Origins and Impact of HCM

Introduction

Healthy Cities Movement (HCM) emerged from the Ottawa Charter (1986) which was conceived in the First International Conference on Health Promotion as a way of promoting ‘healthy cities.’ The movement was formed based on recognition that there were several underlying environmental, social and economic conditions that are pivotal to the achievement of a healthy population (Duhl, 2005; World Health Cities Project (n.d). Thus, being in alignment with the World Health Organization’s (WHO) mission of promoting health around the globe, it received much support from the United Nations (UN) as well as other global health organization that is determined to a healthy population. The main aim of this journal article is to explore, in depth and breadth, the HCM and its contribution to public health. It will rely on existing literature to conduct an extensive exploration of the movement and how it relates to other determinants of health such as urban planning, ecology, climate, environmental justice, and other socio-ecological determinants.

Ideally, a healthy city is construed as one that is under a continual creation and improvement of the social and physical environment, and one that has strengthened resources for the population to healthily perform all their daily activities while achieving their full potential (Kickbush, 2003). This conceptualization of a healthy city has several implications. First, it implies that the HCM perceives the city as an enabling ground of the actions directed towards the promotion of people’s health and as a setting for various actions taken against poor health (De Leeuw, 2009). Secondly, it implies that whereas these ‘actions’ towards a healthy population require a significant level of community involvement, there is a critical need for some level of political commitment especially in terms of policy formulation and enforcement.

By all means, the HCM perceives the city from an ecological perspective, construing it as a ‘habitat’ where public health functions as a network of systems coordinated by different entities to produce a single outcome: a healthy population (Deleew & Thomas, 2005; Kearns n.d). According to Van Naerssen (2002), proponents of the HCM believe that for the city to be termed as ‘healthy’, it must be able to overcome several breakdowns and undergo several adaptations to meet the always changing requirements of public health. According to O’Neill & Paule, (2006), this activity of adaption is more of a process than an outcome and involves several factors such as urban planning, ecology, environmental justice, and socio-ecological models of health.

Ritsatakis (2009) defines urban planning as a political and technical process involving the design and development of land within the built environments of infrastructure, land, air. It is concerned with how transportation, distribution networks, and communication infrastructure move in and out cities and urban areas (Hancock, 1993). According to Ashton (1986), the main rationale for urban planning is the promotion of the public’s welfare through efficient urban movement, sanitation, and environmental protection. Thus, urban planning plays a central role in the promotion of healthy cities because it is the instrument through which other determinants of health such as proper city sanitation are achieved. On the other hand, Socio-ecological models of health are concerned with community settings such as neighbourhoods, workplaces and schools and how these settings are associated with health and well-being (Baum 1993). Thus, the socio-ecological dimension of healthy cities entails various strategies for improving the physical environments of such communities for purposes of ensuring a healthy population. Lastly, the ecological dimension of healthy cities entails the ecological nature of a city and how the city’s ecosystem is conducive to its residents and other living organisms (Dooris et al 2013). According to Ashton et al (1986), it is concerned with the manner in which the city’s settlement is modelled to enable its self-resilience and provide a smooth functioning of the natural ecosystems. Thus, in terms of ecology, a healthy city is one with healthy abundance where its inhabitants (humans or animals) are able to survive without consuming more resources than it produces or producing more waste that it can manage. In practical terms, it means the use of more renewable energy within the city and establishment of effective waste management mechanisms.

In all dimensions, the HCM is related to various elements of public health including social determinants of health. Within the movement’s framework, health is conceived as an important resource for good life, and this conception goes beyond ill-health to cover general wellbeing and quality of life (Hancock 1993). Against this backdrop, as Baum (1993) argues, health emerges as a multidisciplinary aspect which requires a deeper concern for anything that infringes the people’s well-being. Consequently, the HCM focuses on a range of social and environmental determinants of health and highlights the need for various interventions from various sectors to tackle public health challenges. According to Dooris et al (2013), this multi-sectorial approach to health is evident in the way HCM takes a broad new understanding towards public health by shifting its focus from individual health risk behaviours to the meaning and context of various determinants of health as priorities for during the development of urban policies. It entails the giving more focus towards participation and empowerment of people to have the autonomy and ability to live a healthy life (Kent et al 2017).

