Healthy Urbanization Regional Framework for Scaling Up and Expanding Healthy Cities in the Western Pacific 2011 – 2015
Healthy Urbanization Regional Framework for Scaling Up and Expanding Healthy Cities in the Western Pacific 2011 – 2015
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WHO Library Cataloguing in Publication Data Healthy urbanization: regional framework for scaling up and expanding healthy cities in the Western Pacific 2011-2015 1. Urban health. 2. Urban health services–organization and administration. 3. City planning. ISBN 978 92 9061 533 0 (NLM Classification: WA380)
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Table of Contents a. Message from the Regional Director b. Purpose of the Regional Framework Section 1: Rationale for Healthy Urbanization v vi
Urbanization Trends and Impact Healthy Urbanization towards equal and optimum population health Healthy Cities as a pathway to healthy urbanization Scaling up and expanding the Healthy Cities approach
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Section 2: Regional Framework for Scaling Up and Expanding Healthy Cities in the Western Pacific Region Logical framework for scaling up and expanding Healthy Cities Strategic approaches and key action areas Immediate steps to implement the Regional Framework 13 14 17
Section 3: References and Other Resources
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Acknowledgements The Regional Framework for Scaling Up and Expanding Healthy Cities in the Western Pacific (2011–2015) is the product of intensive development, discussion and consultation with Member States and experts in the WHO Western Pacific Region. Review of the draft Framework was conducted during the meeting of the Working Group on Scaling Up and Expanding Healthy Cities in the Western Pacific Region held 16–17 November 2009 in Manila, Philippines. The Framework was further reviewed for finalization during the Meeting of National Focal Points on Scaling Up and Expanding Healthy Cities in the Western Pacific Region convened 8–10 September 2010 in Dalian, China, as well as during the Meeting for Developing Technical Networks and Resource Centres for Healthy Cities convened 26 October 2010 in Gangnam-gu, Seoul, Republic of Korea. In this regard, we recognize the outstanding contributions of the temporary advisers, resource persons, participants and the secretariat of the three meetings.
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Message from the Regional Director Throughout the world we are witnessing a period of rapid and unprecedented urbanization. The Western Pacific Region is home to roughly 30% of the world’s population, more than half of which live in cities. We are faced with enormous challenges trying to make the Region’s cities liveable, healthy and safe. The rate of urbanization predicted for Asia exceeds that of other Regions and our task will become increasingly difficult if we do not act now.
Where we live, study, work and play dramatically impacts our health. Yet for the most part, the health sector has little influence or power to change these things. So here lies the great health sector paradox of the 21st century: we, in the health sector, can treat the sick, but we struggle to keep people healthy. The power to keep people healthy lies, for the most part, outside the health sector. It lies with the whole of government, with national and local government leaders who are responsible for education, for transport, for food and nutrition, for housing, for sanitation, for planning our urban environment, for addressing all the factors that shape urban life and the well-being of individuals, families and communities. The WHO Healthy City Programme, which has existed for more than two decades, was initiated in order to address the issues that can make us sick in our cities, townships and villages. The problems are now becoming more and more global in nature – the causes lie beyond the scope of local governments’ actions. Now more than ever, cities need all the support they can get to work towards well-planned, controlled and healthy urbanization.
It is timely to scale up and expand Healthy Cities in the Region – also with the support of national governments. National governments need to be committed to mobilizing and providing the resources to local governments to address the wicked problems of urbanization. The main target group for this Regional Framework, therefore, includes representatives from the national level. This Framework suggests key action areas specifically for countries and for WHO to support scaling up and expanding Healthy Cities in the Region in order to drive healthy urbanization As the Director-General of WHO, Dr Margaret Chan said, “Cities are the future of our world. We must act now to ensure that they become healthy places for all people”. We in the Western Pacific Region are committed to contributing to this goal.
Shin Young-soo, MD, Ph.D. Regional Director
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Purpose of the Regional Framework This Regional Framework provides a reference point for action primarily for national governments and for WHO as to how they can support scaling up and expanding Healthy Cities within their countries and the Region. The Framework should not be regarded as prescriptive for all situations. It suggests five strategic approaches and recommends key action areas under each of the approaches. These key action areas provide guidance on activities that are considered critical in scaling up and expanding Healthy Cities. They should be considered depending on the countries’ commitment, ability and capacity to scale up and expand action towards healthy urbanization and on the past experience in Healthy Cities – or other initiatives related to healthy urbanization. “Healthy urbanization” is defined as the process of “enabling people to gain greater control over their health and their determinants through good urban governance that creates equal social opportunities for health for all”. Reflecting this definition, the hard work of achieving healthy urbanization lies with the local governments – and with their citizens. This Framework does not suggest that a top-down approach to Healthy Cities will solve the wicked urban problems. Rather, it calls for a systems-wide approach that expands the original concept of Healthy Cities beyond the boundaries of local governments and promotes the need for a strong stewardship role of the national government. As suggested in the final report published by the Knowledge Network on Urban Settings of the WHO Commission on Social Determinants of Health, “National government institutions need to equip local government institutions with the mandate, powers, jurisdiction, responsibilities, resources and capacities to undertake ‘healthy urban governance’”.
