The Diversity of Healthy Cities in Asia and the Pacific

Abstract

The WHO-led Healthy Cities movement, guidance on the ground and capacity-building programmes for cities in Asia, has led many cities in the Western Pacific region to address health as a central issue in urban policy. There have also been long-standing efforts to focus on health development at local, country, and subregional levels. The founding of the Alliance for Healthy Cities (AFHC), a network of cities and organisations, provided momentum for the institutionalisation of Healthy Cities and promoted a generic approach adaptable to local contexts that respects diversities.

Common characteristics observed among Healthy Cities in Asia and the Pacific were comprehensive city planning; institutional developments; public-private partnerships; and evidence gathering. As an empirical application of a ‘health promotion’ concept into specific contexts, many cities have explicitly incorporated the Healthy Cities mission or ethos into their planning. The majority of the Healthy Cities in this region have been founded by city governments and local authorities, and legislative changes have accompanied some schemes. Considerable variety exists between cities’ preferred interpretations of ‘health’ as well as their priorities, capabilities, and circumstances. However, the most consistent themes are the emphasis on citizen engagement and participation, community empowerment, and cooperation between as wide as possible a range of groups with stakes in public health.

Case studies in three cities—Phnom Penh, Cambodia; Changwon, Republic of Korea; and Owariasahi, Japan—exemplify the values of a targeted healthy settings approach, an approach to social and economic development, and a model of comprehensive citywide collaboration, respectively.

While the importance of research for Healthy Cities has been well recognised since the earliest stage of Healthy Cities, examples of systematic evidence gathering or reporting are limited. Therefore, further work is required to assess the sustainability of Healthy Cities’ plans and their suitability to the unique contexts of individual cities.

Overview

Already 50 % of the population of Northeast Asia and 42 % of Southeast Asia live in urban areas, and it is estimated that the total urban population of these regions will increase from 1.1 billion in 2010 to 1.8 billion in 2050 (Asian Development Bank 2011). The quality of urban environments such as infrastructure, housing, economy, education, and cultural diversity; the efficiency of urban life and work; the attainment of optimum and equitable population health; and social policies for ageing populations are major concerns on the public health agenda in this rapidly urbanising region.

Tokyo was the first Asian city to respond to the Healthy Cities movement of the 1980s, establishing the Tokyo Citizens’ Council for Health Promotion in 1991 (Nakamura and Takano 1992). A series of consultative meetings by the WHO Regional Office for the Western Pacific (WPRO ) on urban health issues in developing countries merged into discussions on health in rapidly growing urban areas at the World Health Assembly in 1991 (Ogawa 2003). Following endorsement of the WHO’s Western Pacific Regional Committee, ten countries (Cambodia, China, Fiji, Lao People’s Democratic Republic, Malaysia, Mongolia, Papua New Guinea, Republic of Korea, the Philippines, and Vietnam) implemented the programme (WHO (WPRO) 2000). In 1995 the Ministers of Health of Pacific Island Countries also articulated a vision of Healthy Islands (Galea et al. 2000). Called the Yanuca Island Declaration , it presented an idyllic image: Healthy Islands would be places where children were nurtured in body and mind; the environment would invite learning and leisure; people would work and age with dignity; and ecological balance would be a source of pride. Since then the Pacific Island Countries have applied this vision in areas such as environmental health, diabetes, obesity, mental health, human resource management, and elimination of lymphatic filariasis, tuberculosis, HIV/AIDS, and parasitic diseases.

By 1998 pilot projects, guidance on the ground and capacity-building programmes for cities in Asia, had led to more than 150 cities in the Western Pacific region coming to address health as a central issue in urban policy (WHO (WPRO) 2000). Following a series of meetings and consultations with researchers, practitioners, and city leaders working on Healthy Cities, the Regional Guidelines for Developing a Healthy City Project were published in 2000 (WHO (WPRO) 2000). These guidelines provided a generic approach framework and were a useful reference for innovative local and national Healthy Cities initiatives.

The WHO-led promotion of Healthy Cities found fertile ground in these regions, as there had been long-standing efforts to focus on health development at local, country, and subregional levels. One of these was the National Patriotic Health Campaign Committee established in 1952 in China. While it has adapted in response to changes in the country’s social and economic development (Qifa 2003) its aims remain: to improve health and sanitation in both rural and urban settings , through national, provincial, and local networks. This long-term development became an important basis for the later Healthy Cities movement. In Japan a national government-led programme, Health Culture Cities, started in 1993, followed by the Healthy Japan 21 programme which since 2000 has emphasised planning for health at the local level, together with numerical target-setting and evaluation. A health promotion programme establishing a community leaders’ committee had been practised since 1961 at most local administrative units (Yajima et al. 2001). Healthy Cities in Japan have been developed based on community-led initiatives like this and other public health development efforts, at local and community levels. In the Republic of Korea, following the National Health Promotion Act in 1995, local government and health centres became active in developing health promotion programmes for communities (Nam 2011). These locally led initiatives are regarded as a basis for Healthy Cities. In Malaysia, in both cities such as Kuching (Chi 2003; Edris 2003) and Johor Bahru (Rahim 2003) and in village settings (Kiyu et al. 2006), a Healthy Cities approach has been applied and widely accepted as a way of improving the health of the population.

