Healthy City Projects in Developing Countries

An International Approach to Local Problems

Edmundo Werna, Trudy Harpham, Ilona Blue, Grey Goldstein

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781134180974
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

With the growth of cities and towns throughout the developing world have come significant health problems. The urban poor are particularly affected, faced with the worst of both worlds: urban problems such as pollution and stress, combined with infectious diseases common in both rural and urban areas. The Healthy City Project shows how to put health high on the agenda of urban officials, integrating it into all other planning and development decisions.

Healthy City Projects in Developing Countries presents a comprehensive account of this very important and increasingly influential initiative. Drawing on experience in a range of cities it shows how to design, implement and evaluate the integration of public health into urban management. The results will be very significant to all those making and implementing urban policies, as well as those working in and on public health, urban development and environmental issues.

1	Introduction

THE OBJECTIVES OF THIS BOOK

The ‘healthy city’ initiative, which began in 1987 with World Health Organization (WHO) support, is a development activity that seeks to put health on the agenda of decision makers in cities, to build a strong lobby for public health at the local level, and to develop a local, participatory approach to dealing with health and environmental problems. Ultimately, the initiative aims to improve the physical, mental, social and environmental well-being of the people who live and work in urban areas.

Most experience of healthy city projects has been in industrialized countries. However, there is a growing number of initiatives in developing countries and increasing interest from the international community about the nature and direction of healthy cities in the developing world. This interest has been heightened by: the 1996 United Nations (UN) summit on cities which emphasized action at the local, urban government (municipal) level; the focus of the 1996 World Health Day on healthy cities; and the increased poverty focus of many bilateral and multilateral aid agencies (for example, the UK’s Department for International Development (DFID), formerly the Overseas Development Administration (ODA)). In response to such interest this book aims to:

■ describe the different phases of healthy city projects including planning, implementation and evaluation;

■ illustrate the above phases with examples of healthy city projects in developing countries;

■ consider the sustainability of healthy city projects; and

■ draw together existing knowledge of healthy city projects in developing countries and provide some guidance for their future development.

The intended audience includes urban development practitioners with an interest in health, the international health community (both academics and policy makers), and those involved with healthy cities in both industrialized and developing countries.

This first chapter sets the scene by considering the amount of interest in health in cities of the developing world, emphasizing the importance of intersectoral action, and highlighting those trends in urban development which have implications for health.

HEALTH IN CITIES: IS IT IMPORTANT?

This is a book about public health in cities, and herein lies a problem. This subject is bedevilled with a profound lack of interest. Attention is given to urban conditions, it must be granted, when gridlock causes paralysis of traffic; when people are advised to stay indoors because the air is unsafe to breathe; when the level of violence crosses various thresholds. But in general, complacency is the order of the day.

It is not obvious why this is so. More and more people live in cities. The proportion of the world’s population living in cities is over 45 per cent and rising, while in 1900 it was only 14 per cent. This ‘urbanization’ is perhaps the biggest social change in the history of mankind. Around the world people in cities face escalating urban problems. For one third or even half of the inhabitants of a given city, there may be poverty; insufficient food; crowded, makeshift housing; insecure tenure; poor waste disposal; and unsafe working conditions. These living conditions cause health problems, ranging from communicable diseases and malnutrition to mental illnesses and chronic respiratory diseases. Every type of human misery from crime to drugs to epidemic disease finds fertile soil in squatter settlements and peri-urban fringes. But strangely, the poverty and vulnerability represented by the world’s cities are tolerated and even exploited. Such conditions are accepted almost as naturally ordained.

While a majority of the cities of the world face crumbling infrastructure, declining services and a looming water shortage, scientific and technological advances have become so routine they fail to excite and inspire. A connection between advanced technology and scientific capacity to improve the living conditions in cities and of their poor citizens is never made. A Spanish colleague who marvels at the wonders of science suspects humankind must be under a curse to permit such settlements and asks ‘Why then don’t we live with more dignity?’ An Indian politician chastens us for expecting things to be different: ‘progress is not inherent in history – it is an English concept, and a failed concept’.*

This is not the position taken in this book. The book is dedicated to change and progress. It is a book about a public health programme called the Healthy City Project also known as the healthy city approach, or sometimes the healthy city movement. This flexibility of terms is maintained in this book. Some cities have decided to name their healthy city activities a ‘project’ while others have used the term ‘programme’.

