Movement for Social Responsibility
WHO Regional Office for South East Asia, 2010
How did the Healthy City movement begin?
The Healthy Cities idea was initiated by WHO (beginning in the European Region) in 1986. It was intended to develop principles and strategies of Health for All by the year 2000 through local action in cities. The strategy was devised along the lines of the Primary Health Care (PHC) approach, bringing together a partnership of public, private and voluntary agencies, institutions and organizations to focus on urban health and environment, including other health-related problems as an integral part of sustainable development.
The Healthy Cities movement draws on the principles laid down in the Ottawa Charter for Health Promotion (1986), the European Charter on Environment and Health (1989), the Agenda 21 from the United Nations Conference on Environment and Development (UNCED) (1992) and the Jakarta Declaration on Health Promotion (1997). The movement drew support also from related settings-based initiatives such as the Sustainable Cities programme of the United Nations Centre for Human Settlements (UNCHS), the Model Communities Programme of the International Council for Local Environment Initiatives (ICLEI), the Metropolitan Environmental Improvement Programme (MEIP) of the World Bank, and the United Nations Economic and Social Commission for Asia and the Pacific (ESCAP) Programme on Urban Development through the Regional Action Plan for Sound and Sustainable Development.
Since the turn of the century, the Millennium Development Goals (MDGs) and the recommendations of the World Summit on Sustainable Development (WSSD), the Healthy Environments for Children Alliance (HECA), and other global initiatives for greater health development partnerships have added weight to the settings-based approach as a vehicle to carry all these processes forward. They all recognize the principle of human-centered development and the crucial role that communities play in bringing about sustainable change. The global growth of HCPs over the past several years demonstrates the value of this movement.
What is a Healthy City?
“A Healthy City is 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 in developing to their maximum potential” (Goldstein and Kickbusch,1996).
The Health City concept is an abstraction of the determining factors that interplay in creating a society’s health and well-being (quality of life) within a given setting, and an articulation that positive social behaviour change towards that goal is most possible through the actions of a plurality of partners (partnership). The concept is guided by the “settings” principle which states that the health and wellbeing of a people living in a given setting (home, school, village, workplace, city, etc.) is determined more by the quality of their environment than by the health care facilities that are available there. Furthermore the Healthy Cities concept stresses the process and not just the outcome of this action. It means not only to achieve a particular health status of the people living in a particular geographical locality or setting, but rather a consciousness of health as a community issue for whose improvement all partners must commit to working.
What characterizes a Healthy City in South-East Asia?
There could be different views on characterizing a healthy city based on its level of development and cultural and social context. The views expressed here are based on the results of an opinion survey conducted by the WHO Regional Office for South-East Asia to strengthen the Healthy Cities projects in the South-East Asia Region. (WHO-SEARO-2000)
The responses indicated that environmental quality, environmental infrastructure management and concerns about social environment and social well-being predominate in the characterization of a healthy city. The next most important concerns include aspects of health and healthcare, and the role and performance of municipalities in urban governance and community participation. Surprisingly, economic, political and financial dimensions were not considered very important to the characterization of a healthy city.
Thus, the characteristics of a Healthy City turned out to be the following:
- Balance between human-made and natural environment
- Basic needs met for city people (food, shelter, income safety and education)
- Efficient and effective waste and drainage management
- Absence of communicable diseases
- Intersectoral coordinated action programmes
- Decentralized decisions that involve communities
- Economic and social equality
- Low population density
- Political commitment to people’s health and quality of life
- City authorities/citizens recognize health effects of town planning
Source : WHO-SEARO, 2000. Strengthening Healthy Cities Projects in South-East Asia Region – An Opinion Survey.
What makes a Healthy City programme different from other community development activities?
As the Healthy City idea is increasingly accepted by urban management authorities in the region countries, and as a growing number of similar actions are implemented, concerns about the direct applicability of the original concept—formulated and initially implemented in the context of Western countries—have become more apparent. Notwithstanding WHO’s publication of a guide to implementing HCPs, there appeared to be a number of differences specific to the contexts of different regions that required scrutiny as more countries adopted the Healthy Cities approach. Socio-political and cultural values and institutional arrangements for public administration differed by region and even within regions. Thus, a sound understanding of these contextual nuances was necessary for guiding the effective initiation of actual “settings” programmes. This would determine the potential for success of future Healthy City actions in the SEA Region.
One issue raised by many potential practitioners who sought to initiate an HCP is the ambiguity of what actually characterizes the Healthy City process. While this confusion is often not specifically voiced, it is evident from the very frequent use of the terms Healthy City, urban development, and community development almost interchangeably. This masks the specificity of the Healthy City concept vis-à-vis other types of community/urban development activities; the most basic difference being that, while the Healthy City model reflects a community-owned and -managed initiative, with inherent continuity and sustained action (process-linked) in a self-evolving programme, the others often embody time-bound projects that are largely dependent on external support.
