Healthy Cities: A Political Movement Which Empowered Local Governments to Put Health and Equity High on Their Agenda

Abstract

The healthy cities movement was launched at the peak of the new public health movement in the eighties. It was very attractive to local political leaders, it inspired a wide range of new actors and it spread very quickly. It became a thriving global movement that caught the imagination of thousands of city leaders and professionals concerned with urban health and sustainable development. It is undoubtedly one of the longest running and most successful initiatives ever introduced by WHO. Healthy Cities as a project, embodied a number of key features that proved crucial in its success including a strong emphasis on values, political commitment, partnership-based approaches, democratic governance, strategic thinking and networking. It combined the discipline of a well-defined project involving committed cities with mechanisms of inclusiveness and engagement of all interested cities. Healthy Cities in Europe thrived at the cutting edge of public health, continuously broadening and adapting its agenda to new knowledge, global and regional developments and emerging local needs. It has changed the way cities understand and deal with health. Healthy Cities represents a unique example of a long-term sustainable WHO initiative that forged strategic links with local governments. The evidence and experience accumulated in the past 27 years have demonstrated repeatedly that Healthy Cities works and it makes a difference. This chapter outlines some of the critical factors and preconditions that are required for developing successful Healthy Cities programmes. Healthy Cities is now more relevant than ever. Most global public health, social and environmental challenges as well as the implementation of the new sustainable development goals for the planet require local action and strong local leadership. The time is right for WHO across Regions and governments at all levels to use the potential of Healthy Cities to the full and strengthen its capacity and presence locally, nationally and internationally.

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1 Introduction

Healthy Cities was officially established as a strategic initiative in the European Region in 1988 to act as a vehicle of the WHO strategy Health for All at the local level (WHO 1991; Tsouros 2015). Today it is a thriving and powerful movement in most parts of the world. The aim was to put health high on the social and political agenda of the cities by promoting health, equity and sustainable development through innovation and change. Cities are societal engines for economy, human and social development. The creation of Healthy Cities was based on the recognition of the importance of action at the local and urban level and the key role of local governments. Following a decade of questioning and rethinking health and medicine and setting the values and principles of a new public health era, the 1980s provided the political legitimacy and the strategic means for taking forward an agenda for Health for All, based on powerful concepts and ideas and engaging a wide range of new actors. Most notably, the strategy Health for All (WHO 1984) and the Ottawa Charter for Health Promotion (WHO 1986) inspired new types of leadership for health that transcended traditional sectoral and professional boundaries.

The creation of the Healthy Cities project, as the WHO Regional Office’s for Europe’s strategic vehicle to bring Health for All (HFA) to the local level, was the result of several developments and initiatives in the early 1980s both at the local level and at WHO (Tsouros 2015). Jo Asvall, the director of the WHO Regional Office for Europe, in his speech at the European Congress on Healthy Cities in 1987 (Asvall 1987) said, ‘Building a healthy city becomes first and foremost a formidable challenge on how to create a movement for health where many players can be inspired and motivated for taking actions to think new and better solutions and to work together in new partnerships for health’. The following year in his speech (Asvall 1988) at a meeting to celebrate Copenhagen joining the WHO Healthy Cities project, he said, ‘Why concentrate on cities? For two reasons: on the one hand, their problems are acute and rising; and on the other hand, the city level represents a particularly interesting and promising area for action in HFA . The Mayor of the city has much more power over his area than the Prime Minister has over the country; a city administration can much more easily instruct different sectors to work together in health; and … community participation is not a theoretical issue; it is daily at the finger-tips of the whole city administration’.

Jo Asvall, a truly visionary WHO regional director gave Healthy Cities huge political and strategic legitimacy from the start. He established it as a cross-cutting initiative that had the strategic mandate to actively engage local governments in the implementation of Health for All . Within a very short period the WHO Regional Office for Europe further strengthened its capacity of reaching out to new partners by establishing the health-promoting school and hospital settings networks and soon later the Regions for Health Network.

It should be stressed that Healthy Cities was launched as a political, cross-cutting and intersectoral project to be implemented through direct collaboration with cities. This was a bold and courageous move by WHO which is an organization that mainly works with and is accountable to national governments and predominantly the health sector. The importance of working at the local and community levels was reflected in many WHO resolutions since the 1970s but was not generally regarded as a green light to engaging local political leaders. Today, 29 years on Healthy Cities still represents a key strategic vehicle for implementing the new European Policy for Health and Wellbeing—Health 2020 (WHO 2013) at the local level.