This chapter will show that the Healthy City Project has adopted ideas from many sources. It has incorporated the hard-earned wisdom of the ‘sanitary idea’ of England, of the Alma Ata Conference (on) primary health care, of the Ottawa Charter for Health Promotion, the Rio Conference on Environment and Development and its Agenda 21, and more recently of Habitat II (the City Summit) and the habitat agenda.

The WHO Healthy City programme is a public health approach that builds upon the time-honoured idea that living and environmental conditions are responsible for health. Cities have to deal with health problems arising from many people living and working together in close proximity. ‘The ancient Greeks regarded illness as a disturbance of the natural balance between the internal and external environments of the person, while the Romans made a contribution to public health through the provision of good water supplies, roads and housing’ (Davies and Kelly 1993: p1). McKeown found that – contrary to popular belief – the major factor in the improvement in health in the UK and other developed countries in the 19th and 20th centuries was not advances in medical care and technology, but certain social, environmental and economic changes (WHO 1995a):

■ limitation of family size;

■ increase in food supplies;

■ a healthier physical environment; and

■ specific preventive and therapeutic measures.

One may trace three important strands in the development of healthy city projects: Ottawa Charter, ‘new public health’ and Health Promotion; Alma Ata, urban primary health care and the district health system; and the emergence of local government as a major development force and key player in health and environment since 1992.

Ottawa Charter

The Ottawa Charter has made a substantial contribution to the development of the more holistic approach needed to develop physical, social and economic environments, which better promote and maintain the health of populations. The Charter enunciated five action areas to improve health: building healthy public policy; creating supportive environments; strengthening community action; developing personal skills; and reorienting health services (WHO 1986). Following the development of the Ottawa Charter in 1985, the European office of the WHO proposed a health promotion project to be known as the Healthy City Project. The idea was to demonstrate the Ottawa Charter in action, ‘taking Health for All strategy off the shelves and into the streets of European cities’ (Ashton and Seymour 1988). The intention of the Project was to devise ways to apply the principles and strategies of Health for All described below through local action in cities and to put it on the agenda of local government. Initially, 11 European cities agreed to participate in a healthy city project that would address health issues across sectors such as education, housing, transport, community services, and in planning. The healthy city idea spread rapidly beyond the limits of the initial project to cities and towns across Europe, and it has been influential in the development of healthy city projects in other regions of the world.

Alma Ata, Urban Primary Health Care and the District Health System

The WHO, from its beginning in 1946, has long recognized the interaction of physical, mental and social factors in determining health. In 1978, the WHO launched a major public health movement called ‘Health for All’ at Alma Ata, based on six principles that reflect McKeown’s concern that social, environmental and economic factors in health receive due attention (see Box 1.1).

Box 1.1 Principles of Health for All

■ Reduced inequalities in health

■ Emphasis on prevention of diseases

■ Intersectoral co-operation including reducing environmental risks

■ Community participation

■ Emphasis on primary health care in health care systems

■ International co-operation

The basic concepts and components of primary health care have had a major influence on health systems around the world, and primary health care has been described as the key to achieving health for all. During the 1970s and 1980s the main emphasis in community health in developing countries was on extending health service coverage in rural areas, but since then urban health problems have been highlighted (Rossi-Espagnet et al 1991). While health facilities and services are more concentrated in urban areas as compared to rural areas, poor urban neighbourhoods receive low priority and may be highly disadvantaged, at the same time experiencing serious health risks and high morbidity due to crowded and unsanitary living conditions. An urban district no less than a rural district may be a focus for a comprehensive district health system that includes access to primary and higher levels of health care, and preventive health services and activities.

The Healthy City programme has defined an important role for the health sector in relation to improving living conditions and addressing environment issues in urban development. It is based on the mandate of health authorities to set health goals and targets, and their access to health status (and disease causation) information, and the necessary analytical capability. In many countries the role of environmental health units within the Ministry of Health is changing in a way that may facilitate health inputs into development planning. Many countries are transferring the traditional Ministry of Health responsibilities for provision of various environmental services, such as water and sanitation services, solid waste management, or environmental health inspection of food markets or restaurants to other ministries or departments. The change moves the emphasis away from environmental health services, towards health information, monitoring and analysis, health policy development, and health promotion and advocacy. In a number of countries the health sector is now active in initiating healthy city programmes.