Table 2.2 outlines salient differences between the paradigms of HCPs and those of general community development. The typology is meant neither to be exhaustive, nor critically analytical, but merely to highlight basic nuances of concept and approach.
Qualifying a Healthy Setting type of initiative
The new public health model of the HCP is distinguished from the old public health model by such concepts as citizen control, citizen participation and active citizenship; promoting health is not merely a responsibility of the health sector. The programme represents a change in emphasis from what can be done at the national level and how municipal authorities, community organization and individuals can best be supported in developing and implementing city-based initiatives. The objective of the HCP is primarily to strengthen the capability and capacity of municipal governments, and to provide opportunities for individuals, families and community groups to deal with their environmental and health problems.
Thus, three operational criteria that may help to qualify a community development effort as fitting into the Healthy Setting paradigm are: (1) the existence of a written POA for the setting; (2) a coordinating managerial mechanism that keeps the various players well integrated in the implementation effort; and (3) a process or mechanism for critical involvement of the recipient community in the planning and implementation process. Figure 1 represents the dynamic relationship among the three elements. This is displayed by the degree of relevance or fit each has with the other. In an ideal case, the three elements would overlap perfectly, indicating complete complementarity among the three elements. However, in reality, the relationships will not be so harmonious, and will lie on a range of possibilities from very dissonant to perfect match. In practical terms, this would mean that as trust grows among the participants, and the programme begins to show successful results, the size of the Venn-diagram intersections would expand, depicting greater harmony among the processes of community participation, implementing mechanisms, and relevance of the planned activities. Thus, at any given time, the review of a sample of operating Healthy Cities or Healthy Settings would show a range of these relationships, from tightly knit and harmonized to not so well-fitting, fledgling initiatives.
Minimum requirements for characterizing a Healthy City programme
The attractiveness of the Healthy Setting type of action is strongest in its potential for sustainability of actions in a community. This type of holistic action is clearly different to the constraints of the typical urban development project. Projects are by definition time-bound and often end with the depletion of project funds and thus the dismantling of the project management arrangement that existed. In contrast, the Healthy Settings process by its very nature has a built-in managerial structure for continuing the planned action.
How does one begin an HCP?
Initiating an HCP entails a critical aspect of community ownership of the programme that is formulated. It is not the political leadership that will ultimately sustain the programme once begun, but the resilience of the community and its trust in the fact that actions undertaken will bring benefits to them.
Several principles provide credibility to this perception, particularly in the SEA Regional context:
A person’s sense of identity to a setting is a critical factor in generating/acquiring/creating ownership of tasks undertaken to improve the setting. This implies that choosing geographical locations/areas or settings small enough for the community to have a sense of identity would auger well for the success of the programme. Thus, choosing villages, islands, neighbourhoods, wards, municipalities, schools, marketplaces, etc. that indicate significant homogeneity of culture and values among their occupants would appear to offer greater potential for an HCP. (Examples are the smaller locations in the SEA Region where there have been indications of success as opposed to cities, where the bureaucracies dominate the system, excluding the recipients from the decision-making process.)
People working together within a common framework for action has greater potential for generating success than those working independently. This implies that the programme should formulate a common action plan in which the role and responsibilities of each development partner in the setting are well laid out. In addition to providing the policy basis for inter-sectorality in the execution of the work of Healthy Cities, this principle has great relevance for resource mobilization from within and outside the community. Donors and community groups such as NGOs, and industrial and commercial associations that have similar development aspirations towards improving community wellbeing, will find a common framework for action appealing when considering becoming a working partner. However, the Healthy City management must play a very proactive role in advocacy and partnering in order for these relationships to materialize and be sustained.
New ideas that accommodate current values are more easily acceptable to the community than those that radically question accepted beliefs. This implies that using existing experiences of community participation and community management in promoting the Healthy City idea would appear to be more acceptable. The sustainability of the transition from traditional ways of working to new ways requires that the new approach be socially and politically acceptable, even though it might be technically and financially rational. It would appear very appealing to use existing community development activities in each of the countries (sponsored by donors, government and NGOs, or inspired individuals) and adapt these into a Healthy City type of action that accommodates the three identifying characteristics described earlier. This would perhaps be easier than starting the process from scratch.
When the boundaries of managerial action are within the limits of one’s influence, there is a better chance of achieving success. This implies the need to choose locations (settings) that are small enough so that there is full managerial control for effective execution of the programme. In the parochially deferential culture of Asia, personal charisma is a necessary ingredient to make success of any endeavour requiring leadership. Smaller settings would have a greater probability of finding that leadership which will be acceptable to a majority of persons. Furthermore, the greater the informality with which this leader can provide the leadership, the better the chance of success, since formalized leadership mechanisms give the impression of impersonality and anonymity and lack of ownership and responsibility. Family and community ties appear to be stronger and longer lasting.