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Section 1: Rationale for Healthy Urbanization Urbanization trends and impacts More than half of the world’s population lives in urban areas. By 2030, six of ten people will live in cities, rising to seven of ten in 2050. The demographic shift from rural to urban living is occurring most rapidly in lower income countries, and virtually all population growth will be in urban areas over the next 30 years. The Western Pacific Region of WHO is home to about one third of the world’s population, of which nearly half reside in urban areas.1 We have entered an urban age. the demand for labour. If local authorities do not have the capacity to manage this influx of people, this will result in increased disparities and expansion of slum areas in the cities.3
In addition to the challenges brought on by increased migration, the ageing of urban populations is becoming an increasing concern. This is especially the case in less-developed regions, where the number of older people is growing more rapidly.4 Cities must be able to meet the increasing demand for chronic disease Urbanization can, and should, be beneficial for health care, long-term care and social services. health.2 Economic and industrial development Poorly managed urban settings can lead to accelerate urbanization, creating opportunities increased exposure to unhealthy and risky for better housing and living conditions, conditions. The lack of good (and sustainable) access to safe water and good sanitation, transport systems, for example, contributes to efficient waste management systems, more highly motorized societies, road traffic-related employment opportunities and access to health injuries, physical inactivity and social isolation. and community services and recreational facilities, to name just a few potential benefits Given the urbanization trend in the Western of urbanization. Pacific Region and the growing understanding of the interrelationship between urbanization But unplanned and uncontrolled urbanization and health, the environment and social equity, that occurs too rapidly can strain services, it is timely to consider how to support the damage the environment and health and achievement of healthy urbanization in exacerbate poverty and inequality.2 Although the Region. rural-to-urban migration occurs because people are drawn to better opportunities in cities, local services and amenities may come under severe strain. Migrants tend to find employment in the informal sector, joining an already large segment of the market; and the rate of migration to urban centres may exceed
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Healthy urbanization towards equal and optimum population health
Healthy urbanization is the process of enabling people to gain greater control over their health and their determinants through good urban governance that creates equal social opportunities for health for all.5 It is a coordinated series of health promoting, policy-related activities informed by evidence and research. Healthy urbanization also may be defined as a process of conscious and judicious coordination of urban management practices which can produce health benefits, strengthen social solidarity and ensure efficient and sustainable ways of meeting basic needs of community life. The focus of healthy urbanization is on well-being – of individuals, families, communities and the environment. The protection and promotion of health and quality of life go hand in hand with well-planned and well-managed urbanization. Healthy urbanization, therefore, is a course of action towards the attainment of optimum and equal population health and development.
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Key domains for achieving healthy urbanization
The course of action that makes a difference in the lives of people in urban settings has been identified by the WHO Centre for Health Development2 along eight key domains that are critical in achieving healthy urbanization, as follows:
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Empowerment of individuals and communities Individual empowerment refers to the individual’s ability to make decisions and to have control over his or her life. Community empowerment, which is an important goal in community action for health, involves individuals acting collectively to gain greater influence and control over the determinants of their health and the quality of life in their community.
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Engagement of all sectors Engagement of all sectors leads to greater awareness of the health impact of policy decisions and organizational practices in different sectors and, |through this, facilitates healthy public policy and practice.
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Environmental sustainability Environmental sustainability is defined as meeting human needs without undermining the capacity of the environment to provide for those needs and to support life over the long term.
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Energy efficiency Energy efficiency is a prime method by which a city can work towards environmental sustainability, given that energy derived from nonrenewable sources is by definition unsustainable. An energy-efficient city benefits from policies that enable community and industry to maintain standards of living with lower energy intensity.
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Equity-based health system An equity-based health system includes universal access to basic health care services, information and better quality of care.
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Elimination of extreme urban poverty This means ensuring that no one lives in the most severe state of poverty in which they have limited access to basic necessities such as food, clothing, shelter, education and health care. Extreme poverty is defined as living on US$ 1 or less per day (in an extremely poor country).
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Expression of cultural diversity and spiritual values People are free to exercise their human rights and to express their cultural as well as spiritual values.
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Enforcement of safety and security Policies for human security, emergency preparedness and community and workplace safety are formulated and enforced at all levels, particularly at the municipal, community and household levels.
