pioneered the concept and practical application of Urban spatial planning is a mechanism of environmen- healthy urban planning – tal control influencing health in system- Fig. 10.1. A settlement health map challenging the conventional atic ways. Fig. 10.1 shows a settlement

assumption that only health BAL ECOSYST health map originally developed for the GLO EM care professionals deter- WHO-sponsored practice guide L ENVIRON URA ME AT VIRO NT mine health policy. N LT EN NME Shaping neighbourhoods for UI NT Healthy urban plan- B ACTIVITIES health, sustainability and ECON g CAL OM L ning: a WHO guide y in O Y iv vitality (2). t i i s s v L MUN n l e e o M IT g S A i e c O Y , t i b r m C r r B la , M p e , to planning for a t s EST i g l IF Y l e w o t , p e a L L N a a s s , n t y E e t a d t i m i it r y s g iv W t k i , t i e a p o p t w n v c o e e t t n c a PEOPLE r people (1), i i p a r g e This anthropocentric model k o t o r a c l , n - s r b d o , I a l r u l l i l s c k i h f l m a i a e t i a e i s s s i e t u n l h y b a y , c

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Phase III, posed i sustainable development

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N hereditary a challenging W factors but also recognizes ecologi- cs O ti t li s he agenda for cities to o ce r cal limits to growth. Urban , p r O ne y fo t ig m l h h o a er b achieve 12 key objec- n b r o sprawl damages the environ- o lo e u c g gi rh -e , on o o re s o tives for health and cr u ds ment, but health is also a casu- a lt M u sustainable develop- C The determinants of alty. The decline in regular daily health and well-being ment. These have provided in settlements walking is resulting in increased a framework for healthy urban obesity and greater risks of diabetes and planning as a core theme for cardiovascular diseases (4). The decline in Source: adapted from Barton & Grant (3). Phase IV.We have used them as local facilities, the reduction in pedestrian benchmarks for assessing progress. movement and neighbourly street life all reduce opportunities for the supportive local contacts that are so vital for mental well-being (5). City leadership for health

Healthy city catalyst However, most cities have achieved the second enhanced level of supporting projects that enhance the Healthy cities catalyse intersectoral cooperation quality of life and thereby health: for example, imple- between planning departments and health agencies. menting cycling networks, removing physical barriers to Many coordinators understand well the interplay walkability and inserting new parks into dense cities, all between housing and planning; a diminishing number encouraging health-enhancing physical activity and do not. In Phase II only one quarter reported links. By social cohesion. Of the three most important healthy 21 the end of Phase IV, two thirds of coordinators were urban planning issues, the cluster of green spaces, actively involved with recreation and physi- urban planners and Fig. 10.2. Healthy urban planning activity in cities cal activity is the top influential in shaping 70 priority in 17% of planning programmes. Very poor cities. The transport 60 This resulted in an Poor and accessibility clus- increase in high-inten- 50 Fair ter is a top priority for sity healthy urban High 12% of cities. s e i t i planning in estab- c 40

f o

lished cities (Fig. r As Phase IV ends, e b

10.2). The high m 30 most cities are still u achievers all have N struggling to work vibrant healthy urban 20 across disciplinary planning programmes, 26 and professional 10 21 typically an active 11 15 boundaries to achieve programme of training 0 a holistic approach in and stakeholder meet- 2005 2006 2007 2008 which health is fully 18 cities 32 cities 63 cities 55 cities ings and a programme integrated into the Year and number of cities surveyed including a large urban planning strategic project or many small projects or both. system. Only a few cities identified housing, transport, However many cities new to the WHO Network report- accessibility and other policy areas related to the built ing for the first time in 2006 still had much to learn. environment as affecting inequality in health. However, in contrast to earlier years, strategic urban planning Impact issues now have the highest priority in many cities (22%). All the signs point to a progressively deeper and Integration of health and planning has three distinct broader understanding of the relationship between levels. Some cities new to the WHO Network, mainly in health and urban planning, with action following in its eastern Europe, still operate at a basic level, concerned wake. with the essential life-support role of settlements: providing shelter, access to food and clean water, fresh air and effective sewerage treatment. 11 Active living Johan Faskunger

Key message 1 Healthy cities have moved beyond a traditional focus on dedicated exercise towards active living as a routine part of everyday life. 22 Key message 2 An integrated model of urban development encourages tougher choices in urban investment to optimize the health benefits of physical activity.