In 2003 a regional consultation meeting of WHO WPRO recommended formulating the Alliance for Healthy Cities (AFHC ), a network of cities and organisations (WHO (WPRO) 2003). Since its inauguration in October 2004, members of AFHC have developed their Healthy Cities following WHO guidelines, national and regional recommendations, and their respective steering groups. A vision to improve citizens’ quality of life has been widely shared, and diverse programmes have been implemented. The AFHC provided momentum for the institutionalisation of Healthy Cities (WHO (WPRO) 2010a) and promoted a generic approach adaptable to local contexts. The AFHC network respects diversity and accommodates governments, communities, and private organisations from both non-profit and profit sectors, depending on social and political circumstances. The WHO Collaborating Centre for Healthy Cities and Urban Policy Research, designated by the WHO in 1997 and stationed at the Department of Health Promotion and International Health at Tokyo Medical and Dental University, is providing technical support to this network. In addition, following the WHO Western Pacific Regional Committee’s resolution in 2010 on healthy settings to advocate Healthy Cities and Healthy Islands as a multisectoral development agenda, country-specific guidelines, recognition, and evaluation have been developed.

Creative moves at regional, national, and local levels towards health promotion and development, combined with the conceptual framework of Healthy Cities, have led to the growth of Healthy Cities in this region, aligned with the social and economic development of its nations and its cities.

Structure

There are country-based, subregion-based, and international networks of Healthy Cities. The interactions of these networks and their support for each other have helped expand the Healthy Cities movement because they meet specific regional and national needs, and nurture a spirit of international information-sharing. Among those networks, the AFHC provides international forums for mutual learning from locally based initiatives, following WHO guidelines and advice for developing Healthy Cities (Nakamura 2011). The members of the AFHC include local governments, national agencies, NGOs, academic institutions, organisations from the private sector, and international agencies. Those members pay membership fees and participate in its programmes.

In October 2004, when the Inaugural Conference of the AFHC was held in Kuching, Malaysia, 26 cities and organisations joined AFHC as founding members. Since then the membership has steadily grown: there were 213 member cities and organisations in October 2014.

The goal and objectives of the AFHC are clearly stated in its charter (see box below). The general assembly of the AFHC serves as its main governing body. The steering committee of the AFHC, which consists of 12 elected members, serves as the policy-making arm of the AFHC. The convenor city of the General Assembly is elected for a term of 2 years and serves also as the chair city, hosting a global conference and the meeting of the General Assembly every 2 years. AFHC chapters are organised at country, sub-country, and inter-country level on approval of the general assembly; as of October 2014, five national chapters had been formed in Japan, China, Korea, Hong Kong, and Australia and others were set to follow. These chapters play key roles by disseminating and sharing information in local languages and contexts, expanding membership, and offering mutual mentoring. Collaboration with WHO allows members to learn from the global public health agenda and from urban development challenges.

Goal and Objectives of the Alliance for Healthy Cities (from the Charter of the Alliance for Healthy Cities, October 12, 2014)

Goal:

To promote and protect health and improve the quality of life of urban populations in a sustainable manner through the Healthy Cities approach.

Objectives:

A. To strengthen Healthy Cities initiatives and encourage the development of innovative plans and programmes to improve the quality of life and address the health challenge of specific settings and communities

B. To share experiences in improving the quality of life and addressing common health problems among members

C. To recognise and promote outstanding practices and innovations within Healthy Cities

D. To mobilise and optimise the use of all available resources to promote and support the adoption of the Healthy Cities approach among cities and other communities in the Western Pacific Region and other regions

E. To develop new knowledge and technology in collaboration with the academe, universities, and centres of learning and to package technical resources for the improvement of planning, implementation, and evaluation of Healthy Cities

Membership is granted upon recognition by the steering committee, on submission of documentation providing (1) a written policy statement in support of Healthy Cities; (2) future vision and goals; (3) a profile of the city (baseline data); and (4) analysis of priority health problems. These requirements are mandatory for the initial phase of membership and developments are expected to occur based on these fundamental elements. All member mayors and representatives sign the AFHC charter, which outlines the vision of its members built on the experiences of Healthy Cities worldwide.

The work by national government agencies and related bodies helps develop country-based guidelines and capacity-building programmes, and mobilises seed funds for Healthy Cities planning and programmes when applicable. Academic institutions play roles in consultation, evidence-gathering, providing training for workers, and conducting needs assessments for the planning and efficient implementation of a Healthy City project.

Common Characteristics

Comprehensive City Planning

The health of city dwellers largely depends on their living conditions and lifestyles. The determinants of health are defined by the WHO as ‘the range of personal, social, economic and environmental factors which determine the health status of individuals or populations’ (1998). After developing experience in interpreting the ‘social determinants of health’ in the Healthy Cities context (WHO 1998), a series of works by the Commission on Social Determinants of Health concluded that action was needed so that health equity could be achieved (WHO Commission on Social Determinants of Health 2008).

Studies on the determinants of health of city dwellers revealed the large contribution of socioeconomic and residential environmental factors on a population’s health status, in addition to healthcare-related factors (Takano and Nakamura 2001). It also noted that individual determinants of health interact with each other, producing a need for an integration-oriented perspective in urban health policy interventions. As an empirical application of a ‘health promotion’ concept into specific contexts, the Healthy Cities Guidelines encourage integration of policies and programmes to avoid duplication of efforts, and the sharing of policies with multiple partners (WHO (WPRO) 2000). This is reflected in the experiences of Healthy Cities in the region, in which considerable variety exists between cities’ preferred interpretations of ‘health’ as well as their priorities, capabilities, and circumstances, both human and environmental. Most take a broad conceptual approach to health and are attempting to address it on multiple fronts. As this involves action in many different urban settings and the participation of a range of stakeholders, many cities have explicitly incorporated the Healthy Cities mission or ethos into their planning. The most ambitious have developed master plans entirely dedicated to Healthy Cities objectives and encompassing many different public health concerns, as well as engaging with stakeholders responsible for improving them.