The design of Healthy Cities was not meant to be static. It was launched as a value-based open system that would constantly reinvent itself and evolve, learning from practice and embracing new evidence and ideas to maintain its relevance and grounding itself on local concerns and perspectives. Healthy Cities was to be a pioneer in generating know-how for all urban communities to learn from, not an esoteric movement to benefit only its member cities.

One of the major obstacles in fully embracing the Healthy Cities concept has been the understanding of health. First, it requires understanding then adopting a meaning of health beyond the absence of disease, encompassing physical, social and mental well-being; second, it requires an appreciation of the nature and influence of the environmental, biological, social and political determinants of health; and third, it involves constantly making the case that health is important to individuals, to society and to socio-economic development.

While the overall principles underlying such an approach may appear unchanged over the years, in reality, the meaning, the content and the evidence underpinning these three requirements have vastly changed. The increasing emphasis on enduring values, such as the right to health, equity, sustainable development, and well-being, and the accumulating evidence on the social determinants of health have raised the stakes and the level of attention given to health.

The other part of the equation is dealing with change, making things happen and making arrangements that enable decision-makers, institutions, communities and citizens work together for health and well-being. Again, terms such as intersectoral action for health and community empowerment have been central in the action vocabulary of Healthy Cities’ policy development. The vocabulary has expanded and conceptually evolved both in scope and depth, but the task at the core remains as challenging as ever-reaching out and engaging a wide range of agencies whose actions can impact on health. However, the world today is very different from the early phases of Healthy Cities in the late 1980s and 1990s. Several studies have drawn attention to challenges such as global interdependence and connectedness, the quickening pace of change, the added complexity of the policy environment and the increase in uncertainty.

Healthy Cities has always been driven by the enduring classic health promotion concepts which were based on the Ottawa Charter : creating supportive environments for health; making the healthy choices the easy choices; creating healthy settings, schools, workplaces, universities, health centres and neighbourhoods; and empowering individuals and communities which is a prerequisite for success.

The Ottawa Charter (WHO 1986) defined health promotion as ‘the process of enabling people to increase control over, and to improve, their health’. Giving a voice to individuals and communities and creating the preconditions for empowerment and meaningful engagement are at the core of the Healthy Cities approach.

More than ever before and in the face of the fast-changing social landscapes of cities and towns, there is a need to create inclusiveness and social cohesion. Empowered communities will have the knowledge, the skills and the means to participate in decisions that affect their health and well-being and also navigate and access resources that can improve their health and quality of life.

Table 5.1 below outlines key concepts and issues that should be considered and addressed in a twenty-first century approach to Healthy Cities.

Table 5.1 Modern public health concepts and issues

2 Healthy Cities Mission and Goals

The mission of Healthy Cities is to put health high on the social and political agenda of cities based on a framework of constant values and principles from its inception, namely, the right to health and well-being, equity and social justice, gender equality, solidarity and social inclusion, universal coverage and sustainable development. A Healthy City was described in terms of 11 qualities (see Table 5.2).

Table 5.2 Eleven qualities of Healthy City

Healthy Cities in Europe evolved over 5-year phases. These phases allowed the regular renewal of the goals and requirements; they were long enough to see results and to evaluate progress; and participating member cities could leave the project at the end of the phase at no political cost. Every phase started afresh with a newly (re-)designated group of cities, many ‘old’ and several ‘new blood’. The ‘phase’ approach proved most valuable in keeping the Healthy Cities momentum alive and strong.

The goals and themes of every phase defined the priorities of work over the 5 years of the phase. Within the frame of the overarching goals and themes of each phase, cities had the flexibility to identify and give weight to areas that are of particular relevance to local realities. However, all cities were expected to work on the overarching and innovative themes of every phase, participating also in conceptual development and brokering the new ideas at the local level.

The agenda, themes and goals of each phase reflected WHO European priorities and strategies: global strategies and priorities and issues emerging from the urban (health, social, environmental) conditions in Europe (see the six Healthy Cities action domains (Tsouros 2017) in Table 5.3).