A sustained combination of processes that are geared to the principles of health promotion, such as: 1 visionary leadership and good governance at the city or municipal level; 2 strong intersectoral cooperation at the programmatic level; and 3 active people’s participation and empowerment at the community level are fundamental to healthy urbanization. These processes are central to the development of Healthy Cities, a WHO programme that began in the 1980s and was built on “the time-honored idea that living and environmental conditions are responsible for health”. 6
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Healthy Cities as a pathway to healthy urbanization
Historical perspective and development of Healthy Cities
The Toronto Healthy Cities Project, operational since the early 1980s, and the work by Duhl and colleagues 7, 8, inspired the development of WHO’s Healthy City Programme. Motivated further by the Ottawa Charter on Health Promotion to create supportive environments, strengthen community actions, develop personal skills, reorient health services and build healthy public policies to promote population health, the Healthy Cities movement has gained an international foothold since its inception in 1986. By World Health Day 1996, which adopted the theme “Healthy Cities for a Better Life”, some 3000 cities worldwide had in some way or another linked to the international Healthy Cities network.9 By 2000, a little more than 4000 cities were counted. It is estimated that during the last 20 years, the Healthy Cities approach has been instrumental in the formulation of up to 10 000 initiatives worldwide. In the Western Pacific Region, the establishment and rapid spread of the healthy cities movement coincided with intensified discussions on urban health and the environment and with the worldwide growth of environmental concerns in the mid-1980s. The development of Healthy Cities in the Region can be categorized into three stages. The initiation stage (Stage 1) started in 1987 with pilot projects in Australia, Japan and New Zealand. After a series of regional consultations, China, Malaysia and Viet Nam soon initiated their own Healthy Cities projects. This was followed by the expansion and standardization stage (Stage 2) with the spread of Healthy Cities to countries such as Cambodia, the Lao People’s Democratic Republic, Mongolia, the Philippines and the Republic of Korea.
The Regional Guidelines for Developing a Healthy Cities Project in 200010 was worked out specifically to support local governments. The establishment of the Alliance for Healthy Cities in 2003 led to a more standardized approach to healthy cities. The adoption of the Alliance Charter in 2004 and the conduct of biennial general assemblies and regular training courses and research by the Alliance for Healthy Cities provided the momentum for the institutionalization stage (Stage 3). In March 2005, WHO set up the Commission on Social Determinants of Health (CSDH), a global network of policy-makers, researchers and civil society groups brought together to tackle the social causes of poor health and health inequities and to gather evidence about what can be done to achieve better and more equally distributed health worldwide. The commission recognized the importance of the urban setting as a social determinant of health by forming the Knowledge Network on Urban Settings2, which recommended a broad spectrum of interventions that include, among others, healthy settings as vehicles for healthy urbanization. In October 2010, the 61st WHO Regional Committee Meeting for the Western Pacific adopted a resolution on healthy settings urging Member States to advocate Healthy Cities and Healthy Islands as a multisectoral development agenda. It was intended to support the creation of technical networks and designate national focal points and to establish mechanisms to share information and experiences and recognize best practices on Healthy Cities and Healthy Islands.
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In the course of its development from the initiation stage to the institutionalization stage, and through the recognition of its importance by the WHO Commission on Social Determinants of Health and the WHO Regional Committee for the Western Pacific, there has been significant growth in the adoption of the Healthy Cities approach across the Region by way of different applications of the concept – healthy cities, healthy islands, healthy communities and healthy villages. These meso or contextual level initiatives often have been accompanied by the adoption of a healthy settings approach at the micro level (or elemental level) through health-promoting schools, healthy workplaces, healthy hospitals and healthy markets initiatives. Generally, these efforts seek to improve the quality of life by addressing the social, economic, environmental and governance conditions that affect health and equity. Local action has been generated through intersectoral collaboration and community involvement. The synergistic relationship between contextual and elemental settings approaches operating at multiple levels and at multiple sites contributes to realizing healthy urbanization.
Conceptual framework of the Healthy City model
A Healthy City constantly creates and improves those physical and social environments and expands those community resources which enable people to mutually support each other in performing all the functions of life and in developing their maximum potential.8 Cities are places where health and illness are related to the proximity and conditions in which people live and work. At the same time, they are also governance structures, which have key roles and opportunities in protecting and promoting the health and environment of the population. The term “Healthy Cities” is used generically in recognition of the concept being applicable to a range of forms and administrative structures for human settlements, including townships and villages. Through the years, programmes and projects dealing with a broad spectrum of interventions, such as building social cohesion, improving environments, generating jobs and better employment, accessible health care, safe communities, urban planning and good urban governance, have been instituted to improve existing conditions and create more livable communities with varying levels of success. There is a need to recognize that the challenges of maintaining, promoting and improving health in the urban age are becoming more complex and global in nature and that, therefore, the old fragmented approach is no longer viable.
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There are, of course key success factors that are characteristic of Healthy Cities, including municipal leadership (reflected in a city’s political commitment) and organizational structures for managing and advocating for change (through Healthy City teams, intersectoral committees, etc.) It is now important to place even more focus on urban governance and to ensure that cities have the capabilities needed to be responsive to the health and equity challenges in urban settings. Further, skills and know-how to negotiate with the private and not-for-profit sector and to establish new forms of partnerships are essential to take on the issues affecting our health and the environment. A holistic and mainstreamed approach, supported by all levels of government, which can address the environmental, social, economic, health and human development concerns of cities in an integrated manner, has become indispensable. The original intersectoral nature of Healthy Cities remains essential and results in cobenefits for different sectors, as can be illustrated through Hancock’s (1993) model of health and the community ecosystem, as shown in Figure 1, below. In this model, the central focus is human health and development. Three essential characteristics should be present for the community, the environment and the economy if human health and development is to be optimized.
