The state of the healthy city programme worldwide: a narrative review with a focus on the Eastern Mediterranean region

Abstract

Introduction

Urbanization presents growing public health challenges worldwide, particularly in the Eastern Mediterranean Region (EMR) where rapid urban growth coincides with conflict, migration, and health disparities. The WHO Healthy City Programme (HCP), launched in the 1990s, addresses these through multisectoral urban health initiatives. Aim: This narrative review examines the HCP’s global implementation, with focused analysis of the EMR context.

Methods

A comprehensive literature search was conducted using PubMed, Scopus, and Web of Science, supplemented by WHO and UN documents. Key terms included “Healthy City” and “Urban Health.” Only English-language documents addressing HCP implementation were included.

Results

The HCP has expanded to all six WHO regions, with 35 cities certified in the EMR by 2019. The programme emphasizes equity, emergency preparedness and community participation in this region. Implementation challenges include weak institutionalization, limited inter-sectoral collaboration, and inadequate documentation. The paper specifically notes these barriers in the EMR context, along with the need for better monitoring systems. Successful examples from the region demonstrate the programme’s alignment with Sustainable Development Goals.

Conclusion

Scaling the HCP in the EMR requires stronger governance frameworks and systematic evaluation. The programme’s multisectoral approach remains crucial for addressing urban health challenges, but requires sustained political commitment and adapted strategies for regional implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41043-025-01171-z.

Background

Urbanization and global trends

Urbanization has been a defining feature of human societies since the earliest settlements in Mesopotamia and Egypt, and cities have continued to expand in both size and population over time. In recent decades, this trend has accelerated considerably, with projections indicating that the proportion of the world’s population living in urban areas will increase from 56% in 2021 to 68% by 2050, adding approximately 2.2 billion urban residents [1, 2]. Urbanization refers to the process through which a growing share of the population resides in urban areas, accompanied by social, economic, and environmental changes such as rural-to-urban migration, land-use transformation, and shifts in employment and lifestyle patterns [3]. These changes are particularly pronounced in Asia, Africa, and low-income countries, where urban growth has been rapid and sustained. In these settings, the urban population quadrupled between 1975 and 2020—from around 75 million to 300 million—and is projected to reach nearly 700 million by 2070 [3]. Urban areas in low-income countries are also expected to more than double in spatial extent, making the management of expansion and population density essential to prevent overcrowding, informal settlements, and social instability [1, 4]. Notably, low-income countries have contributed, and will continue to contribute, a disproportionately large share to the increase in the number and size of cities worldwide [1].

Urbanization and its health implications

Urbanization has significant effects on all dimensions of human life, one of the most important of which is health. Although cities often function as economic, social, and technological hubs, their rapid and unplanned growth can also produce adverse conditions such as poverty, social inequality, biological hazards, and a rising burden of communicable and non-communicable diseases [4, 5]. These impacts are shaped by the built environment: urban infrastructures—through construction, industry, transport systems, and patterns of energy and resource use—contribute to pollution, climate change, and environmental degradation, all of which have direct and indirect consequences for population health [6, 7].

The health implications of urbanization have become increasingly evident in recent years. The COVID-19 pandemic alone pushed an estimated 124 million additional people into poverty, while in sub-Saharan Africa nearly one-quarter of urban residents live below the global poverty line. Poorly planned urban areas face growing challenges related to infectious diseases, chronic illnesses, and mental health; disability-adjusted life years attributable to mental disorders have increased by 55% over the past two decades [1, 5]. Cities also remain vulnerable to outbreaks such as Ebola, MERS, and HIV/AIDS and are responsible for nearly three-quarters of global CO₂ emissions, exacerbating climate-related health risks [1, 8]. Inadequate housing, poor nutrition, overcrowding, exposure to disasters, and weak social protection systems disproportionately affect residents of low-income and conflict-affected settings, including many countries in the Eastern Mediterranean Region [4, 8–12].

These complex and interrelated challenges underscore the need for comprehensive and multisectoral approaches to urban health. Addressing issues such as poverty, inequality, housing, addiction, nutrition, elderly care, and universal health coverage requires coordinated efforts, as no single government or agency can respond effectively in isolation. Cities increasingly serve as “national laboratories” where intersectoral collaboration and community participation generate practical models for reducing health inequities and moving toward healthier, fairer, and more sustainable urban futures [13, 14].

Global health and urban initiatives

The UN’s Decade of Action (2020–2030) calls for accelerated progress toward the Sustainable Development Goals. As urban populations continue to grow, achieving inclusive and resilient development has become essential to ensure that no one is left behind. Meeting these goals requires sustained investments in health care, education, housing, transportation, nutritious food, and access to clean water, even in contexts with significant financial constraints. In the Eastern Mediterranean Region (EMR), however, persistent disparities remain; more than 25% of people in six countries live below the international poverty line [15]. Importantly, inequalities are not limited to low-income settings. In England, for example, life expectancy differs by up to seven years—and disability-free life expectancy by 17 years—between urban areas, while in Baltimore, USA, life expectancy can vary by as much as 20 years within the same city [7, 16]. These patterns illustrate how urban environments can simultaneously concentrate both opportunity and disadvantage, and they highlight the central role of addressing health and social inequalities within contemporary urban health agendas.

