he ongoing global pandemic has brought cities a distinct set of urban health challenges and has highlighted the challenges of applying universal policies in specific places, as shown, for example, by the lack of success in applying COVID-19 social distancing measures in high-density informal settlements in the Global South. It is therefore worth reflecting on previous attempts at implementing universal health programmes, such as the World Health Organization (WHO)’s Healthy Cities program and its application in the Global South, particularly in Cape Town, South Africa.
Like the United Nations itself, the WHO emerged in the aftermath of the Second World War. It was created as an intergovernmental agency to exercise international functions with the goal of improving global health. It began with a relatively narrow focus on health care, but from the late 1970s onward, the WHO began to focus on broader health promotion. The period from 1973 to 1988 is regarded as the golden age of the WHO, with Health for All by the Year 2000 a particularly key initiative. This strategy, launched in 1981, advocated that governments were responsible for the health of their citizens and should be active in promoting good health.
The development of this strategy was linked to the rise of the “determinants of health” approach. This growing body of work highlighted that changes in living conditions had a much larger impact than changes in health care on health conditions. In particular, there was a recognition that elements of the urban environment (such as streets, housing, infrastructure, recreation facilities, transport, urban agriculture, food markets, and even the spatial form of cities) have an enormous impact on the health and wellbeing of residents. A related shift in the approach to health was the recognition in the Ottawa Charter of 1986 of the importance of participation by individuals, groups, and communities in decision-making (for example, relating to urban planning) in order to increase control over the determinants of health, and thereby improve their health.
In 1987, the WHO’s European Office initiated its Healthy Cities program “to support integrated approaches to health promotion at the city level.” This ambition, one of the first tangible impacts of the Ottawa Charter, was subsequently adopted in other regions. The Healthy Cities program emphasized the relationship between the urban environment and health, the role of local government in promoting health at a city scale, and the key role of public health officials in local decision-making. A healthy city was defined as “one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.” Fundamentally, the program centers around public health experts driving participatory processes to make cities healthier using a range of tools, from regulations and planning to the implementation of projects.
The introduction of the Healthy Cities program was accompanied by a series of events to amplify this approach, with the first WHO International Healthy Cities Conference held in Liverpool in March, 1988. The Healthy Cities concept spread around the world and was enthusiastically adopted by governments and civil society. What began with 11 designated WHO cities soon became a widespread, “new public health movement.” By the mid-1990s, several hundred cities around the world, mainly in the Global North, had healthy city initiatives underway.
Although the concept of “healthy cities” was intended to be universal, in practice it was tied to the contexts where the idea originated. The concept of the healthy city was initially developed in the Global North and depends on having effective and accountable local governments with sufficient capacity to intervene in the urban environment. Many of the policy tools identified and used did not apply in parts of the Global South, where local government is often relatively under-capacitated and has fewer powers and functions than many in the Global North. Furthermore, many cities in the Global South have a large proportion of residents living in informal settlements, where the state often does not significantly intervene through service provision or regulation.
As a result, as the Healthy Cities program spread to the Global South throughout the 1990s, implementation became increasingly challenging. Nonetheless, the WHO Regional Office for Africa held various capacity building exercises around healthy cities, and by 2000 most African countries had at least one Healthy Cities initiative under way. Notably, even these programs faced the challenge of having to compete with other global programs (e.g. on sustainable cities) and a lack of resources. In 2002, one set of scholars observed, that “although the WHO healthy cities movement has been widely implemented elsewhere, the African region lagged behind.”
The Cape Town Healthy Cities Project
Cape Town particularly illustrates some of the challenges with implementing the healthy cities program in the Global South. As part of the WHO Healthy Cities program, a healthy cities initiative involving participatory decision-making forums was implemented in Cape Town in the 1990s. Cape Town was ripe for experimentation, as it had—and still has—a large and complex burden of disease, very high levels of intra-urban inequality, and was undergoing a change in governance structure, with the 56 existing municipalities merging into a new metropolitan authority, the Cape Metropolitan Council. At the time, South Africa was in the midst of the transition to democracy and experimenting with innovative new policy ideas. The Cape Town Healthy City Project was initiated by the Cape Metropolitan Council (CMC) in 1996 with an extensive public consultation process. The project formally started in 1997. There was an overall steering committee that included local government officials from the Environmental Health and Planning Departments, councilors and other stakeholders, including NGOs, academic institutions and a community representative. The CMC employed a full-time coordinator. Participatory meetings were held at both the city and community scale. In practice, however, public health officials with no experience of community participation struggled to facilitate these complex processes with competing interests.
