The emergence of a modern paradigm for urban health

3.1 The legal recognition of health as a human right

The WHO Constitution (1948) marked the first international and legal articulation of a universal right to health. It advocated for ‘… the highest attainable standard of health as a fundamental right of every human being,’ a right that was subsequently embedded in many other international declarations. Developed in a succession of UN documents and commentaries, the right to health is highly nuanced and does not equate merely to provision of state health care services. In fact, the evolution of the modern concept of urban health has drawn on a wider definition of health, as embodied in the WHO constitution, which states that:

This readily definition acknowledges that aspects of good health, whether at the level of the individual or populations, transcend a narrow medical perspective. For example, the UN Committee on Economic, Social, and Cultural Rights (2000) interprets the right to health as an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, including access to potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, and healthy occupational and environmental conditions, among other things. This wider framing places urban planning, management and development squarely at the centre of current and future efforts to secure health and wellbeing. Yet, the actualization of this concept of urban health is rarely found in urban policy.

3.2 Urban health beyond the health sector; from treatment to prevention and wellbeing

One consequence of the framing of human health as broader than solely ‘the absence of disease or infirmity’ is that securing good health requires action beyond the health sector. The World Health Organization consolidated the grounds for non-medical approaches to health in the Alma Ata Declaration (WHO, 1978), which states that ‘the attainment of the highest possible level of health is a most important world-wide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector’.

Significant too, in the conceptual advance of supporting the need for urban health activity ‘beyond health care’ is a ‘settings’ or place-based approach. In terms of urban spatial planning, much has been written about the close historic relationships (at the advent of formal city planning) between three interests: sociologist traditions looking for betterment of the working classes, public health seeking to minimize health risk, and the aims and techniques of those involved with urban policy, town layout and spatial design. However, the once potent and close interplay between these three elements weakened following the post-war period as these disciplines evolved on separate trajectories.

In 1984, the WHO ‘Beyond Health Care’ conference launched a foundational document that helped the re-emergence of an urban health settings approach, the WHO Ottawa Charter (WHO, 1986). This charter recognised that ‘Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.’ In legitimizing this approach, the Ottawa Charter provided a framework that challenged the all-to-dominant perception of healthcare systems as the sole (or primary) means for creating and sustaining health. Moreover, the charter stated that health was a ‘resource for everyday life’, not simply an objective. The Ottawa Charter called for several ‘areas for action’. Among those particularly innovative at the time, and arguably even now, called for a shift in the urban health paradigm, was the call for nations ‘to create supportive environments’. There was a stipulation that protection of natural and built environments and conservation of natural resources must be addressed in health promotion strategies. Notably, other areas of emphasis included; strengthening community action, building ‘Healthy Public Policy’, and recognizing that the responsibility for enabling, mediating, and advocating for health promotion lay with a variety of stakeholders including those outside the health sector. The second WHO Health Promotion Conference on Healthy Public Policy, in Adelaide 1998, resulted in the Adelaide Statement. This sought to move towards a shared governance for health and wellbeing, stating that government objectives are best achieved when all sectors include health and wellbeing as a key component of policy development (WHO, 2010b). Coalescence of the ‘Healthy Public Policy’ concept can also be found in Promoting Health through Public Policy (Milio, 1980 and 1986), supporting its key role in the Ottawa Charter. Healthy Public Policy advocates using the goal of positive health outcomes across all public policy areas. Its ambition is to create social, economic and environmental conditions for health at population level. As recent commentators note ‘Attention thus moves “upstream” to policies and institutions rather than “downstream” to behaviors or health services’ (Harris and Wise, 2020, p. 1).

More recently, we have seen the rise of the ‘Health in All Policies’ (HiAP) framework. HiAP as a moniker neatly captures the concept of Healthy Public Policy, giving it better policy traction. HiAP is a developing approach to public policy that systematically accounts for the health implications of decisions in all sectors, seeks synergies, and avoids harmful health impacts to improve population health and health equity (Puska & Ståhl, 2010). It emphasises the importance of inter-sectoral work and policy coherence. HiAP relies heavily on the use of scientific evidence and evaluation tools, such as health impact assessments, which come in a wide variety of forms and may include testing of policy or project proposals, health economic assessment, and broad stakeholder input to inform the integration of health into a range of actions.