The origin of the HCM

As hinted earlier in this paper, the HCM originated in Canada during a conference entitled ‘Beyond Health Care’. According to Duhl (2005), a major idea behind the formation of HCM was the increasing global awareness of the need for “healthy public policies” rather than the much blame put on unhealthy lifestyle as impediments to health promotion. Equally, according to Kickbush (2003), the formation of HCM was motivated by a realization that urban environment exposed people to new health risks such as accidents and violence, yet these new risks had not been addressed.

Based on these grounds, two personalities: Leonard Duhl and Trevor Hancock presented themselves to be the key figures behind setting up the movement, and the process of setting up the movement was also facilitated by the then WHO European regional officer for health promotion, Ilona Kickbusch who convened a group of experts to deliberate on the European Healthy Cities project (Kickbush, 2003).

In 1986, the first Healthy Cities conference was held in Lisbon following the adoption of the Ottawa Charter on Health Promotion (De Leeuw, 2009). According to Van Naerssen & Barten (2002), it is during the first Healthy Cities conference that the European Healthy Cities Project was launched. Hence, it emerges that the HCM was facilitated and natured by the WHO which played a major role in facilitating the project by establishing the agenda, raising the nations’ consciousness and establishing the standards of best practices for the movement. Ultimately, according to O’Neil & Simard (2006), the Healthy Cities project acted as a testing ground for the theoretical perspectives on new health movement and as part of the strategy to make improvements in the sector of public health advocacy.

Since its inception, the Healthy Cities project has been implemented in phases running for a period of 5 years each. According to Ritsatakis (2009), the first phase entailed the creation of new structures and a foundation for new ways in which the movement could work in promoting healthy cities as opposed to implementing and monitoring specific action plans. However, according to WHO Regional Office for Europe (2008), there were concurrent conferences with themes that focused on community participation, health inequalities, and public health reorientation. Contrastingly, phase two of the project was more action-oriented with a strong focus on public policies that promote public health as well as the inclusion of public health consideration in city planning (WHO Regional Office for Europe, 2008).

It was phase three of the European Healthy Cities project that saw the beginning of an actual formation of the Healthy Cities Movement. According to Duhl (2005), phase 3 of the project was initiated from 1998 to 2002 and brought together various cities that had been developing the healthy cities agenda by demonstrating their political commitment to the agenda, drawing a city health plan, and commitment to network with other like-minded cities. Of particular focus was the health plan which was supposed to emphasize reducing health inequalities, promoting sustainable development and social development (De Leeuw, 2009). On the other hand, phase 4 continued with phase three’s agenda and saw the project’s expansion into 70 cities and the development of new themes such as healthy ageing, health impact assessment, and healthy urban planning. The currently running phase 5 has been characterised by more revolutionary objectives where cities are encouraged to improve their political commitment to the movement by strengthening their participatory governance and leadership towards health (De Leeuw, 2009). According to Kickbush (2003), it is concerned with the promotion of innovative ideas in approaching city health planning characterised by desirable strategic thinking towards raising the health profiles of the cities.