Emergence of Local Government as a Major Development Force and Key Player in Health and Environment since 1992

The United Nations Conference on Environment and Development (UNCED) held in Rio de Janeiro in 1992, and its global action plan Agenda 21, served to raise awareness and focus attention on global issues of environment and development. The Conference demonstrated the need for a development model that preserves environmental resources and ecosystems for the benefit of future generations. Agenda 21 specifically noted that the wellbeing of humans was ‘at the centre of concerns for sustainable development’. The Rio Conference also underlined the importance of local action and community participation in development, and served to place local government firmly on the development agenda. This theme was taken up in development conferences throughout the decade, and full recognition of the major role of local government and of ‘participatory local governance’ was apparent at the Habitat II Conference in Istanbul in 1996. National plans to implement Agenda 21, and ‘Local Agenda 21’ plans that support sustainable development have provided an excellent context for healthy city work at both the national and local levels in many countries.

While the WHO has been identified with much of the above, one must keep in mind the Healthy City is both a specific programme of the WHO, and a less formal movement involving networks of cities within countries and regions in all parts of the world. The Healthy City Project has roots in the public health culture of many parts of the world, such as the local health systems in Latin America, the Health-Culture movement in Japan, and the urban planning traditions and practice of virtually all cultures.

Healthy city is an idea that has caught fire. In a few short years over 1,000 cities have adopted this approach to solving urban problems. But the coverage of the world’s cities remains slight. What is needed is a major international effort to develop our towns and cities in such a way that all citizens can live a decent life – using existing capabilities and technologies.

As already mentioned there is a problem with a book about public health in cities, namely a lack of interest in the subject. Unfortunately there is another problem. There is nothing new in this book, that has not been written about extensively over the last decade. Nor is there in it a fundamental idea about public health that does not have clear lineage to public health writings of earlier decades and even centuries. Ashton (1992) in describing the evolution of public health in England demonstrated how the Health of Towns Association developed and advocated the sanitary idea of public health and achieved its enactment in legislation – the Public Health Act of 1848. The English sanitary idea has major elements of the current Healthy City programme, and can be summarized as:

■ the legitimacy of working locally;

■ resourcefulness and pragmatism;

■ humanitarianism and a strong moral tone;

■ the recognition of the need for special skills and qualifications;

■ appropriate research and inquiry;

■ the need to focus on ‘positive’ health (that is, to recognize that a programme to improve health may have a different emphasis to one that aims to control diseases, even if both have much in common);

■ the value of producing reports on the state of health of the population;

■ populism and ‘health advocacy’, and what is now called an ‘intersectoral approach’; and

■ the recognition that public health needs to be the responsibility of a democratically accountable body.

One may ask what was missing from the sanitary idea of the 1840s that is now within the healthy city approach? In terms of fundamentals, the answer is not much. One might complain about a lack of environmental sensibility, of discussion of the city as an ecosystem, or the absence of any idea of responsibility for stewardship of the environment for the benefit of future generations. Perhaps this is the price you pay when you are 150 years ahead of your time.

Why then was the sanitary idea lost? Ashton (1992) suggested that the germ theory of disease superseded the sanitary idea at the end of the 19th century, and paved the way for the development of vaccination, and subsequently the therapeutic era of public health commencing in the 1930s. Public health became dominated by the idea that diseases could be controlled by treatment and the implicit assumption that magic bullets could be provided by the pharmaceutical industry for all conditions. So powerful was this idea that to this day public health departments and leaders around the world focus on hospitals and clinics for treatment of the sick and wounded, and generally fail to make purposeful efforts to alter the social and living conditions that cause diseases and injuries.

The current challenges – one might say crises – affecting public health will now be briefly reviewed, as a p...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• About the Authors
• List of Acronyms and Abbreviations
• List of Illustrations
• Chapter 1 Introduction
• Chapter 2 Establishing Healthy City Projects
• Chapter 3 Implementing Healthy City Projects
• Chapter 4 Evaluating Healthy City Projects
• Chapter 5 Are Healthy Cities Sustainable?
• Chapter 6 Conclusion
• References
• Index