Table 5.3 Healthy Cities action domains

Looking back through the agenda and experience of Healthy Cities in Europe since its launch, one can easily trace the history of the new public health movement in the past 30 years. There is no new concept or approach in the areas of public health and sustainable development that was not embraced and tested by Healthy Cities. Healthy Cities became on many occasions the source of innovation and leadership in areas that later gained major significance: for example, the launch of the Solid Facts (Wilkinson and Marmot 1998, 2003) publication on the Social Determinants of Health (SDH) in 1998 with professor Sir Michael Marmot led the way to the establishment of the global commission on the SDH . The strategic focus of Healthy Cities work meant a focus on upstream, high-impact approaches to health development and equity. Table 5.4 shows an overview of the themes and priorities of the Healthy Cities agenda over six phases.

Table 5.4 WHO European Healthy Cities agenda—six phases

Phase VI was launched as an adaptable and practical framework for delivering Health 2020 at the local level. It recognizes that each city is unique and will pursue the overarching goals and core themes of Phase VI according to its needs and processes that were sensitive and adaptable to local socio-economic, organizational and political contexts. Cities were encouraged to use different entry points and approaches but will remain united in achieving the overarching goals and core themes of the phase. Table 5.5 below shows the Phase VI priorities in more detail.

Table 5.5 Goals and priority themes of Phase VI (2014–2018) of the European Healthy Cities

WHO Healthy Cities combined six essential features : (1) local relevance and openness to innovation and a cutting-edge public health agenda; (2) strong leadership and political commitment and a multisectoral approach to health development; (3) partnership-based management of change, transparency and democratic governance; (4) strategic thinking and planning and concrete deliverables and outcomes; (5) adaptability and receptiveness to emerging needs and ideas; and (6) commitment to solidarity and international and local networking.

Healthy Cities can exert their influence on health and equity in a wide range of mechanisms and processes including regulation (Cities are well positioned to influence land use, building standards and water and sanitation systems and enact and enforce restrictions on tobacco use and occupational health and safety regulations.), integration (Local governments have the capability of developing and implementing integrated policies and strategies for health promotion and sustainable development.), intersectoral partnerships (Cities’ democratic mandate conveys authority and power to convene partnerships and encourage contributions from many sectors and stakeholders from the private and voluntary domains.), citizen engagement (Local governments have everyday contact with citizens and are closest to their concerns and priorities. They present unique opportunities for partnering with civic society and citizens’ groups.) and equity focus (Local governments have the capacity to mobilize local resources and to deploy them to create more opportunities for poor and vulnerable population groups and to protect and promote the rights of all urban residents.).

Healthy Cities continued to expand and proved valuable during times of major changes in Europe and the world, including the fall of the Berlin Wall, the Yugoslavian wars, the expansion of the European Union, globalization, the rapid expansion of the information society and austerity waves and significant changes in the social landscape of the region.

3 Healthy Cities Network Model

The WHO European model of Healthy Cities has two operational arms: the WHO Healthy Cities Network consisting of about 60–100 cities which are directly designated by WHO and the WHO Network of Healthy Cities Networks which brings together approximately 30 European National Healthy Cities Networks.

Table 5.6 below provides a typology of the four essential prerequisites for member cities (Tsouros 2017). Evidence of strong political commitment is fundamental requirement for the designation process. In addition to a letter from the Mayor or equivalent interested, applicant cities have to provide a city council resolution expressing support for the participation of the city in this WHO Network as well as partnership intent statements from public, private and voluntary sectors. These are crucial for the sustainability of the programme in cities.

Table 5.6 Healthy Cities four action prerequisites

Managing change and supporting innovation, especially when these imply new ways of working, must be supported by people who have the necessary knowledge, skills and seniority, to enable resources and mechanisms and processes to engage public sectors and agencies and civil society. The requirement for a coordinator and a project office that is strategically located within the city administration (ideally close to the Mayor’s office) is of critical importance to be able to fulfil its strategic and intersectoral coordination function to the full. The profile and seniority of the coordinator have also proven crucial. Healthy Cities cannot reach its potential if it is reduced to a technical project far from the policy and strategy locus of the city. Furthermore, member cities have to establish an intersectoral steering committee and designate a politician (the mayor or one of his deputies) to be responsible for the programme. The European experience has shown that cities can also establish project support structures outside the city organization allowing flexibility for broader collaborations with statutory and especially nonstatutory partners.