There is no defined rigid or prescribed approach for initiating Healthy Cities in the Region. Ample flexibility is an inherent quality of the Healthy Settings process. If the concept is generally accepted by an inspired community leader/s, they may start the process themselves with whatever community resources are available, and technical matters are addressed as and when the need arises. Community development is a natural process that is nurtured by the community itself. Sometimes WHO is asked to facilitate an initiation process which goes somewhat along the general process outlined in the 20 steps to Healthy Cities. The sequence of these steps is by no means sacrosanct and does not have to be followed rigidly. They may be adapted to the varying development stages that a community has already gone through. Review of existing WHO and “settings” collaboration efforts in the SEA Region indicates that frequently such efforts have begun when the political leadership of the setting solicits WHO facilitation.
After providing the needed advocacy to convince the community of the relevance of the Healthy Cities process, the next step to be undertaken is conceiving an action plan. Here, in the planning and implementation phase, a first step is often a community consultation, in whatever form, to explain the purpose of the initiative and soliciting communityinvolvement. This is an extremely important step which reveals the true desire of the community for participation, which is the backbone of the Healthy Settings process. If the community is small enough for full representation of individual voices, they may all be gathered for a larger meeting, or if that is not possible, authentic representatives may be gathered for discussion.
How does one plan a Healthy City Plan?
This can take several forms, from a very simple community gathering to enunciate the community’s felt needs, to sophisticated workshops, consultations and focus group discussions with documentation of supporting evidence.
The degree of specificity and sophistication of the planning process depends on the degree of complexity of health problems in the setting. For healthy village or ward settings where more informal interpersonal relationships prevail, informal discussion may be all that is needed, while in an urban setting where more formality in the administration of city affairs is the norm, a more formalized processes may be needed. The planning process must include a critical analysis of the issues and the opportunities/resources for addressing them within the community itself, prioritizing which actions may be possible. Technical expertise for such analyses is available from NGOs, development agencies and expert individuals. Methods such as logical framework (log-frame), focus group discussions, rapid community assessments, district team problem-solving, Kiva groups, etc. are all appropriate ways of eliciting community issues. Once issues are laid out, the prioritization process must happen, since it may not be possible to address all the needs expressed given the resource constraints in any setting.
There are also many methods to plan for problem-solving. Delphi, decision tree, causal web analysis, fishbone process, group expert consultation, etc. will elicit a multitude of causes that relate to the problem, and thus by understanding the problem in depth, it becomes easier to choose the best actions that may be undertaken, again within the constraints of available resources.
With community acceptance and willingness to participate, an action plan is prepared that outlines the community health issues most felt to require immediate attention, and requisite operational responsibilities are assigned to those who may initiate action. Next, managerial (advisory and executive) committees are set up and technical work groups (task forces) identified and their mandates clarified for implementation. While the specificity and the rigour of the planning process may differ between settings, all such processes identify community health related priorities, assign task forces and set up managerial mechanisms for implementation.
Itemizing the costs of these actions will generate the budget, and the executive process will lay out the implementation agenda. Executing the programme entails careful analysis of existing community capabilities, assigning people responsibilities, and providing the means for them to function effectively. Areas of cross-responsibility that may hinder efficiency must be identified and approaches to harmonize these well outlined.
Monitoring mechanisms must be built into the programme and laid out at this stage, with indicators of progress and achievements clearly stated in tangible and objective terms. Such concrete enunciation of outputs, through describing them as SMART objectives (objectives that are clearly Specific, Measurable, Achievable, Relevant, and Time-bound) will make the monitoring and evaluation process later on very easy. Supervisory and executive functions must also be clearly laid out, with a team approach to getting the project work done. The process of monitoring continues in the implementation phase.
How does one implement a Healthy City Plan?
Here the focus is on how to move action. If resources exist for the action plan that has been delineated, and mechanisms for carrying out the process have been facilitated, success will then be contingent on the responsible execution of the action. This means that the committees and the work groups function responsibly as planned, schedules are kept and quality outputs are generated.
The general process is akin to the implementation of any community development project, with the main difference being that the various tasks outlined in the POA are not simply fund-bound projects that will end when this planned task is completed, but are conceived as interlinked projects that will continue even after the planned actions are implemented and achieved. Thus, further future action continues through the iterative process of re-planning and re-execution. This community-owned sustainability is one of the surest tests for demonstrating the effectiveness the Healthy Settings process.
For effective implementation, continuous monitoring must be maintained, ensuring that objectives are being accomplished as planned and noting the difficulties encountered so that effective and timely remedial action can be taken.