In the Directory of the Alliance for Healthy Cities, examples of comprehensive city planning in the Asia Pacific region are as follows (AFHC 2014).

Japan

Japanese examples are the most consistent. Kameyama is notable for declaring its Kameyama City Comprehensive Plan as a city plan of the highest level; the outline of its basic policy stipulates its guiding goal as ‘Creation of a healthy environment with blessings of nature’, and its Everybody Healthy Project in 2012 made a policy-wide commitment to supporting citizens’ physical and mental health. Owariasahi’s Healthy City programme is based on the 5th Owariasahi City General Plan; Yamato started its 10-year strategy of the eighth Total City Plan in 2009; and the New Healthy Obu 21 Plan, set to run for 10 years, gives its objective as ‘Extend healthy life—healthy city to celebrate longevity’. It is noticeable that these plans tend to state their core goals extremely broadly; these often are realised in multiple pillars of health policy, which may themselves contain a multitude of specific goals and indicators—in Yamato’s case, for example, there are seven basic goals, 23 sub-basic goals, and 1000 projects under the three headings of Human Health, City Health, and Societal Health.

People’s Republic of China

In Wujiang, in Jiangsu Province of the People’s Republic of China, the city releases regular 5-year plans on healthy city construction, the current being ‘Wujiang’s Patriotic Health Campaign and Healthy City Construction Plans’ for 2011–2015. Its goals are to establish five systems for health improvement based mainly on water environment management and measures for medical provision, and to raise health standards through innovative ideas and methods. Another city, Wuxi, issued a 3-year plan in 2008 covering five major tasks and encompassing 21 working plans and 68 targets; since 2011 it has progressed into a second-round 5-year plan.

Republic of Korea

Comprehensive planning is also notable in Korean cities. One of the most distinct is Changwon, the first planned city in the nation: its infrastructure had been well established, especially in transport, green areas and ecosystems, walking courses, and public sanitation. The city of Siheung also stands out, not only for its Siheung Healthy City Model 21 but also for its development of the Baegot New Town project—the first such settlement in the nation to be developed under the Healthy Cities concept from its beginning, to consist of parks and eco-friendly schools, the sea on one side, a rich green environment, and direction by a steering team of experts and citizens from the design stage. The existence of plans at that scale is generally very evident in Korean cities, most of them highly comprehensive and clearly spelling out their visions and goals.

Taiwan

The same is true for Taiwan. Chiayi drafted a 3-year programme called the Chiayi City Healthy City Promotion Project , which underwent a systematic process of preparation and establishment (2006–2007), and then execution and implementation (2008–2010). Most of the city’s public health efforts are conducted under this planning framework, including the installation of many facilities for social welfare, safety, and cultural expression, such as parks, museums, and support or service centres, as well as environmental renovation. Another city of note, Pingtung, has a similarly varied and wide-ranging framework which includes, among many other things, large-scale strategic rehabilitations of countryside villages and reconstruction of flood-prone areas.

Institutional Developments

Along with changes at the level of comprehensive planning have come new institutions, created or adjusted to fulfil these visions of improving health. In the first instance are the cities’ Healthy City representative bodies themselves, which show very varied institutional character and structure. According to the directory of the Alliance for Healthy Cities (2014), the majority of the Healthy Cities of their members have been founded by city governments and local authorities, often in cooperation with other stakeholders, and key responsibilities in overseeing these bodies’ functions remain in the hands of mayors’ offices and public departments. Exceptions include Illawarra and Onkaparinga in Australia, whose representative bodies are non-governmental organisations.

Regardless of their composition, most Healthy Cities stress collaboration with a wide range of stakeholders and engagement with citizens. Many cities incorporate the stakeholders into their leadership structures to form multisectoral committees or other organs for a more consultative, inclusive direction. The core teams and steering committees typically consist of public officials, usually from mayors’ offices or multiple government departments, but they coordinate and rely upon any number of collaborative units to plan and implement their work.

Legislative changes have accompanied some schemes. Logan City in Australia, for example, credits ‘local government reform and changes in legislation’ as laying the foundations for its initiative. In the Philippines, the city governments of Marikina and Parañaque passed ordinances to found their Healthy City programmes. A number of laws have been passed at local level to regulate or promote activities in specific areas. Examples of these include implementing anti-smoking measures, particularly in the restriction of smoking in public places and indoor venues, increasing cigarette taxes, devising public policies advantageous to health, promoting physical activity, promoting dental and oral hygiene, reducing risks and vulnerabilities of older persons by providing discounted services, introducing an insurance system for injured cyclists, preventing atopic diseases, implementing suicide prevention measures, and promoting community participation.

To fund Healthy Cities programmes, Korean cities receive benefits from their national government’s Health Promotion Act, which stipulates that Korea’s Health Promotion Fund, which receives its money from taxes on tobacco, provides money to health promotion programmes (Nam 2011). The money is used for both health promotion activities and Korea’s National Health Insurance, but the allocation to health promotion increased from 17.8 % in 2002 to 43.8 % in 2009 (Nam 2011). The City of Wonju made a further decision to use local tobacco tax revenue for priority projects identified by the Plan of Healthy City Wonju (Nam et al. 2011).

Public–Private Partnerships

A most consistent theme of Healthy Cities in the region is the emphasis on citizen engagement and participation, community empowerment, and cooperation between as wide as possible a range of groups with stakes in public health. The leadership structures of most cities include teams and committees encompassing many different sectors, including both public and private institutions: local government, medical services, academia, health experts, public agencies, NGOs, industry and businesses, and residents’ representatives. Examples of public–private partnerships in the directory of the Alliance for Healthy Cities (2014) are as follows.