Urban health promotion experiences

In response to the widening patterns of urban inequality described above, international organizations and global health agencies have increasingly focused on developing structured approaches to promote healthier, more equitable cities. Over the past two decades, a substantial body of global initiatives and policy agendas has emerged, emphasizing evidence-based action, intersectoral collaboration, and community participation as core principles of urban health promotion. Key examples include major global reports, multi-country collaborations, and city-level interventions that have shaped contemporary understanding of how urban environments can be leveraged to improve population health and reduce disparities [17].

A range of global organizations have contributed to shaping the urban health agenda through the development of technical frameworks, policy tools, and large-scale urban development programmes. One of the most prominent is UN-Habitat, which operates in more than 90 countries through its regional offices and has played a central role in advancing inclusive urban planning, reducing inequality, and integrating health considerations into urban governance [1]. Complementing these efforts, WHO EMRO developed the Urban Health Equity Assessment and Response Tool (Urban HEART), a structured framework used in parts of Asia and Africa to assess disparities, guide intersectoral responses, and support local decision-making [18]. Broader global initiatives—including commitments to Universal Health Coverage (UHC), environmental improvement, stronger infrastructure, rural–urban partnerships to support food security, and enhanced social protection measures—further highlight the increasing emphasis on systematic, equity-oriented approaches to urban health [7, 10, 19].

Several cities have implemented innovative interventions that illustrate how local action can advance public health and reduce disparities. Bogotá’s “Ciclovía Recreativa” programme, which closes 97 km of streets to vehicles on Sundays, has improved physical activity levels, reduced pollution, and lowered health-related costs by more than US$4 per person annually. New York City’s 2009 graphic tobacco warnings increased awareness of smoking risks and boosted quit attempts by 11%. London’s redesign of acute heart attack care in 2010 reduced mortality by 12% [20]. Such examples demonstrate how city-level governance and targeted multisectoral interventions can drive meaningful improvements in health outcomes. As summarized by Danielli et al. [20], efforts to improve urban health can be classified into five categories of systemic change, reflecting diverse pathways through which cities can promote healthier and more equitable environments (Table 1).

Table 1.

Health improvement initiatives categorization

No.	Intervention type	Concept	% of total interventions
1	Education Initiatives	These programmes are prepared for the education or support of society, including citizens, patients or human resources.	26
2	Service Reforms	These programmes have led to changing, redesigning or adding a service in the health system.	23
3	Environmental Change	Programmes to change the physical environment that people in the community interact with.	21
4	Comprehensive Change	This type of initiative is comprehensive instead of a single intervention and includes more than one group.	8

Collectively, these global agendas, frameworks, and city-level experiences have laid an important foundation for more structured approaches to healthy urban development. Building on this accumulated knowledge, the World Health Organization established one of the most comprehensive and widely adopted models in this field—the Healthy City Programme, described in the following section.

Emergence and evolution of the WHO healthy city programme

In line with the UN agenda to tackle important urban issues such as inequality, health, and sustainable development, the World Health Organization launched the Healthy City Programme in the 1990 s in the European Regional Office. This programme seeks to prioritize health in the urban social and political agendas, implement innovative initiatives, and promote multi-sectoral reforms that ultimately support sustainable development [17, 21].

The Healthy City programme began with 11 cities in Europe and has subsequently expanded to include a regional network of healthy cities across all six regions of the WHO as Africa, America, the Western Pacific, Southeast Asia, Europe and the Eastern Mediterranean. Also, the programme shares similar goals, its implementation approach varies by the region [21, 22]. The Eastern Mediterranean Region (EMR) Healthy Cities Programme started in the Islamic Republic of Iran and then expanded to 12 other countries (Afghanistan, Bahrain, Egypt, Jordan, Kuwait, Lebanon, Morocco, Oman, Pakistan, Saudi Arabia, Sudan and United Arab of Emirates) with different implementation phases [11].

Rationale and purpose of this review

Despite its more than 40-year history, the success of the Healthy City Programme has varied considerably across regions, and systematic evidence on its performance and effectiveness remains limited. In many settings—including those of the Eastern Mediterranean Region—documentation is fragmented, implementation approaches are heterogeneous, and locally generated reports are not consistently accessible. Given these gaps, there is a clear need for a comprehensive synthesis to contextualize the policy evolution, implementation patterns, and region-specific challenges of the programme.