The community needs to be convivial, with its members living harmoniously together, building social support systems and participating fully in the life of the community. The built environment needs to be livable, designed to maintain cordial relationships and to sustain a viable human presence. The community also needs to be equitable, where members are treated with fairness and justice, their basic needs are met and equal opportunity exists for all. The economy needs to be adequately prosperous, generating enough wealth to enable all of its members to achieve a satisfactory level of health. This economic wealth must be socially equitable, with wealth distributed fairly within the community. The economy also must be environmentally sustainable so that economic activity does not deplete renewable resources by using them beyond a sustainable level. The environment must be viable for humans, which requires a suitable range of temperature and solar radiation, clean air and water and plants and animals to provide food. The environment must be sustainable over the long term so that the great web of life in all its richness and diversity is maintained. The environment must be livable, considered not only in terms of the natural environment but the built environment.
COMMUNITY Livable Convivial
ENVIRONMENT
Viable
HEALTH Figure 1 Healthy Cities Model (Source: Hancock, 1993)11
Equitable
Sustainable
Adequately Properous
ECONOMY
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How intersectoral work can result in co-benefits for different sectors may be demonstrated by showing the results of action on environmentally sustainable and healthy urban transportation systems, which could include, for example, strengthening the infrastructure for and safety of nonmotorized transport or maintaining and/or increasing the share of public transport. 12 By coordinating efforts at the city and settings levels to enhance urban infrastructure and services, improve health and social programmes and support empowerment of individuals and communities, a scaled-up approach to Healthy Cities has the potential to make a positive impact on the major determinants of health and priorities of populations and contribute to closing the equity gap.
Given the increasingly global forces that shape the economy, lifestyles and environments of cities, it is becoming more important to consider how a regional and national agenda for healthy urbanization can be coordinated with more localized developments. National government institutions need to equip local government institutions with the mandate, powers, jurisdiction, responsibilities, resources and capacity to undertake ‘healthy urban governance’. 2 To drive healthy urbanization, it is timely to revisit the achievements of the work on Healthy Cities in the Region and, drawing on local, national, regional and global lessons, consider how to scale up and expand these efforts in a way that can truly make a measurable difference to the health and well-being of populations in the Region.
Economic benefits Congestion reduction, consumer spending savings, employment creation, small and medium sized enterprise development, traffic accident reduction, technology transfer, reduced dependence on imports/energy security, economic productivity/efficiency improvements
Environmental benefits Noise reduction, water contamination reduction, volatile organic compounds reduction, greenhouse gas reductions, particulate matter reduction, sulphur oxides reduction, nitrogen oxides reduction, carbon monoxide reduction, solid waste reduction
CO-BENEFITS
Social benefits Health improvements (obesity reduction, fitness, etc.) crime reduction/security enhancement, gender equity promotion, universal access for persons with disabilities, scholar access improvement, community sociability, reduction in community severance
Figure 2 Win-win solutions to climate change and transport (Source: Adapted from UNCRD, 2009) 13
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Scaling up and expanding the Healthy Cities approach
Meaning of scaling up and expanding Healthy Cities
The pace and extent of urbanization in the Region calls for scaling up and expanding the Healthy Cities approach so that it has maximum impact over the medium to longer term. Aside from current problems of water and sanitation, occupational health and safety, injury, mental health, communicable and noncommunicable diseases and access to health services, newer (increasingly wicked) urban challenges have emerged affecting health, including emerging diseases, population ageing and job insecurity along with the looming crises of climate change and growing inequities. The 2008 global financial crisis also has revealed the extent to which economic globalization provides an important context for the growth and management of cities. These factors demand more coordinated action from all sectors to work on more health and health-related issues and to involve more partners. It requires greater support through national policies and strong and efficient coordination between national and local policies.
WHO actively has supported the expansion of Healthy Cities following its initial development as pilot projects across the Western Pacific Region. More recent efforts by WHO supported the development of regional and national networks of Healthy Cities (e.g. the Alliance for Healthy Cities). Such networks are vital mechanisms that support and promote the work of Healthy Cities and, of course, for sharing experiences and lessons learnt. While these networks are also important in legitimizing the Healthy Cities approach at a political level, there is a need to ensure that the experiences are evaluated appropriately and lessons are well disseminated so that continued growth of Healthy Cities is built on technical rigor and innovation. The current plan is therefore concerned with achieving sustainable outcomes through scaling up and expanding Healthy Cities in consideration of the countries’ experience, abilities and capabilities and spreading the Healthy Cities approach across the Region with increased national and regional level support.