Hong Kong

The districts of Hong Kong, which place public–private and cross-sectoral collaboration at the core of their approaches, emphasise partnerships. The involvement of businesses and private enterprises is consistently observed. The Kwai Tsing Safe Community initiative combines the joint efforts of over ten local public and private organisations; and Tsuen Wan’s Safe and Healthy City Steering Committee was supported by 20 local public and private groups including businesses, NGOs, large enterprises, and government departments (AFHC 2014). Its Safe and Healthy Occupational Safety Charter Working Group is a good example of these partnerships. Similar collaborations are found in other districts in Hong Kong, and in most Taiwanese Healthy Cities.

Japan

Japanese cities also develop partnerships, but what perhaps stands out most is the involvement of academic, scientific, and medical institutions. Some cities are developing physical fitness programmes and community care for senior citizens in collaboration with a venture firm which began from a university project or a university-led consortium in the private sector. Most cities’ Healthy City or health promotion committees include academics, medical and dental professionals, health promotion personnel, community representatives, and local business representatives. Hamamatsu has chosen to reflect its cross-sectoral collaboration in its logo design, which displays a ‘kite’ representing health as something raised up by the cooperation between many people and many varied groups.

Republic of Korea

Korean cities consistently develop partnerships, with a certain variety in their focus. Government–academic collaboration has involved academic personnel in baseline data collection, analysis of health profiles, and planning and evaluation in relation to a number of Healthy Cities. Siheung Healthy City runs business-oriented activities including the construction of Siheung Business Center, cooperation with retailers to differentiate retail strategies in four marketplaces, and creation of public sector jobs. A strong community focus is another characteristic of public–private partnerships: Guro-gu in Seoul, for example, emphasises community-led projects whereby residents of a community are in charge of planning, carrying out, and evaluating programmes for themselves without intervention from city officials, thus engaging and bringing citizens together and developing a close social network.

Malaysia

Kuching South in Sarawak has an organisational structure consisting of mayors, councillors, and divisional heads, but also community leaders, NGOs, and some prominent private companies. The importance of collaboration between these groups is well recognised by its steering group, which regards ‘the spirit of Corporate Social Responsibility’ as behind the success of the Kuching Healthy City programme. This programme has a long history, working together with Kuching North, the State Planning Unit, and the Health Department of Sarawak since 1994.

Evidence Gathering

The importance of research for Healthy Cities has been well recognised since the earliest stage of Healthy Cities in this region (Takano et al. 1992), and a series of research projects on indicators and determinants of health have been conducted (Takano 2003; Nakamura 2003). Participatory-style research (Takano and Nakamura 2004), jointly undertaken by community members and researchers, involves both groups in planning, implementation, analysis, discussion, dissemination, and evaluation, and gives communities access to evidence-based information that facilitates better planning and improved activities; this is encouraged in Healthy Cities.

According to the directory of the Alliance for Healthy Cities (2014), efforts among current members of the AFHC on evidence-gathering, planning cycles, or needs assessment and evaluation vary. Baseline city health profile information is collected in most Healthy Cities, and results from the monitoring of these profiles are reported in some. Unfortunately, examples of systematic evidence-gathering or reporting are limited. Further work is required to assess the sustainability of Healthy Cities plans and their suitability to the unique contexts of individual cities.

Gathering evidence on specific topics according to the priorities of individual programmes is evident in Hong Kong and Macau. Wan Chai conducted an ethnically and demographically disaggregated survey with interviews to investigate the mental health status of the community; in Sai Kung the focus was on accessibility, with two rounds of inspections of barrier-free facilities carried out in 2009 and 2012, to help define possibilities to improve them and alert the owners of buildings to their obligations to optimise the barrier-free facilities on their properties. Kwai Tsing, with its strong emphasis on physical and occupational safety, conducted surveys to assess the community’s perceptions of safety issues. Kwun Tong carried out a community diagnosis in 2005 to investigate the health status and living habits of residents; the health promotion activities in the years that followed were designed in response to the results. Macau completed a city health diagnosis in its 2003–2004 preparatory and organisational stage, and the identified priorities formed the basis for the six health task forces set up in 2005.

In Taiwan, Taoyuan developed a project cycle based on a framework of 20 steps towards a Healthy City, which it has split into three stages: preparation, organisation, and action. In Hsinchu, evaluation responsibilities are organised across several bureaus. Chiayi set up a wide range of local Healthy City indicators for monitoring and improving its progress, and developed a specific evaluation mechanism; and the Daan district of Taipei carried out a health census in the community, creating a set of health indexes to identify residents’ needs.

Some Korean cities carry out comprehensive analyses of their plans and activities. Yangcheon-gu has evaluation mechanisms by which projects’ inputs, outputs, and results, as well as budget commitment and user satisfaction , are evaluated according to an index. Pohang composed an urban health index profile with five areas and 34 indexes in 2012, and analysed how healthy the public consider the city in different aspects. A number of these cities emphasise citizen involvement: Guro-gu’s community-led health promotion project actively involves residents in planning, carrying out, and evaluating programmes with guidance from the community health centre; and Siheung and Dangjin offer further examples of citizen participation in evaluation. Jincheon holds an open competition for healthy city programmes, where qualified organisations submit their proposals and the best are selected. More generally, Dobong-gu designs businesses and projects on the basis of surveys of residents’ health conditions, requests, and satisfaction, as well as on the results of previous years’ businesses and projects. Wonju’s efforts are based on a ‘plan–do–see’ cycle , and Yongsan-gu carries out evaluations to compare plans at the start of each year with their results at year’s end, with achievements and residents’ satisfaction determining which planning procedures go forward.