The purpose of this review was to map the existing literature on the Healthy City policy context, describe the status of programme implementation across different WHO regions with a particular focus on the Eastern Mediterranean Region, and examine the key challenges encountered in advancing the Healthy Cities approach. Given the dispersed nature of available evidence, a narrative review offers an appropriate method for integrating diverse sources and providing an overarching understanding of this evolving field.

Methods

A comprehensive literature search was conducted using databases include PubMed, Scopus, and Web of Science. Furthermore, gray literature was explored through the Google search engine and Google Scholar. Websites of the World Health Organization (WHO), the United Nations (UN), WHO regional offices, and Healthy Cities Networks were also systematically searched for further evidence. Inclusion criteria were: (1) documents describing the history, implementation, evaluation, or challenges of the WHO Healthy City Programme; (2) publications available in English; and (3) relevance to at least one WHO region. Key search terms included “Healthy Cit*”, “Urban Health”, “Healthy Setting”, and “Healthy Community”. The search strategy shown in additional file 1. The search covered all years from database inception to February 2025 and initially identified 5090 records. After removal of 3800 duplicates, 1580 records were screened and 210 full texts were assessed. In total, 46 documents (30 articles and 16 reports) were included. A PRISMA flow diagram illustrates the screening process. (Fig. 1).

Fig. 1.

PRISMA flow diagram for screening

Results

This narrative review identified results across four major areas: (1) global implementation models of the Healthy City Programme, (2) the current status and characteristics of the programme in the Eastern Mediterranean Region, (3) documented examples of successful implementation in selected cities, and (4) region-specific challenges affecting scale-up and sustainability. These results are summarized narratively below, with a structured overview presented in Table 2.

Table 2.

Summary of results

Theme	Global findings	EMR-specific findings
Vision, principles, and purpose of the Healthy City Programme	• Grounded in WHO Community-Based Initiatives (CBIs) • Prioritizes health in political and social agendas • Promotes equity, UHC, social justice, participation, solidarity, gender equality • Addresses root social, economic and environmental determinants of ill-health • Dynamic, flexible and evidence-informed across regions	• Same principles embedded in EMR implementation • Emphasis on community participation and multisectoral action • Used as a tool for promoting equity and improving urban health in diverse and complex regional contexts
Alignment with global agendas	• Consistent with Health for All, Health 2020, GPW13 and the SDGs • Contributes to 11 of the 17 SDGs (poverty, hunger, health, inequality, sustainable cities, water/sanitation, climate, decent work, environment, partnerships)	• Supports regional priorities shaped by rapid urbanization, inequality, environmental issues and political instability • Promoted as an approach for accelerating SDG achievement within EMR countries
Implementation models	• Implementation differs across WHO regions • PAHO adopts decentralized Healthy Municipalities and phased models (e.g., Argentina’s 4-phase structure) • WHO regions adapt steps and structures based on local governance and political context	• EMRO uses a 3-stage model: Initiation → Organization → Action • 80 criteria across 9 domains (community mobilization, intersectoral cooperation, information, environmental health, health development, literacy, capacity building, low-cost activities, emergency preparedness) • Framework built on regional experience and best practices
Programme coverage and scale	• Expanded from the initial European cities of the 1990 s into hundreds of cities worldwide • Active in all six WHO regions with regional or national networks supporting implementation	• Programme launched in EMR in 1990 • First plot inTehran; Sharjah was first certified healthy city • By late 2010s: ~ 35 certified cities across 15 EMR countries
contextual challenges for urban health	• Global urban health barriers include pollution, inactivity, NCDs, communicable diseases, mental health issues, unemployment, homelessness and infrastructure limitations	• Challenges intensified due to political instability, conflict, displacement and emergencies • EMR has some of the highest conflict-related mortality globally (24.1 per 100k) • Injury-related mortality above 100 per 100k in several countries • These conditions complicate sustainability and scale-up of urban health interventions
Barriers to scale-up and sustainability	• Globally, sustainability depends on institutionalization, governance, evidence generation, data quality and intersectoral collaboration	• Institutionalization deficit: limited integration into governance systems; perceived as extra workload • Unrecorded progress: scarce documentation and reporting; weak visibility • Limited health data: biomedical focus; insufficient SDH/equity indicators • Weak intersectoral collaboration: bureaucratic fragmentation; conflicting priorities; rigid hierarchies • Policy & network gaps: underused regional network; weak feedback loops; need for standardized monitoring and structured exchange

Healthy city programme

Recognizing the significance of addressing critical issues in cities, such as health, socio-economic inequality, and the pursuit of sustainable development as part of the United Nations’ global agenda, the World Health Organization launched the Healthy City Programme in the European region during the 1990s. This programme is grounded in the World Health Organization’s community-based initiatives (CBIs), which focus on empowering local communities and encouraging their involvement in development. In essence, the programme aims to prioritize health in the social and political agendas of cities. By employing innovative strategies and facilitating multi-sectoral changes, it seeks to promote health and equality while advancing sustainable development. The programme gained renewed focus with the World Health Organization’s Thirteenth General Programme of Work (GPW13), highlighting the impact of local governments and cities on public health [17].

