Healthy Cities and Urban Policy Research

Takehito Takano

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781134442362
• Edition: 1
• Topic: Architecture
• Subtopic: Urban Planning & Landscaping

Healthy Cites and Urban Policy Research is a collection of papers by leading experts from academia or international organisations who have been involved in the Healthy Cities Movement. It is the first academic work to combine public health with urban planning. Contemporary issues from various perspectives are included which address evaluation, evidence-based practice, accountability, community participation and information technology.

Chapter 1

Development of Healthy Cities and need for research

Takehito Takano

GLOBAL URBANISATION AND POPULATION HEALTH: BACKGROUND FOR HEALTHY CITIES

Increase in urban population

Urbanisation has been rapidly progressing worldwide in recent years, and this trend has been particularly prominent in Asia and other developing regions. According to United Nations’ statistics (United Nations 1999), urban populations roughly doubled in the industrialised nations and quadrupled in the developing nations during the latter half of the twentieth century. Today, approximately half of the global population of 6 billion people live inside urban areas. The world population is projected to increase to 8 billion over the next 30 years or so, and the number of city dwellers will clearly surpass 6 billion. In other words, in three decades, over two-thirds of the global population will reside within urban areas. In the industrialised nations, over three-quarters of the population already live in urban areas, and this percentage is projected to continue to gradually increase.

Asian urbanisation is characterised by the formation of megacities including Tokyo. Demographers forecast that there will be more than 30 such megacities ten years from now, and that about two-thirds of these will be located within Asia (United Nations 1999).

Together with the globalisation of the economy and the development of new technologies, the worldwide advance of urbanisation is radically changing people’s living environments and living conditions. For residents’ health, these developments offer both new potential benefits and numerous challenges. The acceleration of urbanisation and the development of urbanised societies will have an increasingly severe impact on the global environment, and will influence the very conditions for humanity’s survival. Rapid urbanisation underscores the critical need to adjust course toward achieving a cyclical and sustainable society.

IMPACTS ON POPULATION HEALTH

Urbanisation affects determinants of health in unprecedented ways. On one hand, urban development produces a number of benefits including increased land values, capital gains, and a more active local economy. A number of key factors in urban society improve health levels of the population. On the other hand, although it creates economic growth, infrastructure development, and a sophisticated lifestyle, urbanisation also triggers new problems and issues bearing on multiple aspects of urban life, including food security, housing, employment, living environment, health of future generations, increasing levels of crime, violence, sex trafficking, drug abuse, and vulnerability to natural disasters. Urbanisation also increases the importance of crisis management for natural and man-made calamities and disasters such as outbreaks of infectious diseases.

Problems originating in an urban area can well spill over its borders and encroach on the entire society, as exemplified by urban overcrowding and rural underpopulation, and imbalance between production and consumption. Urban problems, furthermore, impact the world community by affecting populations, resources, economics and the environment. For these reasons, attempts to improve the health status of citizens necessitate the development of comprehensive schemes integrating a wide range of factors pertaining to urban issues.

Urbanisation and the agglomeration of megacities do not necessarily improve living standards. In fact, the number of people concentrated in informal settlements, including squatter areas and other squalid unimproved city districts in developing nations, has risen, and is continuing to increase rapidly (World Bank 2001). Even in industrialised nations, systems sometimes result in a relative decline in health levels in urban areas (Takano and Nakamura 2001b), and these health levels are closely related to the quality of urban living environments (Takeuchi et al. 1995; Tanaka et al. 1996; Takano et al. 2002).

Rapid urbanisation tends to exacerbate disparities in living conditions. The inability of urban infrastructure to keep pace with urbanisation results in a deterioration of living environments and an insufficient supply of essential services, posing severe public health and sanitation problems. And when urbanisation is not accompanied by sufficient economic growth, it expands the ranks of the urban poor, increases the factors that cause social instability, and prevents overall improvements in urban health levels (Asian Development Bank 1997).

Growth in the number of urban poor is evident in the industrialised nations as well and poses diverse social medicine issues: deterioration of living environments, mismatch in supply and demand for essential services, diminished socioeconomic vitality from an aging society and lower birthrates, increased crime and social unrest, and a growing number of homeless people and others with no fixed residence. Moreover, the characteristics of urbanised societies are intimately related to such health issues as the emergence, re-emergence, and spread of new and existing infectious diseases, supply of safe food, stress, and psychological health. Efforts to address traditional urban problems such as air pollution, garbage disposal, safe water and food supply, and the creation, maintenance and management of housing and living environments meet increasing difficulties in megacities with wider income disparities (World Health Organisation [WHO] 1997).

Demands for an integrated activity framework

Urban problems with their related health issues have the aspect of a structural problem, and therefore we need structural solutions to tackle them. That is why we need an integrated policy framework in which to undertake activities.

The conditions of the diverse health determinants in urban areas are becoming increasingly complex, indicating that solutions will by no means be easy. On the whole, the varied health problems challenging cities in recent years are intricately interrelated with the background of general urban problems. Just as rural health activities were developed to improve low health levels in farming districts and industrial health activities to address high health risk workplaces in the past, we now need to develop urban health activities to cope with the numerous health problems suffered in urban areas.