Most cities in Japan monitor health promotion indicators, set objectives for each project, and then compare achievements after a year by considering national guidelines and the cities’ specific priorities. For example, Hamamatsu performed an evaluation in 2011 to re-evaluate initiatives up to that point and used the results to launch ‘Healthy Hamamatsu 21’ in 2013. Fukuroi’s health promotion plan undergoes evaluation by taking into account the changes in performance of projects over the years and comparing them with others in the country and prefecture. Owariasahi holds citywide surveys every year whose results showed an increase of citizens aware of the city’s Healthy City efforts from 26.2 % in 2006 to 56.8 % in 2012.

Case Studies of Developments in Specific Cities

The following case studies consider in more detail the Healthy Cities efforts in three cities in the Asia Pacific region, each of which exemplifies a certain key theme. These are Phnom Penh, Cambodia, which demonstrates a targeted Healthy Settings approach; Changwon, Republic of Korea, which has integrated its concern for sustainable public health into its approaches to social and economic development; and Owariasahi, Japan, a model of comprehensive citywide collaboration.

A Healthy Settings Approach: Phnom Penh, Capital City of Cambodia

Phnom Penh is the national capital of Cambodia, located in the south of the country at the confluence of the Mekong, Tonlé Sap, and Bassac rivers. Established in the fourteenth century, Phnom Penh became the permanent Cambodian capital and seat of government in 1865. Major urban infrastructure investments were made during the French colonial period in the early twentieth century and after independence in 1954, but the city was devastated following the rise of the Khmer Rouge in 1975–1978. Since the early 1980s, with the help of foreign investment and the international community , the city has been steadily rebuilding. It is now a significant political, commercial, cultural, and tourist centre in Southeast Asia, occupying an area of 678.46 km² and with a population of approximately 1.5 million people as of 2012.

Phnom Penh established a Healthy City Steering Committee in 1997. It has been especially notable for organising its Healthy City activities according to a settings approach: that is, an integration of activities to focus on distinct locations and their social contexts in which people interact daily, such as schools, workplaces, hospitals, or marketplaces (Secretariat of Phnom Penh Healthy City 2011). Such a focus can help enable complex interventions specifically suited to particular settings, whose effects then synergise in promoting health in the city as a whole. Within this framework, hygiene, sanitation, and waste management have been foremost priorities in a city which has faced rising urban poverty and challenges in access to latrines and potable water. Medical services have received significant attention, as have road safety and risk factors in the spread of non-communicable diseases.

At the start three settings were targeted: Bak Touk School as a Healthy School, Orussey Market as a Healthy Market, and Phnom Penh Municipal Referral Hospital as a Healthy Hospital. Since then a growing number of initiatives have been added to these efforts, but the settings approach has remained the foundation. In the 2010–2015 period, prototype health settings are being set up under several major categories: Healthy Workplaces (all Capital Hall departments, 7 restaurants, 10 factories, 5 guesthouses); Healthy Markets (2 markets); Healthy Commune Offices (12 communes); Healthy Hospitals (2 hospitals); and Healthy Houses. Healthy Schools remain on the agenda. An overview of these categories, each of which has a specified minimum package of commitments, may suggest the advantages of this approach in addressing the health concerns specific to each setting.

Healthy Workplaces , including factories and small industries, focus on setting up workplace policies such as health and safety training and smoke-free environments, as well as improving the physical environment such as air quality and ventilation, using safety equipment, reducing exposure to work-related hazards, and implementing fire prevention plans. This setting also calls for the provision of health services and education to staff, supporting healthy lifestyles with programmes on personal health skills such as nutrition and smoking cessation, and addressing concerns outside the immediate workplace such as preventing pollution from the external environment and playing a positive role in the community.

Healthy Markets receive clear political commitments and policy leadership from local authorities and market management, while national or provincial authorities promote the concept among governmental and non-governmental agencies. Improving the physical environment is a key concern, and includes building and path maintenance, and providing maps and signs, light and ventilation, and fire prevention plans. Availability of hygiene facilities, such as toilets, clean water, and soap for hand-washing, and water supply for drinking, washing, and disinfecting are high priorities, as are additional sanitation measures such as solid waste management and improvements to the sewerage system. Markets are further identified as a place to promote health education, with training in first aid and food hygiene provided to vendors and employees, and healthy practices in food handling, hygiene, non-smoking, and environmental protection communicated to the public.

Healthy Commune s are also concerned with improving public health education, healthy lifestyles, and solid waste management, supported by commune policies. (Communes are a third-level administrative subdivision in Cambodia, into which districts are divided. Phnom Penh has a total of 812 districts comprising 96 communes.) Additional attention in improving the physical environment is given to paving roads, constructing walking lanes along main streets, planting trees along roads, providing gardens and green spaces, and improving sewerage systems and air quality. Security is also a priority, in terms of preventing crime and drug abuse, implementing village safety policies, and ensuring the absence of gangsters.

Healthy Schools implement improvements to infrastructure and health facilities as well as sanitation. The former includes sports playgrounds and safe play surroundings, fire extinguishers, furniture, and first aid kits; the latter involves providing an adequate number of toilets, and sinks for hand-washing with clean water and soap, as well as solid waste management, sewage improvements, and vector control. Naturally schools are also a site for the promotion of health education, including hand-washing, hygiene, nutrition, and healthy lifestyles.