Healthy City is a programme that centers on the principles of health for all, universal health coverage, community involvement, social cohesion, and innovation. It places health, social welfare, equity, and sustainable development at the core of cities’ social and political policies, grounded in the universal right to health, well-being, peace, social justice, gender equality, solidarity, and social involvement. The Healthy City approach involves systematic and comprehensive efforts to address health disparities, particularly focusing on urban poverty and the needs of vulnerable populations. This programme tackles the social, economic, and environmental root causes of ill health [23].

The Healthy City programme stands out due to its dynamism. This programme will remain flexible by leveraging the latest scientific evidence and expertise, while considering global challenges and focusing on regional, local, and emerging priorities. This adaptability is why the Healthy Cities programme can be implemented across diverse regions with varying political and social contexts. By fostering a supportive environment, the programme promotes integrated and comprehensive initiatives and innovations in local development. Additionally, this programme aligns with the objectives of several global initiatives, such as Health for All and Health 2020, serving as a catalyst to help achieve the ambitious goals set by the United Nations and the World Health Organization [17].

If we want to measure the alignment of the Healthy City programme with the sustainable development goals, which is the agenda of all countries in the world, we will find that intervention in cities in the form of the Healthy City programme is one of the initiatives that countries must support and implement to achieve the goals of sustainable development. The sustainable development goals included 17 goals and 234 indicators, two-thirds of which are mixed with urban factors. The Healthy City Programme encompasses 11 of the Sustainable Development Goals, which include creating sustainable cities and communities, ending poverty, eliminating hunger, reducing inequality, ensuring good health and well-being, providing clean water and sanitation, promoting decent work and economic growth, climate action, improving life on land and underwater, and fostering partnership to achieve goals. Today, The Healthy City programme encompasses various titles such as Healthy Municipalities, Healthy Villages, Healthy Territories, Healthy Islands, and Healthy Communities. The goals of the Healthy City Programme are shown in (Fig. 2) [24, 25].

Fig. 2.

Healthy city program goals

Some of these goals may have been shared among various city organizations engaged in conventional and daily activities. However, it is crucial to fully utilize the potential of this programme through new and multifaceted initiatives when implementing the Healthy City Programme. Ideally, the individual leading the healthy city project should be a senior urban political official, such as the mayor or governor, who possesses the authority to effectively coordinate activities and goals through inter-sectoral cooperation.

The implementation of the Healthy City Programme does not have a specific formula, but it must be implemented in a planned and methodical manner. Each of the regional offices of the World Health Organization may have developed a specific method and steps for the implementation and planning of a healthy city.

The Pan American Health Organization (PAHO) and the WHO Regional Office for the Americas implement the Healthy Municipalities, Cities, and Communities (HMC) program in a decentralized manner across each country, allowing them to adopt models tailored to their economic and political contexts. For instance, in Argentina, the programme is executed in four phases: entry, stabilization, and two accreditation phases [26] The healthy municipalities, cities, and communities executive phases are shown in (Fig. 3).

Fig. 3.

Healthy Municipalities, Cities, and Communities Program Phases in Argentina

The Eastern Mediterranean Regional Office (EMRO) outlines the steps for implementing the Healthy City Programme, as shown in fig. 4. This model consists of three main stages: initiation, organization, and action, with specific operational steps defined for each stage [27]. These stages and steps are developed based on experience and best practices.

Fig. 4.

Healthy City Implementation MOdel in Eastern Mediterranean Region

Healthy city programme in WHO regions

The Healthy City Programme has been launched in the six regions of WHO: Africa, the Americas, the Western Pacific, Southeast Asia, Europe, and Eastern Mediterranean. A summary of the Healthy City Programme in these regions will be compared in Table 3 [21, 22, 26, 28-38].

Table 3.

Comparison of the WHO healthy City programme implementation across six WHO regions

