Healthy Governance for Cities: Synergizing Health in All Policies (HiAP) and Healthy Cities Approaches

Bearing in mind the heightened attention paid to health equity in public and global health, including by key actors like the World Health Organization (WHO) [1, 2], attention should be paid to mechanisms to reduce inequity. More specifically, given that multisectoral action by governments is thought to be required to achieve health equity [3] and has been vocalized as being needed by directors of policy and planning [4], approaches aimed at improving multisectoral action should be prioritized. One such way is through drawing on the valuable Health in All Policies (HiAP) and Healthy Cities approaches, particularly by utilizing research findings that parse out factors for the successful implementation of both HiAP and Healthy Cities approaches, which are discussed below.

Health in All Policies Approach

HiAP is “is an approach to public policies across sectors that systematically takes into account the health implication of decisions, seeks synergies, and avoids harmful health impacts in order to improve population health and health equity” [5]. HiAP is promising because it “systematically addresses health in policymaking by targeting broad health determinants,” rather than focusing on healthcare services [3].

The application of HiAP highlights some important lessons. For example, it is now clear that agenda-setting and capacity building are important drivers of intersectoral engagement [6]. And, while HiAP can yield numerous benefits to countries, it has also been adopted at the local/municipal level. Experiences of HiAP being implemented demonstrate that there are key common themes around: “funding, shared vision, national leadership, ownership and accountability, local leadership and dedicated staff, Health Impact Assessment, and indicators” [5]. Further, tangible lessons on best practices can be adopted (e.g., making intersectoral action mandatory affords levers to public health decision-makers in working across sectors to break through the traditional silos of governments) [7].

However, the approach seems widely underutilized, as the scoping review by Guglielmin and colleagues found evidence of HiAP adoption at the local level in a paltry 14 countries [5]. Looking to evidence from countries which implemented HiAP at the local level, the majority of the evidence arises from Europe, North America, and Australia/Oceania, accounting for 12 countries in the review.

While HiAP is not restricted by the level of government, its application to cities aligns well with the Healthy Cities approach.

Healthy Cities Approach

Because solutions to local problems arguably lie at the local level, it has been recommended that the role of urban health be decentralized from national to municipal levels [8], which is in large part what the Healthy Cities project of the WHO advocates. While decentralization is stated to be taking place in many locations, true decentralization should work to devolve more power to the municipality while providing support from the central level [9]. Aligned with this thinking, the Healthy Cities project was designed to “support integrated approaches to health promotion at the city level” [10]. “Healthy Cities” implement intersectoral health plans, along with collaborating with other cities to support further Healthy Cities development and establish networks [10].

It is important to note that Healthy Cities have been adopted across the world in various different ways [11]. Healthy Cities have implemented the process with degrees of rigidity, ranging from being “by the book” to those which have selected elements from WHO guidelines as desired [11]. Similarly, with community participation being emphasized, this has also been taken up in different ways, including both civic participation and through representative organizations [11].

Therefore, Healthy Cities cannot be typologically categorized, given their inherent diversity [11].

Synergizing the HiAP and Healthy Cities Approaches

These two approaches, HiAP at the local level and the Healthy Cities approach, may be synergized to great potential. This view is supported by the experience of European Healthy Cities which were successful in working across numerous sectors both within and outside government [12]. However, special consideration should be given to careful implementation to avoid these complementary approaches from being seen as “antagonistic,” as has been raised as a potential view of Healthy Cities and other movements [11].

One Potential First Step: Implementing a Municipal Multisectoral Coordinating Body for HiAP

One potential mechanism to synergize these approaches and overcome challenges associated with multisectoral projects is through the establishment of a coordinating body. This is similar to the role a “project office” plays in Healthy Cities projects, where the office plays an operational and managerial role to coordinate plans across partners [13]. However, through the inclusion of the HiAP approach, the coordinating body would work horizontally across local departments, including traditionally “non-health” departments (e.g., transportation), and vertically or across levels of government (i.e., provincial/state, federal, and international).

