The Healthy City Response

A setting is a place comprised of a location and its social context in which people interact daily.  Examples of settings include schools, workplaces, hospitals, marketplaces, and so on.  The environment of a setting influences health considerably.  The settings approach provides an effective way to create supportive environments, as it enables complex interventions that are designed specifically to suit particular settings.

If health problems are largely experienced in these settings of everyday life, then they can also be identified and addressed there, so that the settings themselves become environments that are supportive of health. Examples of elemental healthy settings implemented in the Region are health-promoting schools initiatives (which may include environmental clean-ups and greening programs, immunization campaigns and nutrition programs), healthy marketplaces initiatives (which may include improvement of food handling practices, improvement of the market’s physical facilities), healthy workplaces initiatives (which may include the modification of the workplace environment, smoking cessation campaigns and promotion of physical activity) and healthy hospitals initiatives (which may include organizational shifts to health promotion or improving the waste disposal in the hospital).


A ‘healthy market places program establishes partnerships between all concerned to address issues such as the health conditions of stall holders and food handlers (water, toilets, availability of health services); how food staffs are handled and stored; ho to minimize any adverse impacts of markets on surrounding residential areas; garbage removal and maintenance of cleanliness of the market areas; the methods of inspection by government authorities (for example, how food inspectors can play a more educational rather than a punitive role); and finally the role of the market pace in health education.

A healthy hospital initiative is about more than starting a series of health promotion projects. To be most effective an initiative should see health promotion integrated in to the organisation. This means it should be part of the role of all hospital staff and that the organisation should develop a supportive infrastructure such as policy a statement, evidence of senior management support and incentive programs such as special funding.

Many countries have now started healthy schools projects. Again the most developed of these take a whole organisational approach and considers the health of students, staff and the community within which the school is situated. Typical projects will be those concerned with bullying, improving the environment of the school, sexual health education, school ground clean up.

Healthy city concept and projects emerged in WHO-SEAR as a response to deteriorating environmental, social and health conditions associated with urbanization as discussed above. These projects were based on the principles and strategies of Health for All and the principles embodied in the Ottawa Charter for health promotion. The HCP strategy advocates an inter-sectoral approach to health development that focuses on the environmental, social, and economic determinants of health. HCP aims to bring about a partnership of public, private and voluntary agencies to focus on urban health and to tackle health-related problems with a broad approach. In addition HCPs aims to build a strong case for public health at the local level and to put health issues onto urban political agendas.

The primary health care principles of the 1978 Alma Ata Declaration and the 1986 Ottawa Charter for Health Promotion continue to be relevant and appropriate documents from which to derive a set of guiding principles for the development of Healthy Settings. The concept of participatory development is also very relevant to Healthy Settings.

The Alma Ata Declaration espoused some fundamental principles which broadened previous definitions of health care. The principles, as contained in the Declaration are:

  1. Health is a fundamental human right
  2. Disparities in people’s health status between developed and developing countries as well as within countries are unacceptable. The key to reducing these disparities and to achieving health is in social and economic development.
  3. Equitable distribution of services
  4. Community participation in planning and implementation of health care as both a right and a duty
  5. Focus on preventive and health promotion services
  6. Appropriate technology
  7. Multi-sectoral approach

Healthy settings projects have been developed because of the recognition that health determinants are complex, that the control of health determinants is often outside the responsibility and capacity of the health sector and that effective actions to solve health problems require the integration of the efforts of various sectors.

The healthy settings approach presents a range of challenges, including low political commitment at the local level, lack of NGO and community leader participation, lack of mechanisms to negotiate with national agenda and lack of linkages between community based and thematic-driven activities. Healthy Districts can address these local level issues well as enabling the improvement and expansion of the healthy settings program

For WHO the broad Healthy City Projects objectives are:

  • Political mobilisation and community participation in preparing and implementing a municipal health plan;
  • Increased awareness of health issues in urban development efforts by municipal and national authorities, including non-health ministries and agencies;
  • Creation of increased capacity of municipal government to manage urban   problems and formation of partnerships with communities and community based organisations (CBOs) in improving living conditions in poor communities; and 
  • Creation of a network of cities that provides information exchange and   technology transfer.