Regions	Start year	Urban challenges	Implementation approach	Executive institution(s)	Programmes priorities
Africa	1990s	Migration from rural areas to cities, land management issues, informal settlements, and inadequate infrastructure despite high population growth	Decentralized for each city	The WHO Regional Office for Africa	Addressing common diseases such as cholera, diarrhea, and malaria by implementing measures to improve public health like sanitizing toilets in schools and public spaces, providing safe drinking water, enhancing the health standards of food markets, and improving waste management. In some cases, the programme also prioritizes more advanced issues, such as increasing urban green spaces and beautifying environments, expanding public transportation, and regulating intra-city transport, interventions for non-communicable diseases, addiction, and violence against women
the Americas	1990	Poor housing, the growth of informal settlements, lack of sufficient infrastructure, violence, the spread of alcohol and drugs, the existence of vector-borne diseases, the growth of non-communicable diseases	Decentralized for each country	PAHO’s Working Commission for the Regional Movement of HMC	Strengthen Health Sector Action on Climate Change, equitable health outcomes, particularly for vulnerable populations, given the region’s high levels of social inequality, Tackle the unique vulnerabilities of the region to climate change, Promote Climate-Resilient Health Systems, Mitigate Social and Economic Impacts
the Western Pacific	1980s	Environmental issues, road safety, violence and related injuries, non-communicable diseases, and the health of pregnant mothers, neonates, children, and women, aging	Decentralized for each country	The Alliance for Healthy Cities (AFHC)	environmental issues, road safety, violence and related injuries, non-communicable diseases, and the health of pregnant mothers, neonates, children, and women, aging
Southeast Asia	1994	increase in suburbanization in some countries, Aging and changes in the population pyramid, diseases like malaria, influenced by the tropical climate	Decentralized for each city	Regional Laboratory on Urban Governance for Health and Well-Being (Regional Lab on UGHW)	Urban planning and rapid growth, Urban poverty and health inequalities, Urban health access and needs
Europe	1987	Ageing Society, Migration population health challenges, socio-economic inequality and inequity	Decentralized for each country	WHO European Healthy Cities Network	Address Health Inequities, Community Involvement, Empower, Local Leadership, Health-Focused Urban Design, Environmental Resilience, Peace and Security, Enhance Literacy, Foster Partnerships
Eastern Mediterranean	1990	environmental pollution, inactivity, communicable and non-communicable diseases, mental illnesses, physical disabilities, drug abuse, unemployment, homeless people, refugees, urban violence, overcrowding, and inadequate infrastructure, inadequate access to clean water, or sanitary facilities, Conflict, war, legal and illegal refugees, and the state of emergency in some countries	Decentralized for each city	The WHO Regional Office for the Eastern Mediterranean	reducing health disparities and ensuring equitable access to health services, Promote participatory governance by involving communities in decision-making processes, Address the social, economic, and environmental factors that influence health outcomes, Foster collaboration among various sectors, including government, civil society, and private organizations, to implement health initiatives, Emergency Preparedness, Encourage healthy behaviors and lifestyles through community-based initiatives and programmes.

Healthy City programme in the Eastern Mediterranean region (EMR)

The WHO Eastern Mediterranean Regional Office launched the Healthy City Programme in 1990 as a dynamic and multisectoral effort to increase commitment at the highest political level and create a shared vision of public health among all institutions, stakeholders, and civil society. The Healthy City in the Eastern Mediterranean region was first started in Iran, and an area of Iran’s capital, Tehran, was the first city to be registered in this region.

The Eastern Mediterranean region includes 22 countries and has more than 700 million populations. In this region, relatively large diversity can be seen in terms of political, ecological, and economic situations. Economically, the difference is so significant that some of the richest and poorest countries in the world belong to this region. This region, like other regions, faces health challenges due to urbanization, such as environmental pollution, inactivity, communicable and non-communicable diseases, mental illnesses, physical disabilities, drug abuse, unemployment, homeless people, refugees, urban violence, overcrowding, inadequate infrastructure, and inadequate access to clean water, or sanitary facilities, etc. In addition to these challenges, political issues in this region have overshadowed the living conditions and health of the residents. Conflicts, wars, legal and illegal refugees, and the state of emergency in some countries of this region intensify the health challenges of urbanization and cause the complexity of health promotion interventions in this region. In addition to these challenges, political instability and conflict continue to affect health and living conditions in several EMR countries. According to WHO EMRO reports, the Region has among the highest conflict-related mortality globally, with an estimated 24.1 deaths per 100 000 population—nearly ten times higher than the global average (2.5). Injury-related mortality also remains a major concern, with seven countries reporting rates above 100 per 100 000 population. These indicators highlight the significant security-related pressures that complicate urban health promotion efforts in the region [10, 39].

To implement the Healthy City programme through community-based initiatives, this region has established a guideline encompassing 80 criteria across 9 domains of community mobilization and organization for health development; inter-sectoral cooperation; availability of information; environmental health; health development; education and literacy; skill development and capacity building; low-cost activities; and emergency preparedness and response. The Regional Healthy Cities Network (RHCN) was launched in 2012 in the EMR facilitating HC scale-up throughout the region. To be awarded as a Healthy City, cities must register and declare their interest and commitment to the HC principles -urban health promotion through community participation and multisectoral action- in the regional network, organize the local committees, and plan to implement the required initiatives in light of regional guideline criteria, submit a self-assessment report to the EMR regional office, and undergo a field visit by the experts from the regional office, which would lead to an evaluation report indicating the HC progress in the city and the regional committee decide on the HC awarding [27]. Cities are required to meet at least 80% of the criteria to qualify for this title. Sharjah, a city in the United Arab Emirates, was the first city in the region to be awarded as a healthy city. By 2019, 35 cities have been awarded as healthy cities in the EMRO region. Iran is the first country to establish a National Healthy City Network to support the HC candidate cities.