Natural Active health environment in enhancing their social and built w Built ea er th environment to encourage at vironme er w en nt urb rt an Changes in city environments, po de active living (Fig. 11.1). In ns Social sig tra n vironmen in en t com less physically demanding re e Phase IV, a task group of tu ul dividua eq c In l u s i working lives and techno- n t t cities on physical activity r s rmina y f e o i n r e ie t t g t l e a p s g r a t n e d s e o b e o a o e i g p c r n s i r logical innovation have all e a and active living led by Physical a e e n d l s

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contributed to sedentary o Turku helped to develop

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s active living lifestyles, posing a threat an innovative agenda for to public health. Strong Fig. 11.1. Influences on physical activity in communities the WHO European

scientific evidence shows Source: adapted from: Edwards & Tsouros (2). Healthy Cities Network. that regular physical activity promotes health. Physically active people are not To assess progress in Phase IV, the following questions depressed as often, have better cardiovascular and were asked. musculoskeletal fitness, a healthier body composition I How do you promote walking, cycling and physical and a biomarker profile more conducive to enhancing activity when planning your neighbourhoods? bone health and preventing cardiovascular disease and type 2 diabetes (1). I How does your city’s active living programme link to public health concerns, including heart disease and All levels of government are concerned with promoting obesity? physical activity and limiting the potential burden of disease. However, individual education and fitness I How does your city reach out to sedentary people in programmes have not succeeded in reversing the your population? sedentary trend. Promoting physical activity and active I Is the active living approach incorporated into your living in urban environments: the role of local govern- city’s plan and strategies for urban development? ments. The solid facts (2) therefore emphasizes shifting focus towards promoting active living as part of the I How does your city measure and monitor levels of daily life of a city. City governments have a critical role physical activity in the population? City leadership for health

Activity types and targets equality and reclaiming the streets to enhance both physical and mental health. Action includes singular Healthy cities reveal a definite shift away from the tradi- events such as cycling and health days. More often, tional focus on callisthenics – dedicated exercise, often there are sustained community schemes and in gyms or clubs or classes – towards an active living programmes – such as cycling courses, community approach. Although exercise classes are important and clubs, walking groups or buddies – and financial incen- team sports may keep people fit, tives to encourage target 23 Fig. 11.2. City investment in active living domains city responses emphasize integrat- groups to become active. 100 ing physical activity into everyday routines – especially cycling and 90 Integrated 49 walking for work and leisure. A 80 cities planning whole-population approach is 70 41 s e required, including older people, i Mirroring the assessment t

i cities

c 60 35 f

children, ethnic minorities, women o of healthy urban plan-

e cities

g 50 and disabled people. a ning (Chapter 10), rela- t n

e 26 c 40 tively few cities report r e

P cities Urban environment 30 fully integrated urban planning processes to 20 Cities mainly highlight action in encourage active living. the urban environment to encour- 10 Although 40% refer to age everyday activity. The highest 0 city transport plans that Walking Cycling Parks Community investment priority (Fig. 11.2) is include traffic-calming improving the infrastructure for walking. Barriers are and reducing motorized road traffic, few cities make removed by lowering kerbs on pavements and improv- systematic links to health or education plans. Only 14% ing road junctions. Connectivity is enhanced by opening of cities refer to integrated plans for active living. Twice up culs-de-sac. Pedestrian-friendly zones are created in as many have specific programmes to tackle overweight city centres. The second priority is investing in cycling and obesity among adults and children. infrastructure, with action to introduce cycle priority lanes, connect suburbs with city centres and make Optimizing design and development crosswalks safer.The third priority is improving or creat- ing green spaces or parks, to provide facilities and raise Deploying an ecological model would facilitate better people’s spirits in dense and often deprived residential understanding of the interaction between various areas. People-friendly urban spaces, such as piazzas, are elements of city development. It would also encourage also important. wise investment via cost–benefit analysis. For example, less than 1% of Sweden’s national transport budget is Social environment invested in walking and cycling despite evidence that 30% of all trips are by foot or bicycle. One way ahead Cities in the WHO Network are fostering social contacts is to make decision-makers more aware of the health and cohesion, preventing segregation, promoting effects of travel choices. 12 National Healthy Cities networks in Europe Zoë Heritage & Leah Janss Lafond

Key message 1 Of the 25 active national Healthy Cities networks in Europe, most significantly influence public health policy at the city, regional and national levels. 24 Key message 2 National networks are now better organized than before, with clear strategies and annual plans. More than 70% now have a formal strategy document.