In 2002, the Cape Town Healthy City Project was terminated. Although the reasons remain unclear, it is likely that this was linked to the local government restructuring and a large amount of new local government legislation. The introduction of a new intersectoral planning process (which required local authorities to produce Integrated Development Plans) essentially spelled the death knell of the initiative in Cape Town as it didn’t have political champions. As the Cape Town Healthy City Project drew to a close, there was the potential for the new City of Cape Town’s Integrated Development Plans (IDPs) to become a vehicle for achieving a healthier city. At first, the signs were promising. The new unified City of Cape Town’s first IDP, drawn up in 2001, included the goal of “a healthy city for all the people.” The contents of the IDP reveal a relatively broad understanding of how a number of activities across different sectors would be required to improve health indicators. But in subsequent Cape Town IDPs, this broad focus on health withered away. By the 2004-05 IDP, the only mention of health was in relation to stopping the spread of HIV/AIDS and Tuberculosis.
Despite the rapid spread of healthy cities projects around the world, the achievements of the projects have been generally modest, with research suggesting that “progress has been largely incremental or marginal, rather than the radical changes that had been hoped for”. In Africa, although there have been a number of Healthy Cities initiatives that have achieved progress with regards to important issues such as the provision of water and sanitation, the challenges have been severe, including insufficient mobilization of financial resources, insufficient monitoring and lack of commitment from municipal authorities. While there are many flourishing Healthy Cities initiatives elsewhere in the world, in Africa comprehensive Healthy Cities initiatives have, in practice, largely been replaced by initiatives focusing on healthy villages, healthy homes, healthy schools and healthy food markets.
The modest achievements of Healthy Cities projects are most likely a result of over ambitious objectives and a failure to sufficiently account for the complexity of governance and participation processes. The Healthy Cities concept, at least initially, was based on “the modernist belief in the power of science and expertise to solve problems” , and on the belief that “technical-rational solutions can solve complex socio-political problems.” The Healthy Cities program was thus arguably turned from a value-driven movement to “a technomanagerial process.” In addition, it is noted that the program was “conceptually contradictory, because, on the one hand, it claims popular participation; but, on the other hand, is a top-down international program.”
There is still a WHO Healthy Cities program, but it has undergone a shift from implementing participatory health-driven initiatives to trying to get policy makers and urban planners to think about health and incorporate health objectives. The Urban HEART tool for local decision-makers, for example, is used for prioritizing place-based urban health interventions. Since 2016, the 2030 Agenda for Sustainable Development and the Sustainable Development Goals have essentially subsumed much of the Healthy Cities work.
The story is in some ways simple: a global agency with the best of intentions struggled to implement a global program to make cities healthier. The need to make cities healthier is more important than ever, and the need for global agencies and global programs to support, through financial resources and technical support, those ends remain. But they should not done through top-down techno-managerial programs; rather, such initiatives require the flexibility to allow for different processes to emerge in different places, including through the use of co-production methodologies that bring together policy makers, civil society and other stakeholders to redefine problems and develop context-specific solutions. Experiences with co-production methodologies show that, although complex and time consuming, bringing different stakeholders with different perspectives to collaborate on policies and projects can help contribute to more equitable cities that are better places to live in.
Editor’s Note: This essay was adapted from the workshop “Geopolitics and Urbanisation in Africa” held by the African Centre for Cities on May 7, 2021. The Project is a collaboration of global leaders in international and urban affairs: the Chicago Council on Global Affairs, the University of Pennsylvania’s Perry World House, the University of Melbourne’s Connected Cities Lab, the Argentine Council for International Relations (Consejo Argentino para las Relaciones Internacionales), the Barcelona Centre for International Affairs (CIDOB), and the African Centre for Cities.
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The World Health Organization, Healthy Cities, and Africa
Photo by Zoe Reeve via Unsplash.