Sharjah, UAE

In 2015, Sharjah was awarded as the first healthy city in the EMR. According to external evaluation reports, Sharjah fulfilled approximately 88% of the defined Healthy City criteria.Sharjah has made significant investments in sustainable development projects across cultural, social, economic, and environmental sectors. As a result, it has successfully achieved a diverse economy characterized by resilience, where no single Economic segment accounts for more than 20% of the gross domestic product.

In addition to developing public transportation, one of the most valuable projects undertaken in this city to protect the environment was the establishment of an integrated environmental and waste management company. The city’s integrated environmental and waste management company has reportedly diverted around 70% of waste from landfill and is currently constructing one of the largest waste-to-energy facilities in the region. Furthermore, the creation of natural shelters for endangered species, actions aimed at improving the emirate’s biodiversity, and the implementation of laws to combat environmental damage are key initiatives of Sharjah’s Healthy City. The Pink Caravan, a nationwide breast cancer awareness and screening campaign, is another significant initiative. The Pink Caravan has screened more than 93,000 people throughout the UAE, with special emphasis on reaching outlying areas. This programme emphasizes Sharjah’s dedication to early disease detection and preventive health. Moreover, the city has included several health-related initiatives, gaining praise as a baby-friendly, child-friendly, adolescent-friendly, and age-friendly city, with intentions to grow to a family-friendly classification. These initiatives taken together help Sharjah to be a worldwide model for healthy urban living. The city has also invested in promoting Islamic culture, introducing it to the world, and maximizing its tourism potential, ultimately earning the title of Arab Tourism Capital [24].

Maraghe, Iran

Iran was the pioneer country in the region implementing the HC programme in the region. The new approach to the HC in Iran was started in 2016 which resulted in awarding ‘Sahand’ city in the East-Azerbaijan province as the first Healthy City in Iran and among the middle-income countries. Following this, ‘Maragheh’ city, also started the HC initiative with community participation and multisectoral collaboration. Promoting access to health services using the community representatives and health volunteers’ potential, improving community voice in urban policy-making, developing effective initiatives on road traffic injury prevention, Healthy lifestyle promotion, and urban public and green spaces expansion were among the highlighted programmes in these cities.

Additionally, the city formulated and implemented health system response plans for disasters and emergencies, organized programmes to enhance mobility and social engagement among older individuals, provided comprehensive mental health and social care services, expanded safe cycling paths, and implemented the health-promoting schools programme. Furthermore, a social emergency system was established which facilitates the response and management of social harms such as suicide, violence, etc [11, 39-43].

HC Scale-up in the EMR: challenges and solutions

The Healthy City programme is becoming increasingly popular, but various challenges are slowing its progress. Currently, cities from 15 countries in the EMR have applied to the regional network. Some of these, have demonstrated strong interest and political will to develop the programme further, while others have had inconsistent and short-term involvement. As a result, the history of the HC programme in this region has been uneven. To scale up this programme effectively, it is crucial to identify challenges and develop appropriate solutions to address them.

The institutionalization deficit

A key challenge impeding the expansion of the Healthy Cities Programme in the Eastern Mediterranean Region is the failure to institutionalize its core concepts and methodologies within national health and development sectors across member states. The Healthy City Programme and its related activities should not be implemented temporarily; without a commitment to sustainability, positive outcomes and impacts cannot be expected. Therefore, the Healthy City Programme includes measures that must be ongoing and consistent. In other words, these concepts should become part of the city’s governance culture so that they are inherently recognized as expectations by city officials and become habitual for citizens. Some city officials perceive the Healthy City Programme as an additional workload, yet it is a vital initiative that, through careful planning and an emphasis on health in sustainable urban development, establishes the priorities of the city, fosters teamwork, and encourages community and official participation for urban development. This is an inherent responsibility of individuals and governing organizations in every city.

Unrecorded progress

The lack of documentation and evidence production at the local level is one of the challenges in developing a healthy city programme in the EMR. The scarcity of documented implementation evidence - including peer-reviewed studies, technical reports, and outcome evaluations - from regional and local Healthy Cities initiatives has created both knowledge gaps and missed opportunities for cross-national learning, potentially slowing regional scale-up efforts. The lack of comprehensive reports reduces the capacity to promote the programme at the regional level, leading to many countries and cities being unaware of this programme. Furthermore, city officials’ view of the Healthy City programme as an additional workload, as mentioned earlier, poses a challenge in the EMR. This perception may stem from insufficient promotion of the healthy city concept and its core values, as well as a lack of adequate reporting in this area.