Figure 3 Areas for scaling up and expanding Healthy Cities
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Scaling up and expanding in this context refers to the following:
up and expanding in terms of 2 Scaling moving from a programmatic approach to an institutionalized approach. Institutionalization of Healthy Cities should draw on the lessons from current practices and consider how to adopt the approach as an integral part of urban management so that the approach becomes embedded in existing processes, programmes and systems. A system-wide approach to institutionalize Healthy Cities will need a stronger stewardship role of the national government and the development of mechanisms and processes for building capacity on health impact assessment and integrating health in all policies. A national policy direction and action plan can be a vehicle to bring system-wide embedding of the Healthy Cities approach across the country. This can occur through at least two mechanisms: a vertical push in which the national government promotes the expansion of Healthy Cities through appropriate policy and administrative levers and a horizontal push in which Healthy Cities are advanced through sister city relations, city-to-city networks and other intercity-based projects supported by the national government. The role of the national ministry of health in advocating for Healthy Cities is crucial to its institutionalization, legitimization and development.
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Scaling up and expanding in terms of increasing overall physical coverage. Within a country means increasing the number of cities that are adopting the Healthy Cities approach. This can be motivated and driven from the national level through a top-down push supported by policy direction and resource mobilization. Through increased national government support, the goal is to achieve the following within cities: a increased equitable population coverage within Healthy Cities interventions; b increased number of settings; c increased number of partners engaged in intersectoral actions; and d increased priority areas of work. Within the Western Pacific Region means increasing the number of countries that are implementing the Healthy Cities approach. This can be driven by WHO and other international development partners through technical assistance, capacity-building and resource mobilization to support national governments in creating conducive environments for Healthy Cities to flourish.
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up and expanding in terms of 3 Scaling continuous quality improvement to achieve more depth, rigor and innovation. Emphasis on continuous quality improvement (CQI) as a platform for supporting technical work on Healthy Cities will strengthen the impact of the approach. To make cities more sustainable, there needs to be more rigor and innovation; more learning through monitoring and evaluation; more comprehensive and larger-scale intersectoral action; greater engagement of professionals across disciplinary boundaries and development of transdisciplinary teams; more emphasis on community empowerment; a more strategic approach to address present and
future key public health issues; greater focus on equity and social determinants of health; and greater focus on effective and efficient use of resources. CQI could drive a process of improving existing infrastructure, then developing capacity and then enhancing performance. Thus, if the aim is to achieve more depth, rigor and innovation into the interventions, and ultimately the institutionalization of Healthy Cities activities, then there needs to be more evaluation and benchmarking across countries, more action research to support CQI and more diffusion of innovation.
Figure 4 Continuous Quality Improvement, CQI Continuous quality improvement (CQI) is derived from management theory and is the process of continually planning, reflecting and evaluating for constant quality improvement. Features of CQI are similar across sectors and include (adapted from McLaughlin and Kaluzny, 2004)14 : 1 2 3 4 5 6 7 understanding and adapting to external environments empowering stakeholders to analyse and improve process adopting a norm that the community and consumers are the primary determinants of quality developing a multisectoral approach which goes beyond traditional boundaries adopting a planned and articulated philosophy of continuing change and adaption setting up a mechanism to ensure implementation of best practices providing the motivation for effective process analysis and change
CQI is historically focused on organizational settings. However, with a view to bringing about healthy urbanization and a systems approach, this focus should extend to the intervention levels of systems, programmes and projects and be applied to national, local, organizational and individual structures. The diagram below illustrates how CQI could drive a process of improving existing infrastructure then developing capacity and then enhancing performance.
Improving Infrastructure
P lan P
Do D
A ct A
S tudy S
Developing Capacity
P lan P
Do D
A ct A
S tudy S
Enchancing Performance
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Key areas to consider in scaling up and expanding Healthy Cities
and projects in place within 2 programmes meso or contextual settings such as cities, townships, villages or islands. Here the priority work areas cut across sectors and the engagement of stakeholders must be multisectoral, requiring involvement of players outside the health sector such as public works, transport, housing, peace and order, labour and employment and economic sectors, to name just a few. Strong municipal leadership, stable partnerships and strong coordination mechanisms at the local level are essential requirements during this phase. system-wide approach is already being 3a pursued at a local level and where Healthy Cities are expanding from a programmatic to an institutionalized approach, tapping onto the clear mandate and considerable authority of local governments to protect and promote the health of their citizens. Emphasis is on the stewardship role of the local government. Critical policy domains should be considered such as environment and physical infrastructure, social and human development, economics and employment and governance and people’s participation, among others. Emphasis is also on the development of mechanisms and processes for continuous quality improvement (CQI), health impact assessment (HIA) and integration of health in all policies (HiAP) at local levels. system-wide approach is expanding 4a beyond the boundaries of local governments and where strong emphasis is being placed on the stewardship role of the national government, the establishment of networks and the development of mechanisms and process for CQI, HIA and HiAP at the national level. National government support is crucial in a system-wide approach that cuts across multiple sectors and policy domains and several levels of governance.