In broadening responsibility for health to non-health sectors there is an implied and sometimes explicit shift from curative to preventative approaches. For example, the Ottawa Charter articulates an ambition to ‘reorient health services’, stating that the health sector must move increasingly in the direction of health promotion, beyond clinical and treatment-based services. Some municipal administrations may now be rising to this task, as they begin to embrace HiAP and health impact appraisal approaches that rely on processes less familiar to health practitioners, such as those for options testing for place-making, housing policy or urban infrastructure investment proposals.

COVID-19 provided a strong, but maybe short-lived, boost to the realisation that protecting health was not just the preserve of the health sector. Of course, there were plenty of lessons for national handling of pandemics (Sachs et al., 2022; Ali et al., 2024). But there was also a focus, receiving less attention, on lessons for the wider determinants of health (Ellis et al., 2021). To take just one example, in addition to a variety of restrictions on social mixing and physical mobility, in many countries urban public space was quicky adapted to permit use, whilst also reducing the potential for infection. Through these measures and others, it became evident to all that both urban health risk and safeguarding were not the preserve of the health sector, but were also impacted by elements baked into many aspects of society. Visually evident, in the public realm, governance and design of urban space came to the fore. To create safe public outdoor places, adaptation often re-allocated space; reassigning road space to favour pedestrians and cyclists. In terms of physical activity, air quality and road safety, some of the measures taken echoed what evidence-based public health had been saying for years, and they were popular, some led to permanent changes. Many hoped for a step change in understanding and actions for urban health as new ways of working became evident and new agendas arose (Honey-Rosés et al., 2020). The potential for a new salutogenic approaches through collaborations between public health and built environment professions was touted (Capolongo et al., 2020). However, with discourses and agendas forever on the move, the long-term impact of this powerful but short-lived ‘natural experiment’ and insightful period, that revealed new ways of ‘doing’ urban health, risks being lost (Ellis & Grant, 2021).

3.3 The growing emphasis on health equity

The 1978 Alma Ata Declaration also placed health equity firmly on the table, stating that: ‘The existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially, and economically unacceptable and is, therefore, of common concern to all countries.’

In 2005, WHO established the Commission on Social Determinants of Health to support countries and global health partners in addressing the social factors leading to ill health and health inequities. The Commission relied on several knowledge networks established to inform the report, including one for urban issues. The Commission’s 2008 report and subsequent updates focus on improving daily living conditions, tackling the inequitable distribution of power, money, and resources; and better measuring and understanding the problem and assessing the impact of action.

Partly based on evidence and analysis within the Commission’s report and subsequent work, health equity has achieved greater and greater resonance in urban health thinking. It has become a vital strand weaving together a multitude of perspectives. The reach of health equity and its core focus on supporting health across a variety of population groups can be seen in the ever-relevant report from the World Health Organization, Centre for Health Development, and the United Nations Human Settlements Programme ‘Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings’ (WHO/UN, 2010). A fundamental building brick and platform for the foundational document of modern sustainable development ‘Transforming Our World: the 2030 Agenda for Sustainable Development’ (UN, 2015); advocating that ‘a rights-based approach to health requires that health policy and programmes prioritize the needs of those furthest behind first towards greater equity’.

On-the-ground research has also contributed to the policy shift toward a greater focus on health equity. For example, a series of field studies in the 1990s in Latin America and Africa changed the landscape for urban health by demonstrating the enormous disparities between the health status of urban populations living in the most deprived compared to the least deprived areas (Stephens et al., 1994; Stephens, 1996; McGranahan et al., 1999). These types of studies helped move the focus from the urban poor as an isolated and at-risk sub- population to the broader issue of urban inequity in town and city governance. Moreover, the work of Pickett and Wilkinson in ‘The Spirit Level’ (2010) demonstrated how large income inequalities can lead to a breakdown in social cohesion, with both direct and indirect negative consequences for physical and mental health plus wider impacts across society. A more recent driver of health equity awareness, with a global in vivo demonstration of the links between social gradients and adverse health outcomes for disadvantaged population groups has been COVID-19 (WHO, 2021b). The pandemic disproportionally affected the poor, disadvantaged minorities and a range of vulnerable populations. This was largely due to its inequitable spread in areas of dense population, populations with limited temporary mitigation options, and whose work in critical service-level industries, such as food industries, deliveries services and social care, put them more at risk. These populations also tended to had a higher prevalence of pre-existing chronic conditions and poor access to high quality health care. It also became clear that collateral effects of the pandemic such as the global economic downturn, and social isolation and movement restriction measures, also were unequal in impact; affecting those in the lowest stratas of societies to a greater degree (Shadmi et al., 2020).