Ideally, given the importance of this coordinating body, there should be an individual employed on a full-time basis to initiate the activities until they have demonstrated successes [13]. This will allow the coordinator to have sufficient time to dedicate to the role, which was a problem in the Chittagong Healthy Cities project where the coordinator was cross-appointed in another demanding role [13]. Employing a coordinator at the office who plays an “action-oriented” role to visit partners to help motivate, discuss, coordinate, participate, and plan [13] is crucial. For example, the coordinating body can set up a schedule for coordinator visits that is cyclical to initiate a continuous process of monitoring [13]. In addition, this coordinating body should seek to capitalize on social entrepreneurs, people who are exceptionally able “to analyze, to envision, to communicate, to empathize, to enthuse, to advocate, to mediate, to enable and to empower” [14]. Accordingly, it has been recommended that social entrepreneurs should have a multi-frame perspective and be both proactive and reflective [14, 15]. While the role of a social entrepreneur has been studied in terms of personal characteristics (as outlined above), their role has not been fully explored in policy [14]. Kingdon’s Multiple Streams Framework, which posits that the three streams of problems, politics, and policies must converge to form a window of opportunity for policy change [16–18], provides insights into the potential for the social entrepreneur(s). The social entrepreneur(s) at the coordinating body is thus in a key position to raise numerous issues on the agendas of governments when a window of opportunity arises — which is in addition to their duties of working vertically and horizontally across governments.

Similarly, Healthy Cities which were able to connect urban planning and social change paradigms to a broader understanding of health were able to begin and sustain community health promotion programs [19]. And in the case of Victoria, Australia, local governments were legislated to develop municipal health plans and were provided evidence-based guidance for local policy development that is explicit about a social model of health [20]. This approach was evaluated and determined to change the way local governments thought about and planned for health [20]. Therefore, a major recommendation is to ensure all relevant city staff, including those working outside of strictly health departments, are aware of holistic definitions of health and its wide-ranging implications across various sectors — a task the coordinating body could undertake.

Conclusion

Because HiAP and Healthy Cities approaches both share similar values — including common roots in the Ottawa Charter for Health Promotion — the time is now to draw on the successes of previous initiatives and synergize the approaches to maximize benefits to health and improve equity. We can no longer stall when challenges seem daunting and the current COVID-19 pandemic has demonstrated that governments can act swiftly [21].

With widespread implementation of each of these approaches, the associated lessons learned and best practices can be drawn on in implementing synergized HiAP and Healthy Cities approaches. For instance, information that is gleaned from realist synthesis studies on Healthy Cities can be drawn on [22, 23], with recognition of some shortfalls of the methodology [24]. And similarly, findings from studies of HiAP, which demonstrate “win–win” strategies, can facilitate implementation through focusing in on acceptability and feasibility [25]. There is also an opportunity for a synergized approach between Healthy Cities and HiAP to allow for further study to inform practice. For example, health impact assessments, which is a tool designed to improve efforts and present recommendations, can be used and in fact have been found to help both sustain Healthy Cities and promote HiAP [26]. It is crucial to not only ensure proper documentation of processes undertaken and their outcomes, but also establish and build up key areas where deficits remain. For instance, only a few cities in the WHO European Healthy Cities Network had local-level data to monitor changes in health inequalities [27], despite cities’ commitment to this when joining the Healthy Cities network [28]. These important steps can help inform and guide others who seek to undertake similar work in other cities. Global actors, such as the WHO, should continue connecting cities through their work on the Healthy Cities Network, as it has been determined to drive local leadership for policy action [12], and can also broker knowledge on HiAP simultaneously. And further, through focusing on cities on the global south in these efforts, may be able to better overcome challenges faced in a rapidly urbanizing world [29].

Through decentralizing urban health policymaking to the municipal level and working in a multisectoral way to ensure health is considered in all policies, we are likely to move closer to achieving health equity.