Constraints in engaging the healthy settings process  

First, is the lack of the deeper understanding the concept and practice of “healthy settings”. The Healthy Settings idea seems deceptively simple at the surface, for it masks the complexity of the implementation process where sustainability must be the focus. Just any health action carried out in a community may not suffice as an example of a strict healthy settings label. There must be synergy between the plan, the management and the community for ensuring program sustainability. With government and community leadership continuously in a state of flux because of inevitable job turnovers in the system, this concept awareness needs to be continuously kept up to negate the possibility of this comprehensive process slipping into being just another project .

Second, the internal municipal governance bottlenecks also hinder the progress of the process of healthy setting. Lack of coordinated urban infrastructure responsibilities and related turf issues militate against cooperative engagement among municipal players. Structural issues of internal administration and bureaucracy in local governments, even in the now decentralizing situations find limitation. The inability or opportunities or forums for working together with other sectoral ministries, while not having a forum to deal with common issues, are constraining factors. While the health issues are a common denominator, policies and mechanisms to address these may be available only in a multitude of sectors. This necessitates collaborative approaches within and outside of participating municipal arms.  

Third, to bring holism and empowerment into the healthy settings process requires also addressing the issue of participation of the poor. The analysis reveals that there is a little evidence of participation by the poor in the healthy settings process. And because of their absence in the process, their needs are often neglected in the agenda of the settings program. Moreover, even if they were present, perhaps there will need to be the requisite egalitarian mindset of the management to give the poor the voice to articulate their needs. This is also evident from prevailing situations of the local government having little interest to promote the “settings” idea in slum areas because they are considered illegal/unauthorised settlements. 

Another limitation is the Regional country ministries of health’s low priority on preventive services and related policies. Alsor, chronically low budget allocations, weak organizational structures that accommodate comprehensive programming and collaboration and the lack of civil service requirements for public health expertise in policy level positions in MOHs are also constraints in advancing healthy settings programmes. Most MOHs are structured along clinical disciplines, curative healthcare and vertical programmes. Even budget allocation and mandates are devised along these lines. The administrative process for teamwork is limited or hindered. Inasmuch as the need to promoting the ideas of addressing health comprehensively, there is critical need to reassess and evaluate the role that Ministries of health must play in these present times of promoting sustainable health development, including the capacity building to effectuate such changed positions. 

Even with the increasing institution of democratic reforms and decentralization in many countries, the governance structures that move the system is still in a time warp. While there is move towards democratic governance through empowerment at the local levels and inclusiveness in decision making, the central authority still displays bureaucratic and vertical structures. The move one would hope to see is for more delegation and team work even at the top levels of the ministries in governments to complement and facilitate the change towards greater local autonomy. Unfortunately, even existing dual purpose or multi-sector responsibility mandated Ministries are seen to be fragmenting into uni-sector functionaries, thus having to form lateral linkages all over again for needed coordination. An analysis of why this is being so is beyond the scope of discussion here, but perhaps not so in the overall context of a healthy settings program development discourse.

Participants in a Healthy settings Program

  • Civil society    
  • Public Sector    
  • Private Sector
  • Private medical practitioners
  • Community-based groups    
  • Local government authorities    
  • Chambers of commerce
  • Consumer advocacy groups
  • Local and district health services, both community and tertiary
  • Self-help groups    
  • Schools and higher education institutions, including community colleges    Media – print and electronic
  • Social clubs, recreation clubs, including groups for aged, youth, women and so on    
  • Welfare departments
  • Religious leaders
  • Non-government organizations (NGOs) in health and other sectors (welfare, education, philanthropy, and so on)
  • Housing department    
  • Peak NGO organizations    International Development Agencies    
  • Trade Unions