To date, nationwide public health measures have been subdivided into individual systems for maternal and child health, elderly health, psychological health, communicable diseases countermeasures, environmental health, and other fields. With the trend toward decentralisation of government authority to the municipal level, municipal government bodies are now being called upon to develop new city health frameworks to address urban health problems effectively in an integrated manner.

The majority of urban problems directly impact on residents’ health, and close cooperation among governments, residents, businesses, and other bodies will be essential to solve these challenges. A new collaborative approach is needed to bring together a partnership of the public and private sectors and the community to focus on urban health and to take a broad approach in dealing with health issues. The complex problems, increased responsibility of city governments, and the possibility of partnerships have created demands for a new integrated framework like ‘Healthy Cities’.

EVOLUTION OF ‘HEALTHY CITIES’

WHO Healthy Cities Project/Programme

The Healthy Cities concept emerged in the 1980s on the basis of a new public health movement (Kickbusch 1989; Ashton 1992; Baum 1998), the Ottawa Charter (WHO 1986), and the Health for All strategy (WHO 1981). It is an innovative means for improving urban living conditions and the health of the population (WHO Regional Office for Europe 1992). According to a number of WHO publications, Healthy Cities projects require a holistic approach by emphasising the importance of intersectoral collaboration and community participation to create environments supportive for health (Tsouros 1990; WHO Regional Office for Europe 1992; WHO 1995a, 1995b; WHO Regional Office for the Western Pacific 2000).

The publication entitled WHO Healthy Cities: A Programme Framework (WHO 1995a) stresses several key concepts including intersectoral collaboration, a partnership approach (among NGOs, private companies, community organisations and groups), a supportive environment, and ‘settings’ approach. A supportive environment for health has been defined as one which helps to improve physical, economic, and social conditions supportive of health. Municipal Health Plan (MHP) was recognised as follows:

MHP promotes collaboration between sectors and serves to generate awareness of health and environmental problems by municipal authorities, non-government agencies, and communities; and mobilizes resources to deal with the problems.

(WHO 1995a)

According to Twenty Steps for Developing a Healthy Cities Project published by WHO: ‘A healthy city is one that improves its environments and expands its resources so that people can support each other in achieving their highest potential.’ Healthy public policy, an important characteristic of Healthy Cities, can be achieved through political decisions, intersectoral action, community participation, and innovation (WHO Regional Office for Europe 1992).

The WHO chose Healthy Cities as the theme for World Health Day 1996, and encouraged a global network among cities (Goldstein and Kickbusch 1996). The fourth International Conference on Health Promotion held in Jakarta, Indonesia, in July 1997, recognised the global Healthy Cities movement and announced the ‘Statement on Partnership for Healthy Cities’. Monitoring and analysis have been raised as an important topic in the publication Building A Healthy City: A Practitioners’ Guide (WHO 1995b).

Many cities are now trying to develop Healthy Cities by respecting individual cities’ characteristics as well as regional ones. Further development of Healthy Cities will be encouraged by participation of various cities and by efforts towards appropriate research development.

A setting-based approach

‘Healthy Cities’ derives from a concrete application of the principles and strategies of the Ottawa Charter for Health Promotion in urban settings (WHO 1986); it is a comprehensive setting-based approach.

While settings are simply ‘areas’, such as schools, workplaces, markets, shopping districts, and city blocks, the Healthy Cities approach does not view settings as just physical locations. Rather, the settings are understood from a wider perspective as venues for daily activities, for the actual manifestation of diverse environmental conditions, and above all as the concrete objects of intensive health-related policies. According to the WHO’s Health Promotion Glossary (1998), a setting for health is defined as:

the place or social context in which people engage in daily activities in which environmental, organisational and personal factors interact to affect health and well being. A setting is also where people actively use and shape the environment and thus create or solve problems relating to health. Settings can normally be identified as having physical boundaries, a range of people with defined roles, and an organisational structure. Action to promote health through different settings can take many different forms, often through some form of organisational development, including change to the physical environment, to the organisational structure, administration and management. Settings can also be used to promote health by reaching people who work in them, or using them to gain access to services, and through the interaction of different settings with the wider community. Examples of settings include schools, work sites, hospitals, villages and cities.

The advantages of the setting-based approach include greater ease in securing community participation by identifying specific areas within cities, in forming linkages and clarifying the division of work among related institutions, organisations and wide-ranging concerned parties, and in integrating individual policy measures. As a result, the setting-based approach facilitates the effective utilisation of personnel, goods, budgets, and other limited resources. Settings where the Healthy Cities concept has been introduced are called, for example, ‘healthy schools’, ‘healthy markets’, and ‘healthy towns’, with Healthy Cities as the overriding, comprehensive concept.