3.4 Complexity and the ‘causes of the causes’ of ill-health

Growing understanding of what is now seen as a ‘web of causality’, along with experience in examining the process and outcomes of interventions targeting the social and environmental determinants of health, have pushed the conceptual paradigm for urban health toward an embrace of complexity. The world is increasingly interconnected, complex. and uncertain, with significant implications for the way we generate, disseminate, and use knowledge. As such public health work needs a systems approach to address its complex evidence-base (Rutter et al., 2017).

Recognition of the role of urban complexity and the need for systemic approaches in research, policy development, and the design and practice of implementation is slowly spreading, from antecedents which span the last several decades. For example, in the 1990s, work on transport and environment identified issues for cross-sectoral cooperation for health in public policy (Dora & Phillips, 2000). HiAP, too, implicitly recognizes the role of complexity in contemplating cross-sectoral synergies, untended consequences and co-benefits. From the early 2000s, the International Science Council (ISC) has promoted transdisciplinary science as a means of grasping and dealing with complexity when interacting with the major challenges facing humanity, including urban health. Moreover, the ISC programme on Urban Health and Wellbeing, founded in 2014, has focused strongly on systems thinking as a means for understanding and addressing urban health and wellbeing challenges (Gatzweiler, 2020; Gatzweiler et al., 2017, 2023).

In parallel, the ongoing work of the Stockholm Resilience Centre (e.g. Rockström et al., 2009; Richardson et al., 2023) to define and raise awareness of planetary boundaries and their possible impacts on health has stimulated several systemic urban health research programmes. These include the Wellcome Trust’s Our Planet Our Health funding initiative and several national programmes for non-medical public health place-based research (e.g. Canada’s Healthy Cities CIHR funding, Australia’s HEAL NHMRC funding, UK’s NIHR’s Public Health Research programme and streams within the US’s NiH programmes). Through networks of researchers and stakeholders involved in projects funded by these programmes, we are starting to see the creation of a more widespread contemporary understanding of urban health.

However, not all innovation promoting a greater focus on complexity has been initiated by health interests in the urban family: organizations that have brought attention to combined health and environmental issues in cities include city networks like Metropolis and Cities Alliance, civil society organizations like Slum Dwellers International, think tanks like IIED, and multilateral agencies like UN-Habitat, UNESCO, the OECD, and the World Bank. Intellectual work like Kate Raworth’s Doughnut Economics (2012) and other work on systems thinking (Puppim et al., 2015) has focussed attention on the social origins of many environmental problems, helping to bridge the gaps between natural science assessments and potential applications in urban health, while signposting how integrated work on urban health needs to go beyond traditional urban policy.

Arguably better awareness of the ‘web of causality has led to a wider understanding of the need to work on the upstream ‘causes of the causes’ of ill-health (Braveman and Gottlieb, 2014). For example, how decision-taking in the built environment, housing, and construction sectors affects health (Pineo, 2022; Le Gouais et al., 2023), and how approaches to financial risk, investment decisions and the embedded culture in the development industry can influence health (Black et al., 2024). In parallel, a new emphasis is emerging on the Commercial (Gilmore et al., 2023) and Political Determinants of Health (Dawes and Gonzalez, 2023).

3.5 The Commercial Determinants of Health

Gilmore et al. (2023) define the Commercial Determinants of Health as: ‘the systems, practices and pathways through which commercial actors drive health and equity.’ (p1195). Within the main conceptual frameworks of the social determinants of health, the Commercial Determinants of Health does not appear to be explicitly or prominently included (Maani et al., 2020). Shedding more light on this apparent gap, Buse et al. (2023) wanted better to understand ‘how a range of related concepts and fields inform approaches to “healthy societies”’(p7450). They undertook a thematic analysis of conceptual frameworks, since the Alma Ata Declaration (WHO, 1978). Although screening over 200 political declarations, commissions and United Nations reports, peer-reviewed papers, commissioned evidence reviews and non-governmental organisation guidance notes, they concluded that the role of the commercial sector in influencing political and scientific processes received scant attention.