Healthy Hospitals’ commitments include implementing infection control, and physical improvements such as ensuring adequate light and ventilation for safe operations, the availability of basic hygiene facilities, and the establishment of treatment plants. Policy commitments from management boards establish conditions for developing hospitals as healthy workplaces, while education is provided on breastfeeding, maternal and child healthcare, and other areas.

Healthy Houses are committed to a general range of improvements such as access to safe drinking water and sanitary facilities, good ventilation, solid waste management and sewerage systems, healthy lifestyles, and a non-crowded and smoke-free environment.

In addition to these settings, Phnom Penh runs an Environmentally Sustainable and Healthy Urban Transportation (ESHUT) initiative (WHO (WPRO) 2010b). This seeks to address healthy and safe road transport and urban beauty; it promotes such varied activities as cycling to reduce traffic congestion and accidents and the construction of gardens and parks. As a next step in relation to health and transport, Capital Hall has introduced a bus system, and is expanding the number of bus lines from three in 2014 to ten in 2015 (Alliance for Healthy Cities 2014).

Taken together, Phnom Penh’s approach has enabled it to target interventions effectively, in accordance with the requirements and conditions of specific settings, drawing on the knowledge and leadership of their primary stakeholders and enabling overarching priorities, such as sanitation and safety, to be implemented in ways most suitable to each environment (Secretariat of Phnom Penh Healthy City 2011). Although much work remains to be done, this approach has enabled Phnom Penh to make significant improvements under its Healthy City initiative: these have included reductions in infant and maternal mortality (Fig. 11.1), expansion of primary health service provision, improvements in road quality, and a decline in temporary settlements: by 2008, 86 % of households had access to safe water, electricity, and toilets compared with 66 % in 1998. The city thus stands as a leading example of a Healthy City initiative which takes a healthy settings approach to overarching public health challenges, and provides a valuable point of reference for other cities attempting to implement a settings-based approach, as well as a source of lessons for further development of the healthy settings concept itself.

Fig. 11.1

Trends in childhood mortality in Phnom Penh (data source: 2000, 2005, and 2010 Cambodia Demographic and Health Survey.)

Integration of Sustainable Health Development and Economic Development: Changwon, Republic of Korea

Changwon is a city in the southeastern Republic of Korea (ROK). It is the capital city of Gyeongsangnam-do (Gyeongsangnam Province ), and is located close to ROK’s second-largest city, Busan. The city, over 600 years old, was designated an Industrial Base Development Area in 1974. This involved constructing the Changwon Industrial Complex in the southern part of the city, and pursuing a development plan by which Changwon became the fourth planned city in the world and the first in Korea. In this capacity it has become an important centre of manufacturing, agricultural production, and knowledge-based high-tech industry, with a well-established public infrastructure in transport, sanitation, and parks. Rapid urbanisation and worker migration gave it a population of about 500,000 by 2008. In 2010 three neighbouring cities were merged with it, bringing its area to 736.34 km² and its total number of inhabitants to over one million.

Changwon’s Healthy City initiative, Healthy Cities Changwon, has operated in the midst of this rapid economic development and transformation , and through it the city has sought to harness opportunities to improve the health and welfare of its citizens, and manage the drawbacks. Health promotion efforts have been carried out in the city since 1989, but since joining the Alliance for Healthy Cities as a founding member in 2004, it has consolidated these efforts into a set of systematic programmes under a comprehensive vision and organisational structure, with a settings approach, a broad and inclusive concept of health, and full engagement with communities and stakeholders to make programmes responsive to citizens’ needs.

Changwon’s principal health challenges are inseparably linked to its development journey over the last few decades, and the initiatives to address them have been grounded in that context. This may be illustrated by a brief exploration of some of its focus areas: urban planning, health equity, and communicable and non-communicable diseases.

First, Changwon has experienced very rapid structural, industrial, and population growth , particularly centred on its industrial complex. Although most of its factories are non-polluting, an increase in greenhouse gas emissions, mostly from rising motorised vehicle use, has contributed to climate change and air pollution. In response, Changwon has declared itself a ‘cycling city’, the first in Korea, placing the bicycle at the centre of an urban planning framework to promote healthy living and working conditions, lifestyles, accessibility, and social networks. It has identified cycling as a source of health benefits across the board: it is clean, relatively affordable, and efficient; it provides an opportunity for physical exercise and helps cultivate a sense of independence; it contributes to the goals of reducing pollution and congestion from car usage in a highly condensed population; and ultimately it creates an environmentally outstanding sustainable city. Under its Environmentally Sustainable and Healthy Urban Transportation (ESHUT) programme (WHO 2010b), a variety of resources and many new jobs have been created. A rigorous urban planning framework, with considerable budgetary support, has emerged to support pursuit of this vision with infrastructure plans such as improvements to cycle lanes and facilities, and social initiatives such as provision of bike insurance and bike hire systems, as well as numerous public events. To create a clean, beautiful urban landscape, the construction of pedestrian overpass bridges in the city has been avoided except for a single bridge between an existing elementary school and a renovated apartment complex, required for student safety.