One way to monitor the status of the Healthy City Programme across different countries is to support and encourage research. This research, which can be either quantitative or qualitative, should explore several dimensions, including the programmes that have been implemented, their successes, the factors that enable them, obstacles to programme implementation, and the challenges faced by the Healthy City Programme at the city, country, and regional levels. By explaining the current situation of this programme across regions and countries, regional networks can develop effective plans and strategies to expand the Healthy City Programme. The studies and reports generated from these research efforts, combined with connections among the international network of healthy cities, can foster synergy and leverage diverse regional experiences and resources. This collaboration ultimately promotes the expansion of the Healthy City Programme, which is a multidimensional intervention aimed at achieving sustainable development goals [9].

Limited health data

Although the Healthy Cities Programme promotes comprehensive health monitoring, which includes social determinants of health (SDH), disaggregated equity indicators in addition to basic health indicators like mortality and morbidity, many Eastern Mediterranean national health information systems continue to place an excessive emphasis on typical biomedical metrics. This limited focus results in a significant data gap that hinders the development of equitable policies, evidence-based planning, and efficient programme monitoring. Without systematic integration of SDH and equity-related indicators, the region risks undermining the Programme’s foundational goal of reducing health disparities through urban health interventions.

Limited inter-sectoral collaboration

The Eastern Mediterranean Region faces critical governance challenges in implementing Healthy City programmes due to weak inter-sectoral collaboration. Because of inadequate inter-sectoral collaboration, the Eastern Mediterranean Region faces significant governance challenges when implementing Healthy City initiatives. Although collaboration involving the municipal, industrial, educational sector, civil society, etc. is crucial to the initiative, bureaucratic fragmentation, conflicting priorities, and inflexible hierarchies routinely undermine these collaborations. Comprehensive urban health initiatives become ineffectual single-sector interventions as a result of these structural flaws. These difficulties are made worse by political and financial limitations, which lead to a conflict between institutional capacity and acknowledged need. The region will continue to struggle to achieve the integrated approaches necessary for significant improvements in urban health unless governance reforms are implemented to allow for sustained inter-sectoral collaboration.

The following policies are suggested to improve inter-sectoral collaboration for Healthy Cities in the EMR: (1) creating high-level multi-sectoral coordination bodies with decision-making authority; (2) putting in place shared performance indicators and joint budgeting to encourage cooperation; (3) implementing standardized monitoring tools to monitor progress. In order to overcome bureaucratic fragmentation and accomplish significant improvements in urban health, these governance reforms require ongoing political commitment at the national and local levels [24, 44–46].

The policy coherence gap and untapped potentials of healthy City regional network

The Healthy Cities programme in the Eastern Mediterranean Region (EMR) operates through an interconnected network structure, where national networks of participating cities link to a broader regional network, as outlined in WHO EMRO implementation guidelines. This foundation presents significant - yet underutilized - potential for programme scaling through three key mechanisms.

First, the regional network serves as a vital platform for performance monitoring, systematically assessing national network implementation across member states. Second, it functions as a knowledge hub, analyzing collected evidence to both troubleshoot challenges and disseminate proven solutions through technical reports and guidance documents. Third, the network provides a structured channel for continuous quality improvement by facilitating cross-border exchange of successful practices and regional capacity building. However, the current implementation reveals critical gaps in network functionality. While the structure exists on paper, operational constraints limit its full potential. National networks often fail to consistently engage with regional mechanisms, and feedback loops between local implementation and regional support remain weak. Strengthening these connections through formalized reporting systems, regular regional assessments, and structured exchange programmes could transform the network from a passive framework into an active driver of programme improvement. The regional network’s untapped potential lies particularly in its ability to: (1) standardize monitoring frameworks across countries, (2) accelerate learning through comparative analysis of urban health interventions, and (3) advocate for political commitment by demonstrating collective progress. Realizing this potential requires investment in network governance structures and the development of practical tools for knowledge translation tailored to the EMR context.

Discussion

The implementation of the Healthy Cities Programme in EMR has shown both progress and ongoing challenges. Although several cities have embraced the initiative, the degree and effectiveness of its implementation vary widely across the region.

One significant challenge is the insufficient institutionalization of the Healthy Cities concept within local governance structures. This lack often results in fragmented efforts and limited sustainability of health-promoting activities. Additionally, there is a noticeable absence of comprehensive documentation and evidence-building at the local level, which impedes the ability to assess progress and share best practices among municipalities [11, 24].

Community participation and empowerment are essential for the success of Healthy Cities. However, evaluations in the EMR reveal that while community involvement is acknowledged as important, the mechanisms to facilitate genuine engagement are often inadequately developed. This shortfall restricts communities’ ability to influence decision-making processes and contribute to the sustainability of health initiatives [9, 11, 24, 46, 47].

In comparison, global experiences demonstrate that robust inter-sectoral collaboration and the integration of health considerations into all policies yield significant benefits. Cities that have effectively implemented the Healthy Cities approach often display strong political commitment, cross-sector partnerships, and a focus on addressing the social determinants of health [13, 21, 48].