While the activities of commercial entities can contribute positively to health, and in urban health we need to find ways to channel benefits, there is growing evidence that the products and practices of some commercial actors, are responsible for escalating levels of avoidable ill health, planetary damage and health inequity (Gilmore et al., 2023). The Lancet Planetary Health (2023), warned that poor planetary and populations health outcomes are perpetuated by “vested interests seeking to preserve the status quo”(p. e441) as such they run counter to the conditions needed to support healthy societies. Lobbying by companies and their associations for policy environments favourable to their own interests (Buse et al., 2023) has been important in framing of the developing discourse on the Commercial Determinants of Health. It is system level issue. The system level is all-encompassing and includes major industry sectors, global trade, products, practices, services, working practices (WHO, 2023b) and even news media (Even et al., 2024). Of course, these are all very relevant in the urban health sphere, as much any other.

WHO has initiated a new programme of action, the Economic and Commercial Determinants of Health, which has four goals: to strengthen the evidence base; develop tools and capacity to address the commercial determinants; convene partnerships and dialogue; and raise awareness and advocacy (WHO, 2023c). Echoing the Ottawa Charter WHO state that ‘Commercial activities shape the physical and social environments in which people are born, grow, work, live and age – both positively and negatively’.

However, when viewed through the lens of a settings approach there seems to be a profound oversight in the Commercial Determinants of Health discourse to date; the drivers of the spatial policy and spatial form in our towns and cities. Urban spatial form, a key determinant of planetary health, human health and health equity, is heavily influenced by commercial interests and private corporate investments. Urban spatial form sets the context for daily life and life choices – transport modes, access to work and commuting distances, distribution of green space, air quality, thermal comfort, food access, community safety, social interaction; and importantly, neighbourhood and housing quality and their characteristics. This devastating oversight is partly due to the continuing gulf between the public health and built environment professions, in particular their antipathetic ontologies and approaches to evidence (Grant & Davis, 2019).

However, the agenda is not only about commercial risk to health, there are also many glimpses of how commercially driven policy and finance can be geared towards healthier place-making. In terms of upstream drivers of place-making, approaches range from the philanthropic to the pragmatic. With longer-term or more broadly developed property investment portfolios, there are examples of social impact bonds, which can incentivise private sector participation in urban health initiatives and examples of neighbourhoods developed for healthier ageing. An example of the latter though linking health insurance interests with estate development investments, and so making the hard financial case to keep an ageing population in good health, through healthy place-making.

In support their Fourteenth General Programme of Work, the WHO are currently preparing the first WHO Global Report on the Commercial Determinants of Health, which they say will be to protect public health and safeguard against conflicts of interest while leveraging the potential of the business community.

3.6 The political economy

A reciprocal relationship between politics and economic interests can be found weaving through the developmental concepts outlined above. This interacts with, and to a large extend determines ‘widely accepted’ understandings of what is meant by urban health (de Leeuw et al., 2021). A significant impact being that, in spite of a well-articulated academic discourse about challenges to urban health having a systemic basis, the dominant urban health paradigm is all too reductive. Kelly and Green (2019) argue that there is untapped empirical and theoretical potential within sociology, which could and should be harnessed for urban public health. However, if urban sociology and the political economy are ignored, or taken as a given and immutable context, although local solutions may be found – has anything changed in contextual understanding and the upstream drivers that led to the problem in the first place? This upstream context has the potential to re-create the problem again and again, at another time and/or in another place. A system’s approach looks both upstream, at drivers, and downstream, at outcomes (Cavill et al., 2020). A complex intervention (Skivington et al., 2021) is needed to address the political economy, whilst also obtaining practical health outcomes, and not veering into conceptual and theoretical realms. A productive avenue being explored in this context is the use of action research approaches. Especially important are those methodologies that can deal both with emergent issues as the research project proceeds; and are also grounded through a theory of change which recognises the importance of participatory generation of systemic solutions (Nobles et al., 2022; Cavill et al., 2020; Felmingham et al., 2023).