National Networks (WHO 2015) play a key strategic role in promoting the healthy Cities principles and ideas, supporting their member cities, organizing training and learning events as well as working with different ministries and participating in national programmes. National Networks also represent an important public health platform at European level. National networks are accredited by WHO at the start of each phase on the basis of explicit criteria reflecting the scope and goals of the phase as well as minimum managerial requirements similar to those applied by the WHO Network cities (WHO 2014a, b, c, d).

Unlike membership to most other international networks which is usually based on signing a statement or declaration, the members of the WHO Healthy Cities Network are required to meet political and organizational requirements and commit to addressing a set of themes and targets. This has always been a source of respectability and prestige for the membership to this WHO Network . The chapter at hand discusses the main features of Healthy Cities in the European Region and will particularly focus on a number of issues that have been and continue to be critical for its success.

Healthy Cities is a movement committed to change and innovation, and it needs to sustain its strategic course to fulfil its potential. An important attribute of Healthy Cities is the political legitimacy to address challenging issues such as equity, vulnerability, the determinants of health and sustainability. One of the greatest strengths of the Healthy Cities movement is the diversity of political, social and organizational contexts within which it is being implemented across Europe. Concepts such as healthy public policy, intersectoral action, Health in All Policies and whole-of-government and whole-of-society approaches continue to be elusive for many national governments. These concepts constitute the premise on which Healthy Cities was designed: a whole-of-local-government approach to health with strong emphasis on equity and partnerships with statutory and nonstatutory partners.

4 Local Leadership for Health and Sustainable Development

The well-being, health and happiness of the citizens depends on politicians’ willingness to give priority to the choices that address equity and the determinants of health. Ultimately health is a political choice that should match the values and aspirations for protecting and constantly improving the health and well-being of all citizens. This means creating supportive social and physical environments and conditions for enabling all people to reach their maximum health and well-being potential. It is thus important for city leaders to visualize what society they wish to create and decide on the values that will underpin their visions for the cities.

Municipalities have evolved as key drivers of city health development, providing not only leadership but continuity and adaptability in administrative structures and processes. Leadership for health and health equity takes many forms and involves many actors, for example, international organizations setting standards, heads of governments giving priority to health and well-being, health ministers reaching out beyond their sector to ministers in other sectors, parliamentarians expressing an interest in health, business leaders seeking to reorient their business models to take health and well-being into account, civil society organizations drawing attention to shortcomings in disease prevention or in service delivery, academic institutions providing evidence on which health interventions work (and which do not) and research findings for innovation and local authorities taking on the challenge of Health in All Policies.

Such leadership for health in the twenty-first century requires new skills, often using influence, rather than direct control, to achieve results. Much of the authority of future health leaders will reside not only in their position in the health system but also in their ability to convince others that health and well-being are highly relevant in all sectors. Leadership will be not only individual but also institutional, collective, community-centered and collaborative (Kickbusch and Gleicher 2014; Kickbusch and Thorsten 2014). Such forms of leadership are already in evidence. Groups of stakeholders are coming together to address key health challenges at the global, regional, national and local levels, such as the global movement on HIV. Similar movements are emerging around noncommunicable diseases, environmental health and health promotion.

Cities have the capacity to influence the determinants of health and inequalities—‘the causes of the causes’ as it is commonly referred to. They can promote the health and well-being of their citizens through their influence in several domains such as health, social services, the environment, education, the economy, housing, security, transport and sport. They can do this through various policies and interventions, including those addressing social exclusion and support, healthy and active living (Edwards and Tsouros 2008a, b) (such as cycle lanes and smoke-free public areas), safety and environmental issues for children and older people, working conditions, preparedness to deal with the consequences of climate change, exposure to hazards and nuisances, healthy urban planning (Barton and Tsourou 2000) and design (neighbourhood planning, removal of architectural barriers, accessibility and proximity of services) and participatory and inclusive processes for citizens. Intersectoral partnerships and community empowerment initiatives can be implemented more easily at the local level with the active support of local governments. Local leaders acting beyond their formal powers have the potential to make a difference to the health and well-being of local communities by harnessing the combined efforts of a multitude of actors (Kickbusch and Gleicher 2014; Kickbusch and Thorsten 2014).

In the complex world of multiple tiers of government, numerous sectors and both public and private stakeholders, local governments have the capacity to influence the determinants of health and well-being and inequities. They are well positioned to have such influence through whole-of-local-government and Health in All Policies, regulation, integrated strategies and plans and partnerships across society.