Second, health equity in Changwon also reflects the city’s transformation. A significant divide has emerged between its east side, consisting mostly of newly constructed offices with modern-style architecture and facilities, and its west side, the old town experiencing a sense of relative loss or deprivation that has deepened with the rapid population growth. The city has identified these socioeconomic inequalities —in income distribution, long-term unemployment, education, access to nutrition, clean water, and essential services—as a major source of adverse health outcomes and inequality, including the unequal presentation of non-communicable diseases, lifestyle-related issues like obesity and smoking, and overall life expectancy. A gendered dimension is also apparent in inequities arising from women’s lower socioeconomic status relative to men. Changwon has taken these problems seriously. It has committed to the principle that health is a human rights issue and a development responsibility, and has acknowledged the need to increase the overall financial and resource pool, to allocate a bigger share of it to the most vulnerable groups, and to do so not only in primary healthcare provision but also in all policies and programmes relating to health, including those outside the immediate remit of the health sector. It has identified good governance, thorough data collection and analysis, and collaborative inter-sectoral partnerships as vital action points, and derived three principles of action on health equity: improving conditions of daily life; tackling inequitable distribution of power, money, and resources; and developing public awareness of the social determinants of heath. A new publicly funded health-promoting centre, in addition to public health centres, was established in the west-side old town in 2002. Critically, for a city whose modern history is predominantly told as a story of economic development, the city has asserted that economic growth, rather than a goal for its own sake, must be a means to health and health equity through appropriate social policies and action on the social determinants of health across all sectors of government and society.

Third, Changwon has experienced an increasing health burden from non-communicable diseases (NCDs ) such as cardiovascular diseases, diabetes, cancer, arthritis, and obesity, which have disproportionately impacted on disadvantaged sectors. The city has identified NCDs as serious public health concerns and considers them closely linked to social and economic forces. Its strategies to address them have been synergetic: healthcare provision for NCD research, detection, and treatment is being strengthened and the health sector reformed, but the efforts to reduce risk factors have extended far beyond the health sector and affect public policy in areas like agriculture, pharmaceutical production, finance, trade, transport, education, urban planning, taxation, and sport. Cross-sectoral collaborative efforts have been established in a full range of settings. For example, to increase the physical activities of citizens, the city has encouraged the development of walking trails in apartment complex areas, and 85 % of its citizens now have access to these trails. To improve citizens’ responses to health emergencies, the city provides instructions on cardipulmonary resuscitation. Automated external defibrillators have been installed in public places such as apartment complexes or shopping malls.

Fourth, Changwon, like much of Korea, experiences infectious diseases like autumn diseases, HIV/AIDS, and especially tuberculosis (TB) as leading causes of death. It suffered significantly from the swine flu pandemic of 2009. School-age and elderly persons have exhibited particularly high rates of TB infection, the former because of transmission between students sharing classrooms, and the latter because of endogenous reactivation of remote infections acquired when TB was more prevalent. Ethnic minorities also appear more vulnerable. In response the city has placed control of communicable diseases at the forefront of its urban development responsibility, and is implementing comprehensive awareness-raising initiatives, educational interventions including hand-washing programmes, and control measures on transmission in hospital settings, among others.

Changwon’s Healthy City programme has infused the city’s fundamental approach to development, re-framing the concept so that rather than being an end in itself, economic development is harnessed to improving the health and welfare of citizens, as a defining goal and primary public responsibility. This has given the city advantages in the ability to authorise and fund public policies to address health comprehensively: establishing wider social and economic challenges within the remit of public health, including those of fairness and equity, and implementing measures to address them in those terms. This gives Changwon tremendous potential as an international model, above all for cities where development narratives and frameworks are currently influential.

Healthy Cities Changwon has since evaluated its progress and identified six components contributing to its long-term sustainable development : (1) making the development of initiatives and their incorporation in existing community institutions a routine activity; (2) advocating policy change; (3) mobilising community residents; (4) changing community norms; (5) engaging stakeholders; and (6) providing leadership and political will.

Citywide Collaboration Towards a Healthy City: Owariasahi, Japan

Owariasahi is a city of approximately 83,000 inhabitants in Aichi Prefecture, central Japan. It is well connected by road and rail links, and its neighbourhood includes the major city of Nagoya and also Seto city, whose pottery and ceramic production is a key part of Owariasahi’s industrial and cultural heritage . The city covers an area of 21.03 km² and has 49 m² of park space per capita, including the Aichi Prefectural Forest Park (Shinrin Koen). The city became a founding member of the Alliance for Healthy Cities in October 2004, has developed its own Healthy City programme, and has contributed to expanding the Healthy Cities in the region by showing steady progress through the teamwork of its city council, mayor’s office, Healthy City Promotion Office, all divisions of the city, private organisations, and community groups (Fig. 11.2).

Fig. 11.2

Owariasahi’s guidelines (source: Owariasahi Healthy City Programme, December 2005)

The Owariasahi Healthy City Programme began in 2005, and adopted three overarching guidelines: ‘A city that prevents people from becoming bedridden’; ‘A city people want to go out into’; and ‘A city where people would always want to live’. Each guideline has been targeted through a set of policies: the first through strategies for physical, mental, and children’s health; the second through strategies to infuse personal warmth into the city, make it easy to get around in, and offer many enjoyable activities; and the third through strategies to offer an attractive living environment where people consider and take good care of each other and their natural surroundings. These, through effective collaboration, have guided specific initiatives such as the Genkimaru health evaluation system, a muscular training course and walking programme, the Asapy City Bus system, and an annual Health Fiesta.

The city has continuously monitored progress, conducted evaluations, and updated leading plans. An initial evaluation was carried out in 2010, 5 years into the programme, and found general improvements across the board, particularly in the average length of periods of independence in people over 65 years old. It also identified issues requiring further work, such as mental and physical health, public infrastructure including pavements and train stations, and consideration for natural surroundings. A progress report in 2012 found further progress on elderly people’s periods of independence, especially with their increasing use of the Asapy bus system. Indeed, when the city revised its plans and added new strategies in 2014, it cited elderly self-reliance, low costs of elderly nursing care, and a low percentage of elderly citizens requiring such care as among its proudest achievements. As of 2014 the city pursues seven leading plans : (1) cycling for health; (2) enhancing the health of the elderly; (3) making the city enjoyable for walking; (4) being refreshed; (5) providing food education for health; (6) developing an eco-garden city; and (7) renovating the whole city.