February 24, 2022
T
he ongoing global pandemic has brought cities a distinct set of urban health challenges and has highlighted the challenges of applying universal policies in specific places, as shown, for example, by the lack of success in applying COVID-19 social distancing measures in high-density informal settlements in the Global South. It is therefore worth reflecting on previous attempts at implementing universal health programmes, such as the World Health Organization (WHO)’s Healthy Cities program and its application in the Global South, particularly in Cape Town, South Africa.
Like the United Nations itself, the WHO emerged in the aftermath of the Second World War. It was created as an intergovernmental agency to exercise international functions with the goal of improving global health. It began with a relatively narrow focus on health care, but from the late 1970s onward, the WHO began to focus on broader health promotion. The period from 1973 to 1988 is regarded as the golden age of the WHO, with Health for All by the Year 2000 a particularly key initiative. This strategy, launched in 1981, advocated that governments were responsible for the health of their citizens and should be active in promoting good health.
The development of this strategy was linked to the rise of the “determinants of health” approach. This growing body of work highlighted that changes in living conditions had a much larger impact than changes in health care on health conditions. In particular, there was a recognition that elements of the urban environment (such as streets, housing, infrastructure, recreation facilities, transport, urban agriculture, food markets, and even the spatial form of cities) have an enormous impact on the health and wellbeing of residents. A related shift in the approach to health was the recognition in the Ottawa Charter of 1986 of the importance of participation by individuals, groups, and communities in decision-making (for example, relating to urban planning) in order to increase control over the determinants of health, and thereby improve their health.
In 1987, the WHO’s European Office initiated its Healthy Cities program “to support integrated approaches to health promotion at the city level.” This ambition, one of the first tangible impacts of the Ottawa Charter, was subsequently adopted in other regions. The Healthy Cities program emphasized the relationship between the urban environment and health, the role of local government in promoting health at a city scale, and the key role of public health officials in local decision-making. A healthy city was defined as “one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and developing to their maximum potential.” Fundamentally, the program centers around public health experts driving participatory processes to make cities healthier using a range of tools, from regulations and planning to the implementation of projects.
The introduction of the Healthy Cities program was accompanied by a series of events to amplify this approach, with the first WHO International Healthy Cities Conference held in Liverpool in March, 1988. The Healthy Cities concept spread around the world and was enthusiastically adopted by governments and civil society. What began with 11 designated WHO cities soon became a widespread, “new public health movement.” By the mid-1990s, several hundred cities around the world, mainly in the Global North, had healthy city initiatives underway.
Although the concept of “healthy cities” was intended to be universal, in practice it was tied to the contexts where the idea originated. The concept of the healthy city was initially developed in the Global North and depends on having effective and accountable local governments with sufficient capacity to intervene in the urban environment. Many of the policy tools identified and used did not apply in parts of the Global South, where local government is often relatively under-capacitated and has fewer powers and functions than many in the Global North. Furthermore, many cities in the Global South have a large proportion of residents living in informal settlements, where the state often does not significantly intervene through service provision or regulation.
As a result, as the Healthy Cities program spread to the Global South throughout the 1990s, implementation became increasingly challenging. Nonetheless, the WHO Regional Office for Africa held various capacity building exercises around healthy cities, and by 2000 most African countries had at least one Healthy Cities initiative under way. Notably, even these programs faced the challenge of having to compete with other global programs (e.g. on sustainable cities) and a lack of resources. In 2002, one set of scholars observed, that “although the WHO healthy cities movement has been widely implemented elsewhere, the African region lagged behind.”
The Cape Town Healthy Cities Project
Cape Town particularly illustrates some of the challenges with implementing the healthy cities program in the Global South. As part of the WHO Healthy Cities program, a healthy cities initiative involving participatory decision-making forums was implemented in Cape Town in the 1990s. Cape Town was ripe for experimentation, as it had—and still has—a large and complex burden of disease, very high levels of intra-urban inequality, and was undergoing a change in governance structure, with the 56 existing municipalities merging into a new metropolitan authority, the Cape Metropolitan Council. At the time, South Africa was in the midst of the transition to democracy and experimenting with innovative new policy ideas. The Cape Town Healthy City Project was initiated by the Cape Metropolitan Council (CMC) in 1996 with an extensive public consultation process. The project formally started in 1997. There was an overall steering committee that included local government officials from the Environmental Health and Planning Departments, councilors and other stakeholders, including NGOs, academic institutions and a community representative. The CMC employed a full-time coordinator. Participatory meetings were held at both the city and community scale. In practice, however, public health officials with no experience of community participation struggled to facilitate these complex processes with competing interests.