Healthy Cities as a strategy to develop a comprehensive policy package

The term ‘Healthy Cities’ as used by the WHO does not actually refer to cities whose residents enjoy a high level of health, but rather to cities that have introduced Healthy Cities programmes, and to the methodologies that they are developing. The Healthy Cities approach began in the latter 1980s, mostly in Europe. At that time, these efforts were referred to as Healthy Cities projects. In line with the greater emphasis on Healthy Cities as an overall concept, the recent trend has been away from referring to specific efforts as individual projects, and toward adopting titles such as Healthy Cities programme, Healthy Cities policy or Healthy Cities approach. In many cases, urban governments are simply referring to their policy strategies as just Healthy Cities.

The Healthy Cities strategy was initiated amid the rapid progress of urbanisation worldwide, in both industrialised and developing nations. The advance of urbanisation poses new challenges for maintaining human health. While urbanisation results in economic development, improved urban infrastructure, and more sophisticated lifestyle technologies, it also presents varied challenges in such diverse areas as food supply, the production and distribution of foodstuffs, housing, and changes in the living environment. City problems are by no means limited to urban areas alone, but rather constitute issues for an entire society (including rural regions), such as excessive population density in some areas and depopulation in others, and the overall structure of production and consumption. Moreover, urbanisation has international repercussions via demographic shifts, allocation of resources, economics, and the environment.

To respond to these types of changes in living conditions from the effect of urbanisation on human health, and to boost the physical, psychological, and social health levels of urban residents, it is necessary to establish a framework to secure the health of city dwellers by espousing the Healthy Cities approach and supporting Healthy Cities programmes. These efforts are based on a recognition of the need to secure the conditions required to maintain human health in urban environments and involve people who have conventionally been perceived as outside the purview of the medical and healthcare sector.

With their dense and complicated structures and functions, cities need to adopt comprehensive strategic policies to promote the health of their residents. The development of Healthy Cities is based on recognition that there is a common structure within urban problems that lies behind individual health issues, and that it is difficult to promote the health of city dwellers via public health policy alone, as narrowly defined (Takano and Nakamura 2001a). Accordingly, the Healthy Cities principle is being developed as a key pillar to advance the overall health of urban residents, primarily at the individual city level, by ensuring that health aspects are incorporated into all city policies and works, including urban development, planning, administration, and management – that is, as a citywide structure to support residents’ health.

The Healthy Cities approach, which is based on but transcends conventional health promotion measures, is becoming established as an effective means of realising sustainable urban development and the formation of healthy, stable, high-quality local societies in and around cities through the introduction of urban environmental management and other novel methodologies.

In practice, the Healthy Cities approach takes the form of Healthy Cities programmes. These are comprehensive, integrated policy packages encompassing all the major factors for sustaining urban health, ranging from the formation and implementation of healthy public policy to vision sharing, a high level of political commitment, the establishment of structural organisations, strategic health planning, intersectoral collaboration, community participation, a settingbased approach, the creation of a supportive environment for health, the preparation of city health profiles (which serve as an urban health index database), the establishment and use of active national and international networking, utilisation of participatory research, the establishment of periodic monitoring and evaluation processes, and the design of mechanisms to ensure the sustainability of projects.

Since Healthy Cities as a strategy spread to diverse cities worldwide and experience has been accumulated from individual cities adopting model approaches, Healthy Cities is developing into a comprehensive policy package to carry out individual projects and activities effectively and efficiently.

THE NEED FOR RESEARCH TO ADV...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• List of tables, figures and boxes
• Notes on contributors
• Preface
• Chapter 1 Development of Healthy Cities and need for research
• Chapter 2 The third phase (1998–2002) of the Healthy Cities Project in Europe
• Chapter 3 Healthy Cities Project in the Western Pacific
• Chapter 4 Health and sustainability gains from urban regeneration and development
• Chapter 5 Analysis of health determinants for healthy Cities programmes
• Chapter 6 Indicators for Healthy Cities
• Chapter 7 The effectiveness of community-based health promotion in Healthy Cities Programmes
• Chapter 8 Applicability of information technologies for health
• Chapter 9 Nurturing Healthy Cities
• Chapter 10 Examples of research activities for Healthy Cities
• Chapter 11 Baseline Data in ASEAN member countries
• Appendices Country and city experiences in Healthy Cities
• Appendix 1 Experience of national hygienic cities in China
• Appendix 2 Lessons learned from the implementation of Healthy Cities in Lao People’s Democratic Republic
• Appendix 3 Mongolian Healthy Cities Programme and prospect for the future
• Appendix 4 Master plan for Healthy Cities development in Vietnam 2000–2005
• Appendix 5 Canberra – a healthy capital: Australia
• Appendix 6 Activities on healthy workplace in the city of Haiphong: Vietnam
• Appendix 7 Community participation and urban policies on health and environment of the city of Hue: Vietnam
• Appendix 8 Using community action to stimulate and implement healthy urban policy: Illawarra, Australia
• Appendix 9 Towards a Healthy City Johor Bahru
• Appendix 10 Healthy City Kuching
• Appendix 11 Healthy City Malacca
• Appendix 12 Olongapo City healthy program implementation: the Philippines
• Appendix 13 Municipal public health planning
• Appendix 14 Tagaytay City welfare in progress