Owariasahi is exemplary of cities taking a comprehensive citywide approach to health promotion, with systematic collaboration between departments and sectors across many aspects of city life. This was envisaged from the outset, and since 2014 has been consolidated under the fifth Owariasahi City General Plan, which replaced the previous one that ran for 10 years. The new plan introduced and integrated the term and concept of the Healthy City into the core municipal policy framework. With regard to its central leadership, the programme is overseen by a subsection of the mayor’s secretary section in the city’s planning department, whereas an administrative evaluation system is provided by its Healthy City Promotion board of directors, which includes the mayor, the vice-mayor, the superintendent of schools, and the city’s nine division managers. This provides strong political support at the core of the programme’s coordinating structure .

Several additional structures are in place for cooperation between these officials and a wide range of citizens and stakeholders . Most prominently, a round-table conference, established to create a forum to incorporate the views of citizens, is held on a regular basis. Its 12 members include a university professor; professionals from the industrial, commercial, agricultural, sports, healthcare,, and education sectors; representatives of several community bodies and clubs; and two unaffiliated members of the public. In addition, the city has sought expert advice from numerous academic and professional specialists in formulating its policies, including the Tokyo Medical and Dental University. The city also supports the development of citizen leaders and their own projects and programmes: for example, the Asahi Health Meister recognition, started in 2008, commends and helps motivate citizens to further continuously engage in health promotion activities in communities, with efforts made on a citywide basis. Questionnaires every 2 years assess citizens’ views on the achievement of policy targets, for use in continuing programme design. Recently, in preparing the fifth Owariasahi City General Plan, studies and discussions were undertaken with citizens, including groups such as junior high school students, to identify their needs and opinions.

This citywide engagement and collaboration extend into programme practice. Such processes are illustrated in three of its most prominent projects: the Asapy City Bus, the Asahi Health Fiesta, and Hotto Challenge Walking. The Asapy City Bus , one of the city’s leading achievements, is a case in point. Rather than directly administering it, the city authorises an entrusted manager to manage the bus system with skill and flexibility, reducing costs and providing benefits for citizens. Citizen involvement and initiatives have been drawn on at all stages: a public petition in 1999 first put the idea of a city loop bus on the agenda; citizens were invited to choose the system’s name in 2004, and were directly involved in discussions to develop the system and plan its routes to meet their needs and cover all required areas. A second example is the Asahi Health Fiesta, held on 29 April each year, which serves as a major event representing the city’s efforts and promoting comprehensive health knowledge and services. The Health Fiesta has now grown to encompass a huge range of participating groups such as public divisions in all sectors, even those not immediately obvious in their relation to health; medical providers such as hospitals and health associations; corporations and consumers’ groups; university and students’ groups; and sports, art, and music organisations. A final example is the Hotto Challenge Walking activity, which since 2010 has held walking events and promotes the joy of walking: to this end, the organisers cooperated with a private business to develop a smartphone app, seeking to extend the activity’s appeal to young people.

There are several additional examples of collaboration with the private sector . A company that runs a cafeteria helps supply a Healthy Lunch with low calories and salt content every Wednesday, supplemented by the city’s special vegetables and fruit (petit vert—a new hybrid of Brussels sprouts and kale well suited to small-scale suburban intensive farming—and figs, respectively) contributed by local agricultural cooperatives. Businesses have also cooperated in the Company Cafeteria Lunch Tasting Tour to Promote Health since 2014, in which participants visit companies and sample health-conscious lunches in the employees’ cafeterias. All five 24-h convenience store companies cooperated to set up defibrillators at their branches in the city, so that they are available within 5 min in 35 % of the city area, at any hour. An Agreement Regarding Cooperation in Health Promotion and Emergency Response was made with a leading pharmaceutical company in July 2014 to implement heat stroke and metabolic syndrome prevention measures, and set up food-vending machines with products available free of charge during disasters. The Green Curtain programme involved an experiment in which business operators gave away bitter gourd seedlings in exchange for tickets.

In other projects, administrators have worked with health promoters in offering muscular training, walking, and laughter activities; with neighbourhood associations in park conservation and development and in crime and disaster prevention; with local sports clubs in promoting enjoyment of sport; and with the local public transportation council, consisting of citizens, relevant experts, and transport business operators, in improving transportation services. From all of this it is clear that a great range of sectoral, professional, or neighbourhood bodies—committees, associations, clubs, volunteer groups, and so on—have become essential to the design, implementation, and community involvement in the city’s projects.

Owariasahi also cooperates on an external basis. Nationally it has held discussions and lectures to explain its efforts and share information with other cities, encouraging them to join the AFHC network. Internationally, the city has actively provided information on how it developed its Healthy City Programme and the lessons it learned, through the exchange of experiences during visits by foreign professionals. The city has been an active AFHC member, engaging in global conferences and programmes, and has shared its experiences at other international events. Presentations at meetings and exchanges of experiences with people from other countries are brought back to Owariasahi’s city office and shared, not only as learning opportunities for its representatives but also for the capacity building of all people committed to the city’s work.

Owariasahi has developed a highly comprehensive approach to its Healthy City programme , encompassing a full spectrum of health concerns and constantly engaging with the public. It has been able to do this because of a citywide approach that emphasises cross-sectoral collaboration and participation at all levels in the city’s day-to-day activities. Citizens’ views and involvement are constantly sought, and communities given essential leadership roles in designing, implementing, and providing evaluation on projects that best suit their needs and can be delivered with maximum effectiveness.