In 2002, the Cape Town Healthy City Project was terminated. Although the reasons remain unclear, it is likely that this was linked to the local government restructuring and a large amount of new local government legislation. The introduction of a new intersectoral planning process (which required local authorities to produce Integrated Development Plans) essentially spelled the death knell of the initiative in Cape Town as it didn’t have political champions. As the Cape Town Healthy City Project drew to a close, there was the potential for the new City of Cape Town’s Integrated Development Plans (IDPs) to become a vehicle for achieving a healthier city. At first, the signs were promising. The new unified City of Cape Town’s first IDP, drawn up in 2001, included the goal of “a healthy city for all the people.” The contents of the IDP reveal a relatively broad understanding of how a number of activities across different sectors would be required to improve health indicators. But in subsequent Cape Town IDPs, this broad focus on health withered away. By the 2004-05 IDP, the only mention of health was in relation to stopping the spread of HIV/AIDS and Tuberculosis.
Despite the rapid spread of healthy cities projects around the world, the achievements of the projects have been generally modest, with research suggesting that “progress has been largely incremental or marginal, rather than the radical changes that had been hoped for”. In Africa, although there have been a number of Healthy Cities initiatives that have achieved progress with regards to important issues such as the provision of water and sanitation, the challenges have been severe, including insufficient mobilization of financial resources, insufficient monitoring and lack of commitment from municipal authorities. While there are many flourishing Healthy Cities initiatives elsewhere in the world, in Africa comprehensive Healthy Cities initiatives have, in practice, largely been replaced by initiatives focusing on healthy villages, healthy homes, healthy schools and healthy food markets.
The modest achievements of Healthy Cities projects are most likely a result of over ambitious objectives and a failure to sufficiently account for the complexity of governance and participation processes. The Healthy Cities concept, at least initially, was based on “the modernist belief in the power of science and expertise to solve problems” , and on the belief that “technical-rational solutions can solve complex socio-political problems.” The Healthy Cities program was thus arguably turned from a value-driven movement to “a technomanagerial process.” In addition, it is noted that the program was “conceptually contradictory, because, on the one hand, it claims popular participation; but, on the other hand, is a top-down international program.”
There is still a WHO Healthy Cities program, but it has undergone a shift from implementing participatory health-driven initiatives to trying to get policy makers and urban planners to think about health and incorporate health objectives. The Urban HEART tool for local decision-makers, for example, is used for prioritizing place-based urban health interventions. Since 2016, the 2030 Agenda for Sustainable Development and the Sustainable Development Goals have essentially subsumed much of the Healthy Cities work.
The story is in some ways simple: a global agency with the best of intentions struggled to implement a global program to make cities healthier. The need to make cities healthier is more important than ever, and the need for global agencies and global programs to support, through financial resources and technical support, those ends remain. But they should not done through top-down techno-managerial programs; rather, such initiatives require the flexibility to allow for different processes to emerge in different places, including through the use of co-production methodologies that bring together policy makers, civil society and other stakeholders to redefine problems and develop context-specific solutions. Experiences with co-production methodologies show that, although complex and time consuming, bringing different stakeholders with different perspectives to collaborate on policies and projects can help contribute to more equitable cities that are better places to live in.
Editor’s Note: This essay was adapted from the workshop “Geopolitics and Urbanisation in Africa” held by the African Centre for Cities on May 7, 2021. The Project is a collaboration of global leaders in international and urban affairs: the Chicago Council on Global Affairs, the University of Pennsylvania’s Perry World House, the University of Melbourne’s Connected Cities Lab, the Argentine Council for International Relations (Consejo Argentino para las Relaciones Internacionales), the Barcelona Centre for International Affairs (CIDOB), and the African Centre for Cities.