In developing the plans, programmes and strategies for scaling up and expanding Healthy Cities, it is crucial that countries or cities assess their current situation and capacities on the following key areas: 1 2 3 4 5 6 leadership and political commitment at national and local levels governance structures and institutional arrangements strategic policy thrusts and key areas for action human resources financial resources management support systems and processes
Assessment of these six key areas will determine the scope and magnitude of capacity-building and resource requirements necessary to institute, scale up or expand Healthy Cities. Depending on the extent to which these areas are developed, there could be different entry points for scaling up and expanding Healthy Cities. Countries could support and promote up-scaling and expanding Healthy Cities, where:
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interventions are in place which involve micro or elemental settings, such as schools, workplaces, hospitals and/or food markets. The focus here could be on sanitation and hygiene, occupational health, maternal and child care, health education and advocacy and other primary health care services.
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It is also crucial to determine performance indicators and establish a system for monitoring and assessing the progress of implementation of Healthy Cities at both national and local levels. Key areas to consider in tracking performance include the following:
Impact
This relates to ensuring wider population coverage, gaining broader political, social and cultural acceptability of interventions and achieving greater momentum towards optimizing health and human development.
Efficiency
This pertains to maximizing resources by investing in the right interventions, eliminating redundancy and duplication of efforts among agencies and building synergy among sectors and stakeholders with shared objectives.
Equity
This deals with focusing on the poor, the marginalized and the vulnerable groups who will most benefit from the interventions and ensuring that health outcomes are more equitable.
Quality
This concerns incorporating more depth, rigor, innovation and learning in the interventions through continuous quality improvement.
Sustainability
This means moving from a programmatic and a project-based approach to a system-wide and institutional approach to Healthy Cities
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Section 2: Regional Framework for Scaling Up and Expanding Healthy Cities in the Western Pacific Region Goal The goal is to promote, expand and upscale Healthy Cities through national government support as a pathway to healthy urbanization towards the attainment of optimum and equal population health and development.
Logical framework for scaling up and expanding Healthy Cities The inherent logical framework for healthy urbanization through the expansion and scaling up of the Healthy Cities approach through national government support is illustrated below. (Figure 5) The Framework for scaling up and expansion of Healthy Cities is anchored on five strategic approaches: 1 2 3 4 5 strengthening institutional arrangements building capacity for action strengthening the evidence base advancing national policy and action supporting city-to-city learning and networking.
Objectives The following are the main objectives:
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Expand the application and implementation of the Healthy Cities approach to cover a critical mass of urban populations, urban areas and rapidly urbanizing countries in the Region;
the Healthy Cities 2 Institutionalize approach at all levels of governance, i.e. national, subnational and local levels across the Region, also by enhancing intersectoral action; and up the priority work areas on 3 Scale Healthy Cities through the use of evidence-informed strategies and interventions to protect and promote population health. 5 Strategic Approaches 1 Strengthening institutional arrangements 2 Building capacity for action 3 Strengthening evidence base 4 Advancing national policy and action 5 Supporting city-to-city learning and networking
Key Action Areas Country specific WHO specific
Output Increased physical coverage Improved systems and processes towards institutional approach Improved quality of programmes, projects and areas of work
Outcome Healthy urbanization through scaling up and expanding healthy cities in the Region
Impact Optimum and equal population health and development Health Equity
Key action areas are identified under each of the strategic approaches. These key action areas provide guidance on a variety of WHO-specific and country-specific activities that are critical in scaling up and expanding Healthy Cities. They reflect the action proposed in the WHO Regional Committee Meeting resolution on healthy settings. It is recommended that these activities be contextualized within the prevailing situation and perspective in the implementing country or city. It is expected that the key action areas would lead to the attainment of specific outputs and outcomes (such as increasing the population coverage, increasing the number of implementing cities and countries, improving the quality of interventions and intersectoral actions on Healthy Cities, etc.). In turn, these specific outputs and outcomes are expected to contribute to healthy urbanization and its ultimate impact -- the attainment of equal and optimum population health and development.
Figure 5 Logical framework for scaling up and expanding Healthy Cities
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Strategic approaches and key action areas
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Strengthen institutional arrangements to promote healthy urbanization
capacity for action 2 Build towards healthy urbanization
Actions recommended for countries: a Identify national and local focal point(s) b Establish a national technical network(s) to support and facilitate interactions between health and other urban sectors at national and local levels. c Create an information and communication infrastructure to facilitate national and local planning and monitoring of performance and for broader networking and city-to-city learning. Actions recommended for WHO: a Support establishment of national focal points in more countries b Support establishment of technical networks in more countries c Undertake joint planning activities with existing national focal point(s) and national technical network(s) d Initiate studies on the appropriate framework, structures and institutional arrangements for the development of regional and country-specific accreditation systems on Healthy Cities.