3.7 Planetary Health

As the urban health paradigm developed the capacity to encompass virtually all aspects of town and city activity, so too have several terms that look beyond the urban: – to the impact of human activity on the planet, and the impact of planetary systems on health. These have developed, changed and merged in various ways, and include:

As concepts, each with their own research adherents and particularities, they also have influenced ‘urban health’ as a concept. An example being the policy and practical foci on ecosystem services, and nature-based solutions. Important here too is the often overlooked importance of soils, and pointedly urban soils; in realms such as the human micro-biome, urban food growing, water retention and discharge, biodiversity and carbon sequestration. Maybe this can all be summed up by the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution (Anderson, 2020), all three of these are the result of human action, often due to the ever-growing demand for energy and resource consumption (including land), and the dispersal of ‘wastes’, from our towns and cities. In the nature of subsequent health outcomes, it is those who consume the least who are at risk of the greatest impacts. Maybe the best fit image here for planetary health is of the snake that consumes itself, tail first.

The WHO has stepped into this multiple agenda with the ‘Geneva Charter for Wellbeing’, building on the legacy of nine global conferences on health promotion. This charter attempts to draw together many strands of health and wellbeing. It advocates for global commitments and expresses ‘the urgency of creating sustainable wellbeing societies, committed to achieving equitable health now and for future generations without breaching ecological limits’ (WHO, 2021a).

4.1 Healthy Cities movement and other city networks

One of the most important developments in the modern history of urban health is the WHO Healthy Cities movement. This built on novel undertakings in Canada in the 1980s, where the city of Toronto had declared its ambition to become a ‘Healthy City’. A main driver being the strong intent of developers of the Ottawa Charter to move from statements to demonstrable change. They wanted to establish settings-based networks to support a shift in focus, from specific ‘problems to be solved’ towards a wider systemic approach to urban health. The WHO European Regional Office supported the initiation of a small pilot programme, inviting European cities to commit to a set of values and approaches concordant with the Ottawa Charter, further developed in Promoting Health in the Urban Context (Duhl & Hancock, 1988). This approach was accessible with a prescient action-based agenda, dozens of cities expressed their interest, not just the handful that WHO had expected. Interest and commitment quickly radiated to other regions, including Australia, New Zealand, and Japan, where networks of Healthy Cities emerged and were supported by city and national governments. Following that call to action in Toronto and inspired by the booming European network, provincial networks of Healthy Cities also emerged across Canada. Around the world, other local urban initiatives adopted the original Healthy Cities values in part or in whole. For example, Central and Latin American towns that had worked toward primary health care-focused ‘Sistemas Locales Para la Salud’ felt empowered to establish broader new networks for Healthy Cities and Communities (‘Ciudades y Comunidades de Salud’). Networks of healthy cities and towns also emerged in the North Africa Maghreb and southern African regions. In this rapid spread, the central message of the Alma Alta Declaration, that achieving health required the action of many other sectors in addition to health, finally found fertile ground. Each of these individual and networked entities emphasized different priorities as locally relevant. In some contexts, basic sanitary and environmental health concerns were prioritised, in others, processes of equitable urbanization or the health and wellbeing of slum dwellers. Although difficult to assess, one estimate puts the number of ‘Healthy Cities’ styled initiatives at more than 15,000 (De Leeuw, 2017).

However, comprehensive academic assessment and evaluation of healthy city initiatives is sparse. Due to the complexity of attempting to demonstrate causality, published analyses tend to dwell on qualitative aspects and description of process (de Leeuw et al., 2015). What is apparent is the diversity of effort and the importance of certain key elements (Harpham & Molyneux, 2001; Grant, 2015). Such elements include: the level of understanding and degree of political ‘sponsorship’, especially among city leaders; the empowerment of citizens and their understanding of how their quality of life is impacted by urban health challenges; and the existence of mechanisms whereby local health issues and concerns can influence local environments and urban policy.

The emergence of the Healthy Cities movement drew greater attention to urban health in WHO global policy discourses. For example, in 1991, the World Health Assembly (the governing body of the World Health Organisation) adopted a resolution focused on health development in urban areas (WHO, 1991). In response to growing urban populations combined with increases in exposure to health risks, it urged Member States to strengthen their capacity for healthy urban development. Specific actions included: implementation of policies to foster sustainable urban development and preserve health-supporting environments; assessment of the impacts of all urban policies on community and environmental health; and creation of structures and processes for inter-sectoral and community participation in urban policy development.

The Healthy Cities movement represented one of the first global city networks; since then, many others have emerged with synergistic values and comparable packages of commitments. Such themed networks include WHO’s Age-Friendly Cities network, as well as Transition Towns, Child-Friendly Cities, Smart Cities, Sustainable Cities, Resilient Cities, and Slow Cities (de Leeuw, Simos & Forbat, 2020).