To enhance the effectiveness of the Healthy Cities Programme in the EMR, it is crucial to:

1. Institutionalize Health Promotion: Embed the Healthy Cities framework within municipal policies and planning processes to ensure continuity and alignment with broader development goals.

2. Strengthen Community Engagement: Develop and implement strategies that promote active community participation, ensuring that initiatives are responsive to local needs and contexts.

3. Enhance Data Collection and Sharing: Establish systems for systematic data collection, monitoring, and dissemination to inform policy decisions and promote transparency.

4. Foster Inter-sectoral Collaboration: Encourage partnerships across various sectors, including health, education, transportation, and urban planning, to address the multifaceted determinants of health.

By addressing these areas, cities in the EMR can strengthen the implementation of the Healthy Cities Programme, leading to improved health outcomes and the advancement of sustainable urban development.

Limitation

This review has several limitations. First, empirical and experimental evidence on the effectiveness of Healthy City initiatives in the EMR is scarce. Even in cities such as Sahand and Maragheh—where implementation has reportedly progressed—formal evaluation reports or published outcome studies are not publicly available. Second, although the paper aimed to provide an overview of Healthy City implementation across WHO regions, its analytical focus on the Eastern Mediterranean Region was constrained by the limited amount of published evidence from this region, leading to unavoidable gaps in regional comparison. Third, this review was restricted to English sources, while many Healthy City activities in the EMR are documented only in locally accessible grey literature that was not uniformly available, which may have resulted in the omission of relevant evidence. Finally, due to the narrative and non–primary research nature of this paper, access to local municipal documents, internal reports, and context-specific implementation materials was limited, further restricting the depth of analysis.

Conclusion

Currently, the majority of the world’s population lives in cities, and this urban population is growing day by day. For many people, life and death for many people will be in cities. In the 2030 Agenda, the United Nations has established the Sustainable Development Goals (SDGs) document, which sets a clear framework for sustainable development that all countries must follow. The main themes of the SDGs are equity, inclusiveness, and accountability in health and development because a healthy population is essential for progress. Therefore, the interventions designed to achieve these goals should be grounded in these principles. The Healthy City Programme, established by the World Health Organization in the final decade of the 20th century, is a comprehensive initiative aimed at achieving sustainable development goals, with a focus on health and equity. Initially launched in 11 cities across Europe, the programme now encompasses hundreds of cities, along with national and regional networks. Given the urgency for the global community to meet sustainable development goals by 2030, the Healthy City Programme’s approach, which directly and indirectly supports various SDGs, makes its expansion a priority for the World Health Organization in several regions, including the Eastern Mediterranean office. Healthy City programme began in this region in 1990. Since 2012, the WHO has awarded 36 Healthy City certificates across 15 countries in EMRO. However, expanding the Healthy City programme in the region faces several challenges and obstacles. These encompass limited inter-sectoral collaboration, strict boundaries among urban institutions, and an absence of integration of the concepts underlying the Healthy City programme. Additionally, there is insufficient documentation and evidence regarding healthy cities and their indicators, as well as the absence of a continuous monitoring and evaluation system at both the country and regional levels. To address the challenges and remove the obstacles to expanding the programme, it is essential to conduct studies focused on the current status of the programme in the region. These studies should examine the challenges and barriers to implementation in active countries, as well as explore the reasons for hesitance in inactive countries. The findings will provide valuable evidence for planning and improve the programme in the Eastern Mediterranean regional office. The reports resulting from the research, the capacity to promote this programme will increase among other countries in the region and even at the global level.

Abbreviations

EMR

Eastern mediterranean region

PAHO

Pan American health organization

WHO

World health organization

HCP

Healthy city programme

UN

United Nations

UAE

United Arab Emirates

COVID

Corona virus disease

MERS

Middle east respiratory syndrome

SARS

Severe acute respiratory syndrome

HIV

Human immunodeficiency virus

AIDS

Acquired immunodeficiency syndrome

HEART

Health equity assessment and response tool

UNICEF

United nations children’s fund

UHC

Universal health coverage

HMC

Healthy municipalities, cities, and communities

RHCN

The regional healthy cities network

SDH

Social determinants of health

Author contributions

MHP: Study design, Search, Screening, writing–original draft, Final approval. JST: Supervision, Methodology, Writing–review & editing, Final approval. MS: Conceptualization, Writing–review & editing, Supervision, Final approval. MA: Writing–review & editing, Final approval. SE: Writing–review & editing, Supervision, Final approval. SA-A: Project administration, Study design, Screening, Writing–review & editing, Supervision, Final approval.

Funding

This research was funded by the Health Services Management Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. [Grant number: 72700]

Data availability

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Declarations

Ethics approval and consent to participate

The study is part of the PhD dissertation and obtained ethical approval from the Ethics Committee of the Tabriz University of Medical Sciences (NO: IR.TBZMED.REC.1402.832).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.