Actions recommended for countries: a Develop and implement training courses (build capacity) on social determinants of health, urban health equity, effective and efficient use of resources and other priority technical areas b Develop and implement training courses (build capacity) on tools to support action on healthy urbanization, e.g. health in all policies, health impact assessments, continuous quality improvement, Urban Health Equity Assessment and Response Tool (HEART), etc. c Build capacity for instituting national awards and recognition systems for best initiatives and best practices on priority technical areas on Healthy Cities. d Strengthen partnerships for coordinated policy and action among government agencies, private and nongovernmental organizations in health and nonhealth sectors. e Mobilize public and private funding and other resources for healthy urbanization initiatives to support work at national and local levels. f Build capacity for multilevel (national, subnational and local) assessment, monitoring and evaluation of healthy urbanization. Actions recommended for WHO: a Develop and support regional and national networks, expert panels and training centres to support national capacity-building on Healthy Cities. b Support the development of training courses (and provide information on existing ones) on priority technical areas on Healthy Cities.
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c Support policy dialogues on urban health governance and the health impact of urban policies and actions. d Support and expand the awards and recognition system for best practices and initiatives in Healthy Cities in Member States. e Provide awards and recognition of best practices and initiatives on different technical areas on Healthy Cities. f Strengthen collaboration and support to national focal points and technical networks to build academic capacity for research and evaluation on Healthy Cities across the Region. the evidence base for 3 Strengthen governance, policies and actions and value of investment for healthy urbanization
Actions recommended for WHO: a Strengthen collaboration and support to national focal points and technical networks to pursue a priority-driven regional research agenda and strategy and to support and encourage academic research and evaluation on Healthy Cities across the Region. b Facilitate collaboration of research and academic institutions with emphasis on their roles for: i ii iii iv carrying out participatory research; facilitating and coordinating a knowledge network on healthy urbanization; acting as a repository for technical tools and materials; and serving as a clearing house for best practice models.
Actions recommended for countries: a Formulate a research agenda and strategy to address current knowledge gaps about how to develop, implement and sustain Healthy Cities, including gaps in the value of investment for healthy urbanization. b Document, evaluate, publish and disseminate experiences on Healthy Cities in ways that are usable by communities and relevant stakeholders. c Develop academic and research partnerships, mentorships and networks for monitoring and evaluating Healthy Cities (possibly through national networks), including support for continuous quality improvement of the Healthy Cities approach.
c Devise common data sets (including a set of indicators) and a CQI framework for monitoring, evaluating and reporting of Healthy Cities that can be incorporated into national information systems. d Develop, promote and disseminate innovative approaches for intercountry and intersectoral data generation, assessment and response and monitoring and evaluation on healthy urbanization (e.g. Urban HEART). e Institute and commission systematic reviews and provide advice on cost-effective strategic intervention packages for Healthy Cities.
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national policy and 4 Advance action on healthy urbanization
Actions recommended for countries: a Initiate policy dialogues on urban health governance, the health impact of urban policies, urban health equity and health-in-all policy approaches. b Develop, implement and strengthen national policies and actions towards equitable healthy urbanization using the Healthy Cities approach and building on local experiences, innovation and best practices on Healthy Cities (also by using focal points and networks). c Promote Healthy Cities as a multisectoral development agenda and formulate national plans and priorities to address urban health issues.
e Use social communication measures to promote policies and actions on healthy urbanization (e.g. annual thematic promotion and recognition awards). city-to-city learning and 5 Support networking within and across countries
Actions recommended for countries: a Develop and implement city-to-city learning and mentoring activities on healthy urbanization for political leaders and technical staff. b Promote twinning, sister city arrangements, networking and other collaborative arrangements to implement intercountryand intercity projects on urban health. c Support the participation of national and local political leaders and technical staff in regional and global activities on urban health. Actions recommended for WHO: a Support the development of city-to-city learning and mentoring activities and the implementation of intercountry and intercity projects on urban health. b Facilitate and strengthen collaboration and coordination with Healthy Cities movements in other WHO regions through inter-regional activities. c Develop networking and other collaborative mechanisms within and across countries, tapping into national and regional networksto be established. d Increase coordination and improve links between WHO and other international agencies and global initiatives working on urban development to support multisectoral collaboration at national, subnational and local levels.
d Organize advocacy and support for scaling up and expanding Healthy Cities. Encourage, mobilize and assist more cities to implement Healthy Cities initiatives and to join the Healthy Cities network. e Mobilize resources and funding support to implement Healthy Cities interventions at national, subnational and local levels. Actions recommended for WHO: a Support policy dialogues on healthy urbanization at regional and country levels. b Advocate for adoption of United Nations goals and targets related to healthy urbanization. c Strengthen, mobilize and organize technical and logistical support to countries and institutions within countries to formulate and strengthen national policies and action on healthy urbanization. d Support the expansion of the Healthy Cities approach through the various WHO technical programmes and the use of Healthy Cities as a platform to integrate different WHO and other United Nations programmes related to healthy urbanization (improve links with other relevant WHO and related global initiatives).