4.2 WHO support for new thinking, and joint work with UN-Habitat, focussing on urban planning and spatial form

The WHO designates external academic Collaborating Centres to support its work. In 1990, the Institute of Action Research for Community Health in Indiana was the first Global Collaborating Center in Healthy Cities. The WHO Collaborating Centre for Research on Healthy Cities in Maastricht was designated in 1992. However, it was not until 1995, that the WHO European Regional Office established a unit centred on spatial form with expertise in urban planning and place-making through evidence-based design. This was the Collaborating Centre for Healthy Cities and Urban Policy in Bristol, UK, a centre uniquely situated within a built environment faculty, rather than a health faculty. Its distinctive mission was to build bridges between the health and urban constituencies by involving planners, architects and urban designers, geographers and landscape architects in the health agenda. As such, its focus was to act as a European and national hub to embed a deeper understanding of urban form as a determinant of health into public health understanding and practice. As a result of this work, the governance, planning and design of the physical form of cities became a new focus for the WHO European Healthy Cities Network during the 2000s, with the emergence of the concept of ‘Healthy Urban Planning’ (Barton & Tsourou, 2000). Urban planning went on to become a thematic priority during successive phases of the WHO Healthy Cities initiative.

Developed at the Bristol WHO Collaborating Centre, European member cities started to pilot and promote the use of ‘The Health Map’ ( Figure 1) (Barton & Grant, 2006; Dahlgren & Whitehead, 1991), this tool was developed to enable cross-sector understanding and collaborative working on the determinants of urban health for the built environment sectors. There are now four versions of the health map to suit different applications. Having been translated into over 30 languages, the Health Map has now been adopted by a wide range of actors at international, national and local level (Grant, 2023).

Figure 1. The Health Map: The determinants of health seen through the lenses of agency in spatial planning, urban design, place management and city governance.

Also in 1995, WHO established the Centre for Health Development in Kobe, Japan (known as the Kobe Centre), a global research institution that quickly established a leadership role vis-à-vis the urban health agenda. An early symposium entitled ‘Urbanization: a global health challenge’ featured global experts in various sectors voicing support for inter-sectoral research in relation to complex health issues surrounding urbanization. The Kobe Centre was soon seen as a leader in promoting crosscutting research and new integrative approaches for analysing determinants of urban health (and for other pressing global health problems, like those of ageing societies). For example, in 2010, the Kobe Centre published the Urban Health Equity Assessment and Response Tool (Urban HEART), designed to help ministries of health and city-level health officials measure health inequities within and between cities. This tool has been applied in large metropolitan centres (populations over 1 million) in low- and middle-income countries around the world (Pakeman & Collins, 2018).

This activity at Kobe and Bristol laid the foundation for a stream of joint work on urban health involving UN lead agencies for health and for urban settlements (WHO, 2010a), much of this work focusing on the role of urban planning and spatial form.

Also in 2010, and in light of the continuing shift toward an eco-social rather than a biomedical view of health, there were two global landmark reports on urbanisation and health. The Kobe Centre co-produced a report on urbanisation and health with UN-Habitat. ‘Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings’ (WHO/UN, 2010a). This sought to increase attention on urban health challenges, especially health inequities, through building a robust evidence base for action. In the same year, the final report from the ‘Global Research Network on Urban Health Equity’ provided an in-depth review of improving urban health equity through action on the social and environmental determinants of health, including sections on urban planning and housing design (GRNUHE, 2010).

In 2016, the Kobe Centre and UN-Habitat co-produced a second major output, the ‘Global Report on Urban Health: Equitable healthier cities for Sustainable Development’ (WHO & UN-Habitat, 2016). This presented yet further evidence that in cities, health improvement depends not only on the strength of health systems, but also on shaping urban environments. It reiterated, that local governments typically have responsibility over many critical functions that determine wellbeing and liveability in cities such as land use planning, building standards, water and sanitation systems, roads and transportation, and environmental protection. Their actions can thus exacerbate or reduce health inequities. The report asserted that good governance for urban health demands a deliberately integrated approach across many different actors.