Local leadership for health and sustainable development in the twenty-first century means having a vision and an understanding of the importance of health in social, economic and sustainable development; becoming an advocate and active implementer of the health inequalities (WHO 2014a, b, c, d) and the sustainable development agenda (UN 2015); having the commitment and conviction to forge new partnerships and alliances; promoting accountability for health and sustainability by statutory and non statutory local actors; aligning local action with national policies; anticipating and planning for change; and ultimately acting as a guardian, facilitator, catalyst, advocate and defender of the right to the highest level of Health for All residents. Effective leadership for health and well-being requires strong political commitment, a vision and strategic approach, supportive institutional arrangements and networking and connecting with others who are working towards similar goals.

A manifesto for local leaders for health and well-being would read along the following lines. Local leaders should recognize that (WHO 2014a, b, c, d, 2016; PAHO 2016).

• Health is a fundamental human right, and every human being is entitled to the enjoyment of the highest attainable standard of health.

• Health should be a core value in city vision statements, policies and strategies.

• The health status of people and whole communities is profoundly affected by the conditions in which individuals are born, live and work.

• The knowledge and experience on the social, environmental, urban, cultural, commercial and political determinants of health provide the basis for how local decision-makers should understand and deal with health and well-being.

• The public health challenges of the twenty-first century to be addressed effectively require the full engagement of local governments.

• Local governments are well placed to provide effective leadership and capacity for intersectoral work for health and sustainable development, and they can promote and enable community involvement and empowerment.

• Local governments generally have primary responsibility for planning and/or delivering services critical for influencing the social determinants of health (SDH) (e.g. education, transportation, housing and urban planning, and often they have responsibility for health service delivery and public health).

• Local governments have a key and central role to play in the implementation of all the sustainable development goals (SDGs) and in particular address the strong links between SDG 3 (good Health for All) and SDG 11 (make cities and human settlements inclusive, safe, resilient and sustainable).

Political leaders should strive to create Cities for All our citizens by:

• Fully using and integrating in their plans twenty-first-century evidence-based public health and health promotion approaches and solutions that work

• Ensuring that their policies and plans are comprehensive, systematic and strategic aiming at delivering best outcomes and maximum impact

• Integrating health and sustainable development considerations in the way their municipalities plan, design, maintain, improve and manage the build environment, infrastructure and services and by using creatively new technologies

• Valuing social diversity and investing in building trust and cohesion amongst community groups

• Employing whole-of-local-government and whole-of-society and Health in All Policies approaches in their efforts to reaching out to different partners (public and corporate) and civil society

• Focusing in engaging with other sectors on ‘what they can do for health and what health can do for them’ identifying win-win, synergistic and co-beneficial outcomes

• Promoting policy coherence, synergies and better coordination as well as systems enabling joint planning and accountability for health and equity

• Investing in creating adequate capacity for steering, managing and implementing our Healthy Cities initiatives and programmes

• Putting in place the resources and mechanisms for systematically assessing the health and the conditions that affect health in cities as well as for monitoring Health in All Policies and reducing health inequalities’ efforts

• Publishing regularly a city health profile as a basis of identifying priorities and accountability for health in cities

• Increasing city wide policies, programmes and services for disease prevention and health promotion applying the social determinants of health (SDH) , equity and economic lens and aiming at creating social and physical environments that are conducive to health and well-being as well as increasing health literacy (Kickbusch et al. 2013)

• Promoting awareness about individual responsibility and social responsibility for health through an SDH and equity perspective

• Developing strategies and plans that are framed on population-based and life-course approaches

• Developing an intersectoral integrated strategic framework and plan for health development in the city with commonly agreed (amongst different sectors and other stakeholders) goals

• Making sure that local Healthy Cities plans and activities are aligned and connected with the main city development strategies

• Developing local and national platforms, networks and fora that promote social dialogue and broad civic engagement

Figure 5.1 shows a schematic representation of key political considerations for the implementation of Healthy Cities .

Fig. 5.1 Articulating and implementing a Healthy Cities vision

There is an imperative for all truly committed Healthy Cities to work on a number of issues which are crucial for the health of urban communities. This is a minimal agenda for action (Tsouros 2017):

• To ensure that the Health in All Policies and SDG agendas are explicitly and fully integrated in cities visions and plans.

• To give high priority to community participation and empowerment and community resilience.

• To measure and systematically and comprehensively address health inequalities.

• To give all children a healthy start in life with the active involvement of different sectors (such as health, social services, education, housing and planning), families and communities.