The main skills needed here are the technical functions of delivery and executive management. For example, those needing to deliver water and sanitation services may need to have the engineering or technical skills needed to implement the planned output of constructing sanitary latrines in households if that is the stated objective. Or, there may be a need for the skills of educating the local community on the need for hygienic practices in the household, such as disinfecting drinking water or properly washing one’s hands. Yet another skill needed may be educating community youth on the detriments of smoking, for a planned objective of reducing tobacco use.
These are singular skills which may be available in a uni-purpose or multipurpose health worker (they would need to be trained for this); but there is also the very important function of bringing all these providers together into a team process. This is the function of the executive manager or coordinator of the HCP. For this complex task, the executive manager, or the Healthy Settings coordinator requires good skills in leadership, team building, planning and management, and in facilitating group processes.
Usually, administrative and governance difficulties arise during implementation; some are general in such programmes and some are specific to HCPs in the Region. Implementation takes place a varying rates and with varying quality, as is to be expected according to the availability of resources and the commitment of the leadership.
Balancing funding and good management: It is very important that there be a synergybetween the financing and the managing of the Healthy Cities process. Programme funds that are well spent through a strong and efficient management system determine its success. While funds can be procured from various sources, management cannot be purchased or donated: it must be well selected, nurtured and strengthened from within the community itself. Unfortunately, the administrative and governance structures of municipalities in many Asian countries are often weak and thus it is not possible to rigidly follow the same approach and procedures as HCPs in Europe. This is why effective implementation requires contextual concernsfor HCPs which reflects the Region’s uniqueness, and an implementation framework that addresses such distinctiveness.
What are the types of issues/problems that an HCP addresses?
Given that the Healthy Settings actions are primarily for promoting the community’s health, most actions would relate to environmental health risk factors and the mitigation of disease. Ultimately, we want to reduce communicable and non-communicable diseases, and each of these has an epidemiological link to environmental risk factors, whether directly or indirectly. We have to clearly understand these linkages so that the most relevant factors can be picked out for intervention or remedial action.
What are the managerial and other constraints in implementing an HCP?
A major constraint in establishing Healthy Cities relates to generating ownership. Lack of a sense of programme ownership by the recipient community would be a major setback. Programmes initiated through political or personal expediencies do not give adequate voice to the community voice in the start-up process. Another constraint would be a lack of clear understanding of the Healthy City concept by project staff and the community. The principles of self-help and bottom-up action must be seen as the basis of the programme, which should not be viewed as a donor-driven programme which the community is merely participating in without active involvement in decision-making. Further concerns are the lack of managerial capacity and weakness of local-level public administration and decision-making capabilities. The capacity to plan and manage the programme is critical to its success. The other aspect of decision making capabilities is also directly related to the degree of decentralization through devolution of authority. Local-level authorities need to be empowered to function without a higher authority dictating the priorities of the project or controlling its implementation. Even in small settings, this empowerment of authority to function independently is necessary for success in getting the community organized according to their perceived needs.
How is an HCP evaluated?
The general principle behind any evaluation is to assess and analyze how well the programme objectives have been achieved. These can be looked at from the point of view of relevance and adequacy of the input to addressing the given objectives, and the efficiency and effectiveness of keeping to the budget and timelines. Thus, the questions that need to be answered in an evaluation of a Healthy Settings programme are whether the objectives/outputs have been achieved as planned; their quality (if there are a priori criteria to judge this); whether the planned resources were adequate for achieving the stated objectives; whether the actions and strategies were relevant to achieving the outputs; how efficiently the money and other resources were spent; and how well the schedule for action was maintained. The responses to these questions can then be used in the iterative cycle of planning for the next programme phase.
The three elements of the Healthy Settings process—the plan of action, the managerial mechanisms for implementing the plan, and the built-in community involvement process—can be looked at independently for greater depth. There are many methods that can be used to assess the above questions. A SWOT (strengths, weaknesses, opportunities and threats) analysis, focus group discussions, surveys, interviews, secondary data analysis, etc may be used for methods of eliciting data and information. The final analysis may be merely subjective or objective (using simple or sophisticated computer-based statistical analyses). Details and methodology on evaluation can be accessed in many texts on programme evaluation and websites and adapted to the above.
WHO, 1995. A Practitioners Guide to implementing Healthy Cities projects in low-income countries.
This dichotomy is designed merely to clarify the concepts, and not to indicate an unbridgeable difference. In fact, successful community development projects can be the starting point for streamlining the collaborative spirit and the enthusiasm derived from that success to build a Healthy Cities (settings) process for sustainable community health development.
WHO, 1995.Twenty steps to Healthy Cities,
Written POA acionplans
Degree of fit of the “healthy setting” concept and practice. The larger this middle intersection (overlap) area, the better the fit. In the “ideal” case the three ellipses will fully converge.