Context Fig. 12.2. Number of cities in selected national new public health Healthy Cities networks in Europe, 2003–2008 evidence, representing Interest in the concept cities at the national Healthy cities and practice of Healthy City 1000–1300 cities level and expanding Cities extended far knowledge about the beyond the 11 pilot principles of healthy

cities joining Phase I of National Healthy Cities networks cities. Country the WHO European 25 countries (+7 inactive) Healthy Cities Network Phase IV in 1988. National networks were initi- WHO European Healthy Network of European At the end of Phase IV, Europe Cities Network National Healthy Cities ated to encourage there are 25 active (79 cities in Phase IV) Networks wider city participation national networks; and, within a year, had linked together 200 cities in 6 another 7 are inactive or in the process of reorganizing European countries. In 2000, WHO and network coordi- (Fig. 12.1).They vary greatly. Some are long established; nators agreed on common membership criteria for others (Bosnia and Herzegovina and Cyprus) are less national networks. By 2003, national networks repre- than 10 years old. A few have a full-time coordinator sented more than 1000 cities in 29 countries (1) under (Czech Republic, Norway and Slovenia), but most do the umbrella of the Network of European National not. WHO has accredited 20 national networks that Healthy Cities Networks. have met the agreed membership criteria.

Purpose Developing capacity

National networks were initiated to help cities Successful networks develop in three stages: facilitating exchange information and experience and to create exchange between city members, concerted action and more favourable conditions for implementing healthy joint production (2). Every active national network has city strategies. Common aims include enabling access to achieved the first stage, and at least half have reached City leadership for health the highest level in which cities jointly organize training future of the regions. Croatia’s network has been events and produce common strategies. responsible for a training programme in 18 (of 20) counties to improve public health capacity. These achievements require considerable organization, with formal structures for decision-making by an National effects assembly of network members and a secretariat based in a member city or national institution. Technical and More than two thirds of national networks have estab- 25 financial resources are crit- lished partnerships with the Fig. 12.2. Number of cities in selected national ical: two thirds have national government and Healthy Cities networks in Europe, 2003–2008 membership fees, although exert powerful influence by 140 Italy Spain the most successful disseminating evidence on networks, such as the 120 determinants of health and Czech Republic’s network, core themes. Most work 100 have external funding. with health ministries. s e

i Czech Republic t National networks are i Spain’s network helped c

80 f o

becoming better organ- r Israel design and implement the e

b France ized, with 70% producing m 60 Russian Federation Strategy for Nutrition, u Croatia N formal strategies and Turkey Physical Activity and Poland annual plans. 40 Denmark Prevention of Obesity. Slovenia Hungary Portugal’s network helped 20 Portugal Kazakhstan Norway Sweden Finland draft the National Health Impact in cities Belgium Cyprus 0 Plan 2004–2010, and A core function is to 2003 2004 2005 2006 2007 2008 Slovenia’s network prog- Year increase awareness of the ramme was adopted as part social determinants of health among city actors, of the National Public Health Plan (2003–2010). supporting them to produce integrated health profiles and implement city health development plans. National European level networks are key vehicles for disseminating new public health evidence, especially around the core themes of More national networks report projects or partnerships Phase IV. They provide training, support health promo- with international organizations, mainly funded by the tion events and guide cities towards more strategic European Union on topics such as active living, urban interventions. One marker of achievement is an increase health indicators, profiles, HIV and mental health. in cities per network (Fig. 12.2). HEPRO (focus on health and social well-being in the Baltic Sea region) is the largest collaborative project, Regional effects involving 32 partners in 8 countries including the national networks of Denmark, Norway and Poland. National networks influence decision-making at the However, to achieve its full potential, the Network of regional level. Norway’s network injected a public European National Healthy Cities Networks needs extra health dimension into a 2007 government report on the support from WHO in training and information sharing. References