Aims of the Healthy Cities Movement

Enshrined within phase five of the project, HCM has defined its objectives and goals in congruence with the European Health 2020 health policy strategy, also termed as ‘the Health 2020’ (Ritsatakis, 2009). According to Duhl (2005), linking phase five to the Health 2020 was based on the idea that achieving the two strategic goals of Health 2020 would, by all means, translate to achieving the goals and objectives of phase 5. These two goals are:

i. Reducing health inequities and improving health for all

ii. Improving participatory governance and leadership for health

Reducing Health Inequities and Improving Health for All

According to Kickbush (2003), this goal was established based on the idea that health inequities are socially determined, and inadequate health status result from the society’s cultural, social, economic and environmental situation – this is especially caused by the daily living conditions of people from those societies and the decisions that are related to resources, money, and power. Moreover, the movement agreed that health inequities were on the rise and was being escalated by the economic crisis (De Leeuw, 2009). Consequently, it was resolved that there was an urgent need for action against the inequities especially in the wake of the crisis. Furthermore, the resolution to establish this objective was informed by the available evidence of health gaps, the causes of these gaps and the most effective actions against these gaps. It aimed to take various systematic actions towards the existing health inequalities through approaches that involved the active participation of local governments and sought the involvement of the political class.

Improving participatory governance and leadership for health

This goal was established based on the premise that it is important to have community participation and inter-sectorial action within the efforts if reducing health inequality (De Leeuw, 2009). Moreover, according to Duhl (2005), it was believed that addressing the social determinants of health would need the engagement of all stakeholders; yet achieving the attention of all stakeholders has become a major challenge for city leaders. Thus, it was deemed fit to focus on improving health governance. However, according to Kickbush (2003), this goal took a rather unique perspective on governance by applying innovation as a major enabler for participatory and shared governance. It was idealised that to address the health inequities and non-communicable diseases that are currently taking toll of Europe, there needed to be an all-inclusive solution characterised by a full participation of both the government and the society at large.

How HCM Achieves its Goals

The two major goals of HCM of reducing health inequities and developing a participatory leadership towards health would be achieved through four major sub-themes (De Leeuw, 2009). According to Van Naerssen & Barten (2002), these subthemes are deemed as the major action plans through which the movement reduce health inequalities and achieve a participatory leadership/governance.

Empowerment throughout the Life Course

HCM conceived that the first way of achieving its goal was through people empowerment throughout the course of their lives. According to Van Naerssen & Barten (2002), it means improving the determinants of health in all life key stages such as child and maternal health, adolescents, adults, and older people. Thus, based on this theme, cities are required to develop strategies, plans, and policies that focus on preventing disease and promoting the health of people throughout their life course (De Leeuw, 2009). They are expected to focus on early years, older people, the vulnerable, and health literacy as a key priority issue for achieving the two major goals.

Tackle Non-Communicable Diseases

The second way of achieving the goals is to tackle non-communicable diseases, which are the main public health challenge facing Europe (De Leeuw, 2009). According to Duhl (2005), the HCM conceived that it would also achieve its goals by coordinating various health actions and interventions through effective healthcare systems. Thus, cities are required to explicitly display actions that seek to tackle non-communicable diseases by coordinating with the existing governance and political leadership (De Leeuw, 2009). Moreover, their actions against the non-communicable diseases must all seek the involvement of all instruments of governance as well as the entire society – with specific focus on key priority areas such as obesity and diet, physical activity, alcoholism, tobacco, and mental health.

Strengthen and Improve People-Centred Health Care

The third action plan through which HCM seeks to achieve its goal is to strengthen and improve people-centred health care systems as well as improve the capacity of public health. According to Ritsatakis (2009), cities are supposed to improve their health outreach programs through adequate funding while promoting various reward mechanisms for partnerships that promote person-centred care. Ideally, according to Duhl (2005), the key priorities for this theme include improving the delivery of city health services and improving the city’s capacity to deliver public health.

Creating Supportive Environments and Resilient Communities

HCM also aims to achieve its aims by creating supportive environments and resilient communities so that such communities are able to make a proactive response to adverse environmental, social, and economic circumstances (De Leeuw, 2009). Therefore, according to Kickbush (2003), this theme requires cities to systematically assess the negative impacts of the changing urban environment on health and well-being of the population and remedy these impacts with effective action plans that provide health benefits. Some of the key action plans related to this theme include improving the living and working conditions, enhancing disease prevention and socially including people with chronic illness as well as the disabled, implementing healthy urban design and planning, and promoting healthy transportation by adopting a non-pollutant transport system (De Leeuw, 2009, Mottaeva 2018).

