A nine-year investment

World Health • 49th Year, No. 1, Jonuory-Februory 1996 7 A nine·year investment Agis D. Tsouros H ealthy Cities is about changing the ways in which individuals, communities, private and voluntary organizations and local governments think about, understand and make decisions about health. Firstly, it calls for recognition that a city can play a key role in promoting and maintaining the health of its citizens and, secondly, that it has a unique capacity to mobilize action for sustainable development. Ultimately, it is about enhancing the physical, mental, social and environ- mental well-being of the people who live and work in the cities. Over the past nine years, WHO's Healthy Cities Project has developed into a major public health movement at local level, involving networks of over 550 cities throughout Europe. The Healthy Cities Project has brought Health for All to the cities and streets of Europe through a non-health-services door. Making health every sector's business is probably the most significant achievement of this project. World Health Day, 7 April1996, will mark the culmination of nine years of major innovative endeavours for public health at city level in Europe. The WHO Regional Office for Europe (EURO) has played a pio- neering role and has made a consid- erable investment in promoting the Healthy Cities approach throughout Europe. To do this, it created an interdepartmental project (a partner- ship between departments responsi- ble for lifestyles, health and environmental health) designed to involve city administrations and commit them to actively developing and putting into effect Healthy Cities policies and programmes. The project thus became one of EURO's main vehicles for giving effect to the strategy for Health for All. The project strives to realize the vision of a healthy, city by: - securing political commitment (to provide the necessary legit- imization, direction and resources for the project); - giving visibility to health (to City partners sharing their experiences and sustaining their commitment to the WHO Healthy Cities Project. 8 promote wide appreciation and recognition of the major health issues and the factors influencing them); - making institutional changes (to encourage and establish intersec- toral collaboration, modernize public health structures and processes, and promote the active involvement of the community); - and taking innovative steps to improve health and the environ- ment (to promote equity, ecologi- cal management, sustainable development and healthy munici- pal policies). The project has four main opera- tional elements: the WHO project cities network; national and sub- national Healthy Cities networks; multi-city action plans; and special (model) projects in cities of central and eastern Europe. WHO project cities Up to October 1995, 34 cities had been designated to the WHO project cities network: Amadora, Athens, Bialystok, Bologna, the London Borough of Camden, Copenhagen, Dresden, Dublin, Eindhoven, Frankfurt, Geneva, Glasgow, Gothenburg, Gyor, Horsens, Jerusalem, Kaunas, Kosice, Liege, Liverpool, Lodz, Maribor, Mechelen, Nancy, Padua, Pecs, Poznan, Rennes, Rotterdam, Sadnes, Sumperk, Torun, Turku and Vienna. All these cities are committed to the establishment of project infrastructures and processes, the development of healthy public policies and city health plans, systematic monitoring, evaluation and analysis of experi- ence, and the dissemination of good practices. Project cities are "field laboratories" for testing and develop- ing health-for-all initiatives at local level. The first phase, from 1987 to 1992, emphasized advocacy and, by tackling the political and institutional barriers to change, laid the founda- tions for successful work towards Health for All. The strategic objectives for the second phase (1993-98) include speeding up the adoption of policy at city level, strengthening national and subnational support systems, and building strategic links with other sectors and organizations that have a major influence on urban develop- ment. Comprehensive city health plans are setting explicit targets and tackling issues such as equity and sustainable development while establishing mechanisms to promote accountability for health. The 1995 "Healthy and Ecological Cities" Conference in Madrid (organized by WHO and the Organization for Economic Cooperation and Development) produced an impres- sive number of reports on local initiatives- from insulating tower blocks in Sheffield (UK) to restoring a deprived area of Barcelona (Spain), from transforming Krakow's envi- ronment (Poland, with its legacy of pollution from the communist era) to working towards "child-friendly" cities in Italy. Networking National networks started to develop spontaneously as a result of the widespread interest among cities throughout Europe in being actively involved in the Healthy Cities Programme. National networks have been established in many countries, and there are several subnational World Health • 49th Year, No. 1, Jonuary-Februmy 1996 networks involving smaller cities and towns. The countries of central and eastern Europe are receiving special attention in this context. Multi-city action The Multi-City Action Plans bring together groups of cities to work on issues of common concern. There are now 13 such plans, focusing on accidents, AIDS, alcohol, environ- mental issues in Baltic cities, dia- betes, drugs, people with disabilities, health-promoting hospitals, nutri- tion, sports, tobacco-free cities, urban primary health care, and women's health. Special projects In central and eastern Europe, spe- cial projects include initiatives in the fields of health, environmental reform, democratic processes and resource mobilization; they are based on intercity cooperation and a spirit of solidarity with cities most in need. One example of this is the St Petersburg special project, which focuses on care services for mothers and babies. The project has built up a body of know-how and practical knowledge that can be used to de- velop health-for-all policies and programmes, based on intersectoral cooperation and community action. World Health • 49th Year, No. 1, Jonuory-Februory 1996 Sharing information EURO has produced a highly suc- cessful series of publications on the theory, practice and evaluation of the Healthy Cities project in Europe. These include two overall reviews of project developments; the booklet, 20 steps for developing a healthy cities project, which has been trans- lated into 22 languages; a compara- tive analysis of health, environmen- tal and social indicators from 47 cities across Europe; and guidelines for producing city health profiles and health plans. 11What' s in it for you?" Healthy Cities has had a profound impact on EURO's approach to innovation, project development and networking, and has brought Health for All to the cities and streets of Europe through a non-health-ser- vices door. Making health every sector's business is probably the most significant achievement of this project. When WHO project cities were asked "What's in the project for you?" their answers included the following. • The Healthy Cities Project has given us a voice in Europe and legitimization and courage to carry on. • It has given us contacts and access to information and to a wealth of experiences. • It has created a basis on which to build solidarity with other cities. • It has made us think less provin- cially and more about what is really important. • It has given us the WHO label of quality, which has helped to mobilize local support for initia- tives that had been at the periph- ery of our policy focus, such as dealing with inequalities. Our experience has Jet us to arrive at the following six conclusions. • Projects are an important means of achieving change, serving as vehicles for strategic growth, and 9 Healthy Schools - part of the Healthy City Project of Dresden, Germany. An exhibition helps to giVe children a better understanding of environmental issues. powerful tools to deal with change, uncertainty and the building of alliances. • No single recipe can be drawn up for every city. • Project ownership is crucial; health is not a party political issue, nor can the project be the exclusive territory of one party or city department. • The project needs a sustainable commitment to a long-term process which can truly bring health considerations and healthy public policy into the mainstream of municipal decision-making. • Health should be regarded as an investment and not as an expen- diture. • The project was not implemented in a closed system, but was shaped locally through the com- mitment, persistence and creativ- ity of cities; its diversity gives it strength. As we approach the dawn of "the urban millennium", when for the first time the majority of the human species will live in towns and cities, we have a desperate global need for the innovation and the networking that are characteristic of the Healthy Cities network. • Or Agis D. Tsauros is the Healthy Cities proiect Caordmator at the WHO Regional Office for Europe, 8 Scherfigsvej, 2 100 Copenhagen 0, Denmark.