Chapter 1. Introduction 4. Zamaro G, ed. Udine: il profilo di salute della popolazione anziana [Udine: healthy ageing profile]. Udine, City of 1. Commission on Social Determinants of Health. Closing the Udine, 2008. gap in a generation. Health equity through action on the 26 social determinants of health. Geneva, World Health Organization, 2008 (http://whqlibdoc.who.int/hq/2008/ Chapter 5. Healthy city development plans WHO_IER_CSDH_08.1_eng.pdf, accessed 6 October 2008). 1. A working tool on city health development planning: concept, process, structure and content. Copenhagen, WHO Chapter 2. Assessing the impact of Healthy Cities Regional Office for Europe, 2001 (http://www.euro.who.int/ healthy-cities/UHT/20050201_1, accessed 6 October 2008). 1. Commission on Social Determinants of Health. Closing the gap in a generation. Health equity through action on the 2. Green G et al. City health development planning. Health social determinants of health. Geneva, World Health Promotion International (in press). Organization, 2008 (http://whqlibdoc.who.int/hq/2008/ WHO_IER_CSDH_08.1_eng.pdf, accessed 6 October 2008). Chapter 6. Active participation by and 2. Draper R et al. WHO Healthy Cities project: review of the empowerment of communities first 5 years (1987–1992). A working tool and a reference 1. Ottawa Charter for Health Promotion. Geneva, World Health framework for evaluating the project. Copenhagen, WHO Organization, 1986 (http://www.who.int/healthpromotion/ Regional Office for Europe, 1993. conferences/previous/ottawa/en, accessed 6 October 2008). 2. Robertson A, Minkler M. New health promotion movement: Chapter 3. Partnerships a critical examination. Health Education Quarterly, 1994, 1. Targets for Health for All: targets in support of the 21:295–312. European regional strategy for health for all. Copenhagen, 3. Tsouros A. Healthy cities mean community action. Health WHO Regional Office for Europe, 1985. Promotion International, 1990; 5:177-178. 2. City health planning: the framework. Copenhagen, WHO 4. Arnstein S. Eight rungs on the ladder of citizen participation. Regional Office for Europe, 1996. Journal of the Institute of American Planners, 1969, 35:216–224. Chapter 4. Healthy city profiles 5. Davidson S. Spinning the wheel of participation. Planning, 1. City health profiles – how to report on health in your city. 1998, 1262:14–15. Copenhagen, WHO Regional Office for Europe, 1995 (http://www.euro.who.int/document/wa38094ci.pdf, Chapter 7. Equity and determinants of health accessed 6 October 2008). 1. Global strategy for Health for All by the year 2000. Geneva, 2. Webster P. Review of the “city health profiles” produced by World Health Organization, 1981 (“Health for All” Series, WHO healthy cities – do they present information on health No. 3; http://whqlibdoc.who.int/publications/ and its determinants and what are their perceived benefits? 9241800038.pdf, accessed 6 October 2008). Journal of Epidemiology and Community Health, 1999, 53:125–127. 2. Whitehead M. The concepts and principles of equity and health. Copenhagen, WHO Regional Office for Europe, 1990 3. Webster P, Lipp A. The evolution of the WHO city health (EUR/ICP/RPD 414). profiles: a content review of WHO healthy city profiles. Health Promotion International (in press). City leadership for health

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Chapter 10. Healthy urban planning in European cities 1. Barton H, Tsourou C. Healthy urban planning: a WHO guide to planning for people. London, Spon Press, 2000. 2. Barton H, Grant M, Guise R. Shaping neighbourhoods for health, sustainability and vitality. London, Spon Press, 2003. The WHO Regional Office for Europe

The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international City leadership for health health matters and public health. Summary evaluation of Phase IV of the The WHO Regional Office for Europe is one of six regional WHO European Healthy Cities Network offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. The report is a summary evaluation of Phase IV of the WHO European Healthy

Member States Cities Network. It reviews the organization of healthy cities, their enduring values

Albania and the core themes of health impact assessment, healthy ageing, healthy urban Andorra Armenia planning and active living. There are 23 key messages for city decision-makers and Austria Azerbaijan the international public health community. Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan The former Yugoslav Republic of Macedonia World Health Organization Turkey Regional Office for Europe Turkmenistan Ukraine United Kingdom Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark Uzbekistan Tel.: +45 39 17 17 17. Fax: +45 39 17 18 18. E-mail: [email protected]

ISBN 978 92 890 4287 1 Web site: www.euro.who.int