The contribution of HCM to Public Health

A body of literature has attempted to evaluate the achievements made by HCM so far in its quest to reduce health inequality and improve the determinants of health. For instance, the WHO’s evaluation focuses on the reach and scale of the movement and the level at which each city has been able to achieve success in implementing the project requirements by initiating processes that bring a change in urban health (De Leeuw, 2009). Nonetheless, Van Naerssen & Barten (2002) asserts that the project success has largely been evaluated through its phases by identifying how each phase has contributed to improving the social determinants of health or eliminating health inequalities in urban centres.

For instance, a mid-term review of phase one revealed that the healthy cities project achieved much success in mobilizing political support which provided success for the implementation of its key action plans (De Leeuw, 2009). According to Kickbush (2003), the project was able to gain strong political support, appropriate and adequate resources and cooperation between various sectors that acted as a launching pad for the key plans for the improvement of public health, elimination of health inequalities and improvement of social determinants of health in the cities. Indeed, without these achievements, it would have been impossible to achieve any success in the subsequent stages.

A closer evaluation of phase three of the project also reveals considerable levels of achievement in regards to social determinants of health and health equity. For instance, Ritsatakis (2009) acknowledges that at least half of the cities have significantly become more action-oriented in terms of actively implementing the value of equity in urban planning processes. However, the author also observes that there has been a slow shift from merely providing support to the vulnerable population (i.e. the aged and disabled) to getting actively involved in tackling various determinants of health. For example, whereas cities were more focused on lifestyle-related interventions and accessibility of health care, there was a little focus on housing, unemployment, and poverty (Ritsatakis 2009).

On the other hand, an evaluation phase four also reveals several milestones so far achieved by the HCM in its quest for a more equitable health, improved determinants of health and improved public health. For instance, reports by the WHO Regional Office for Europe (2008) reveal that since the inception of HCM, 94% of the cities have engaged in partnerships that promote the movement’s objectives while 76% of them have implemented multi-sectorial programs and collaborative plans as compared to the previous phases. In fact, the report reveals that in line with the actions plans in phase three, most cities have been able to produce important documents such as city development plans and health profiles that help in setting priorities for improvement of public health (WHO Regional Office for Europe 2008). Similarly, the WHO reports that 71% of cities had at least acknowledged health as important to the city and agreed that the movement was strategically important from including health as part of the political agenda. This assisted in harnessing government participation and political support for the project’s goals in improving public health, reducing health inequities and improving the determinants of health (WHO Regional Office for Europe, 2008).

Different pieces of literature evaluating the project’s phase 5 reveal that idea of integrating urban planning and health has made a considerable progress. For instance, 67% of the project coordinators have reported that urban planners are now actively being engaged in considering public health as a priority during urban planning (WHO Regional Office for Europe, 2008). Nonetheless, not all cities have adopted the integration of public health in urban planning. For instance, reports by the WHO indicate that some cities in Eastern Europe that are new to the project are still at the basic levels of the project such as providing food and other life-support services. Nonetheless, most cities in the movement are already in the second level integration and are now working on encouraging social cohesion, eliminating physical barriers to health, and improving road transport networks to and from health facilities.

In conclusion, this paper has established that to promote public health and eliminate health inequality in urban areas, the HCM insists on an integration of inclusive and effective health systems into urban city planning and management, so that the public can have equal access to healthier workplaces, homes, recreational areas, community centres, transport, and mobility. In this regard, the HCM has made a considerable milestone in building a community of cities with the mission of eliminating health inequalities, improving health determinants and improving public health. However, in a broader sense, the HCM has majorly had its focus on city governance and leadership, and now there is a need to shift its strategic initiatives towards gaining more public participation towards building healthier cities. For example, technology and the internet can be used as a platform for bringing residents of various cities together to create a conversation around healthier cities in a manner that initiates the desired change.

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