• To create conditions for healthy and active living for all with emphasis on physical activity, healthy and sustainable nutrition, reduction of obesity and mental stress, controlling the use of alcohol and creating smoke- and drug-free cities.

• To increase health literacy amongst individuals, communities and institutions.

• To invest in healthy environments and healthy urban planning and design creating safe and clean neighbourhoods with access to greens and space for social interaction and good facilities for all and creating age and child-friendly settings.

• A key aspect of the success on the ground and sustainable evolution of Healthy Cities in Europe has been its ability to connect with other local strategies and programmes, to be a convener and facilitator of intersectoral and community dialogue and cooperation, to be continuously open to new concepts and to be sensitive to needs and emerging priorities.

One of the most promising modern ways to promoting health is the life-course approach. This means supporting good health and its social determinants throughout the life course leads to increased healthy life expectancy as well as enhanced well-being and enjoyment of life, all of which can yield important economic, societal and individual benefits. Interventions to tackle health inequities and their social determinants can be derived at key stages of the life course: maternal and child health, children and adolescents, healthy adults and healthy older people.

Without a doubt one of the most formidable goals for a Healthy City, which would require the contribution of many sectors, is giving children a healthy start in life.

A good start in life establishes the basis for a healthy life. Cities investing in high-quality early-years childcare and parenting support services can compensate for the negative effects of social disadvantage on early child development. Promoting physical, cognitive, social and emotional development is crucial for all children from the earliest years. Children born into disadvantaged home and family circumstances have a higher risk of poor growth and development.

WHO in Europe has invested in evaluating progress and achievements at the end of every phase (De Leeuw and Simos 2017; JUH 2013; HPI 2009, 2015; De Leeuw et al. 2014). This chapter has heavily drawn on the lessons learnt from almost three decades of Healthy Cities in Europe. However, a vast amount of knowledge has been generated by the European Healthy Cities movement that remains invisible, undocumented and undervalued. The stories and achievements of cities and networks need to be systematically explored and documented.

5 Epilogue

Mayors are emerging as powerful and influential agents for change, locally, nationally and internationally. City health diplomacy can make a true difference, but this implies coherent and strategic thinking. The local voice is essential in the decision-making governing bodies and international fora of many international organizations and can also be helpful in discussions regarding the engagement of non-state actors.

The new sustainable development agenda provides a new opportunity to strengthen health and equity in our cities and communities. Health 2020 and the sustainable development goal (SDG) agenda are mutually reinforcing and provide enormous legitimacy for strong leadership and action.

Healthy Cities can organically embrace and integrate the SDG agenda, which goes hand in hand with priority areas such as equity, vulnerability including poverty and migrants’ health, community resilience, climate change and the whole determinants of health agenda. Now is the time to scale up Healthy Cities as an important global force for health and equity.

Healthy Cities is a dynamic concept which should be continuously enriched with new developments and emerging priorities and scientific evidence. It is the anticipatory quality of Healthy Cities that has made it attractive to cities in all countries, even those with very advanced public health presence. This is essential for Healthy Cities to maintain its relevance and credibility. Its agenda, themes and goals should therefore reflect WHO regional priorities and strategies, global strategies and priorities and issues emerging from the urban (health, social, environmental) conditions in each region.

The key to using the Healthy Cities concept to its full potential is the capacity for effective leadership and intersectoral action through whole-of-government, whole-of-society and Health in All Policies approaches. Healthy Cities is a value-based movement . Equity, solidarity, sustainability and a commitment to creating Cities for All are crucial. In other words, what matters is not just the average health standard in a city, but making sure that whatever the city has to offer is apportioned to everybody.

The real danger always remains to engage in Healthy Cities using the trademark and, in reality, wasting a great concept and a great opportunity by doing fragmented low-impact ephemeral projects and not working seriously on issues such as health inequalities and healthy urban planning or addressing the special needs of disadvantaged groups.

Increasing the accessibility of the Healthy Cities movement in all regions of the world should be a priority. The time is right to create a strong global Healthy Cities movement. Health Cities provide an adaptable and practical framework for delivering Health for All at the local level. It provides an exceptional platform for joint learning and sharing of expertise and experience between cities, between national and local levels of government and between countries and regions.

Ultimately the future prosperity of urban populations depends on the willingness and ability of local decision-makers to seize new opportunities to enhance the health and well-being of present and future generations.