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Immediate steps to implement the Regional Framework
Implementation of the Regional Framework requires national leadership, institutional structures, human and financial resources and strategy. These need to be detailed in national and city plans. The immediate steps (to be achieved within one to two years) to initiate expansion and scaling up of Healthy Cities are proposed below. Immediate steps by Member States 1 Designate and strengthen a national focal point(s) and define its roles, functions and responsibilities. 2 Identify focal points at local or city levels and define their roles, functions and responsibilities in relation to national focal points. 3 Create national technical networks, learning hubs and support groups for Healthy Cities. 4 Build capacity of national and local focal points and national technical networks to implement Healthy Cities. 5 Develop national policies, programmes and plans for Healthy Cities as a multisectoral development agenda. 6 Advocate and find champions of Healthy Cities at national, subnational and local levels (e.g. health ministers, other ministers, mayors, etc.). 7 Mobilize and coordinate technical and financial resources to implement Healthy Cities. 8 Establish and strengthen a performance assessment system and a national awards and recognition system for best practices and initiatives on Healthy Cities. Immediate steps by WHO 1 Identify an appropriate platform for launching the Regional Framework for Scaling up and Expanding Healthy Cities in the Western Pacific. 2 Support Member States in the development and capacity-building of national and local focal points for Healthy Cities. 3 Create regional technical networks and support Member States in the development and capacity-building of national technical networks, learning hubs and other support groups for Healthy Cities. 4 Promote and facilitate the development of Healthy Cities as a multisectoral development agenda at national and local levels. 5 Mobilize and harmonize international resources to support the implementation of Healthy Cities in Member States. 6 Bring together and clarify the roles of WHO, the Alliance for Healthy Cities and other United Nations agencies and international organizations that support programmes and projects on healthy urbanization. 7 Support the establishment of performance assessment mechanisms and awards and recognition systems in Member States. 8 Study appropriate framework, structures, mechanisms, resource requirements, incentives and other key elements of a regional and country-specific accreditation system on Healthy Cities.
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Section 3: References and Other Resources References 1 World Health Statistics 2010. Geneva, World Health Organization, 2010. 2 Our cities, our health, our future. Acting on social determinants for health equity in urban settings. Report to the World Health Organization Commission on Social Determinants of Health from the Knowledge Network on Urban Settings. Kobe, World Health Organization Centre for Health Development, 2008. Available from: http://www.who.int/social_determinants/resources/knus_ final_report_052008.pdf 3 Overcoming Barriers: Human Mobility and Development. New York, United Nations Development Program, 2009. 4 World Population Ageing 2009. New York, United Nations Population Division, 2010. 5 Healthy Urbanization Learning Circle interim package. Kobe, World Health Organization Centre for Health Development, 2008. Available from: http://www.whoindia.org/LinkFiles/NMH_ Resources_Manual_on_Healthy_Urbanization_Learning_CycleModule_1.pdf 6 Werna E., et al. Healthy City Projects in Developing Countries—an international approach to local problems. London, Earthscan, 1998. 7 Duhl, L. (Editor) The Urban Condition: People and policy in the metropolis. New York: Basic Books Inc., 1963. 8 Hancock T. and Duhl L. The Parameters of a Healthy City. Promoting Health in the Urban Context. Copenhagen, World Health Organization Regional Office for Europe, 1988 (WHO Healthy Cities Papers, No. 1). 9 de Leeuw E. Global and local (glocal) health: the WHO Healthy Cities program. Global Change and Human Health, 2001, 2:34-45. 10 Regional Guidelines for Developing a Healthy Cities Project. Manila, World Health Organization Regional Office for the Western Pacific, 2000. Available from: http://alliance-healthycities.com/docs/ HCguidelines_WHOWPRO.doc 11 Hancock T. Health, human development and the community ecosystem: three ecological models. Health Promotion International, 1993, 8(1): 41-47.
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12 Environmentally Sustainable and Healthy Urban Transport (ESHUT). A strategic focus for urbanization and health. ESHUT Primer. Manila, World Health Organization Regional Office for the Western Pacific, 2010. Available from: http://www.wpro. who.int/internet/resources.ashx/EHH/transport/ESHUT+Primer_ OCT+21_2010+(2).pdf 13 Win-win solutions to climate change and transport. Nagoya, United Nations Center for Regional Development, 2009. Available from: http://www.uncrd.or.jp/env/publication/win_win_solutions. pdf 14 McLaughlin, C. and Kaluzny, A. Continuous Quality Improvement in Health Care: Theory, Implementations and Applications. 2nd Edition. Jones and Bartlett Publishers, 2004.
Other Resources 15 Meeting Report: Meeting for Developing Technical Networks and Resource Centres for Healthy Cities, 2010 October 26, Gangnam-gu, Seoul, Republic of Korea. Manila, World Health Organization Regional Office for the Western Pacific, 2010 16 Regional Committee for the Western Pacific Region Resolution WPR/RC61.R6 on Healthy Settings, 2010 October 14. Manila, World Health Organization Regional Office for the Western Pacific, 2010. 17 Meeting Report: Meeting of National Focal Points on Scaling up and Expanding Healthy Cities in the Western Pacific Region, 2010 September 8-10, Dalian City, China. Manila, World Health Organization Regional Office for the Western Pacific, 2010.
WHO Western Pacific Region PUBLICATION
ISBN-13
978 92 9061 533 0