Also during 2016, the advent of the 3^rd vicennial United Nations Conference on Housing and Sustainable Urban Development (Habitat III) in Quito elevated the intensity of coordinated urban health activity between WHO and UN-Habitat. With a view to influencing the meeting’s outcomes, WHO published ‘Health as the Pulse of the New Urban Agenda’ (WHO, 2016) in collaboration with independent global experts and the International Science Council programme on Urban Health and Wellbeing; other global science groups like Future Earth contributed thinking on the role of systems approaches in achieving urban sustainability (Bai et al., 2016). These inputs fed decades of theory and lessons from practical experience in urban health into the Habitat III process and the New Urban Agenda, reflecting the ideas and insights of a diverse community of researchers and practitioners.

More recent products arising from this collaboration include health input to UN-Habitat’s ‘International Guidance for Urban and Territorial Planning’, which features guidance on how to use spatial planning to achieve better health outcomes (‘Integrating Health in Urban and Territorial Planning: a sourcebook’) (UN/WHO, 2020) and a collection of case studies. Urban health, as a focus, continues to grow as a focus for both agencies.

4.3 Urban health work within WHO

WHO has supported urban health through the work of its secretariat at global, regional, and country levels, providing technical guidance, supporting research, and advocating for action. This has included technical guidance related to specific sectors, including active and sustainable transport (e.g., Health Economic Assessment Tool (HEAT¹); Integrated Sustainable Transport and Health Assessment Tool (iSThaT²), green space (e.g., Green Urban spaces and health tool (GreenUr³), energy (e.g., Clean Household Energy Solutions Toolkit (CHEST), housing (e.g., WHO Housing and health guidelines⁴), and several others. These instruments are widely used: for example, HEAT, which estimates health benefits from healthy transport interventions, has been used by hundreds of cities worldwide and was recently upgraded to include climate pollutants as well as health. There is also an extensive and growing compendium of WHO and other UN guidance on health and environment, with over 400 items. More broadly, WHO provides targeted technical support for urban health in areas ranging from air pollution, non-communicable diseases and injuries, emergency preparedness for COVID-19 and other disasters, vector control, and more.

WHO has also developed set of implementation frameworks and tools for urban health. The urban health capacities assessment and response resource kit is on suite of online tools that supports multi-sectoral teams in assessing whether a proposed initiative is able to meet its goals in a complex urban environment (WHO, 2024). It helps answer the critical question, are the right capacities in place to achieve objectives and influence urban health—whether directly or indirectly? It is a tool for collaboration tool not only to assess, but to highlight and garner implementation capacity. This is sits at the heart of a broader Urban Health Initiative (UHI),⁵ which outlines a model process for integrating health into policymaking in the context of climate and air pollutants. Through such frameworks, it has also supported action research to estimate impacts of urban policies on a range of health impacts. For example, the UHI has applied Health Impact Assessment involving stakeholder and policy analyses to estimate expected co-benefits from sectoral policy alternatives to reduce air and climate pollutants in cities in low- and middle-income countries.

As discussed above, WHO has been instrumental in establishing major networks for urban health including Healthy Cities and Age-friendly Cities, and in supporting others like the Bloomberg Partnership for Healthy Cities. Through these networks and its own engagement, it has sought to mobilize urban health action—for example, through the BreatheLife ⁶ campaign which targets the implementation of city- and individual-level solutions for air pollution in support of global development goals.

In its 13^th General Programme of Work (2019-2023), WHO recognized the relevance of urban health to its programmes across the board, setting up a new cross-cutting urban health unit within the new Department of Social Determinants of Health (SDH). Important objectives of this unit include harnessing the momentum of global work on urban health and supporting countries and local communities to develop positive urbanization trajectories for health equity. This advisory recommendation recognizes a need to increase visibility, better align, coordinate, and build on existing urban health work across the organization. The urban health unit has worked to consolidate a number of strands of urban health work, including by better defining and articulating the scope and possibilities of urban health and of a more strategic approach, the current paper and others in the F1000 ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’ collection are one element of that work. Another significant effort is the development of a global Urban Health Research Agenda for 2022-2032, this draws on an extensive scoping review, widespread consultation, and global and regional mapping of activities and stakeholders. More recently, the urban health unit launched a new repository on urban health, this is a live resource covering urban planning, housing, environmental issues, transport and mobility, nutrition, physical activity, COVID-19, and many others. This searchable system allows users to access WHO materials by health topic category, product type, geographical area, and year of publication/development.⁷

Away from the Geneva headquarters, substantial work on urban health has also been undertaken in WHO’s regional and country offices. For example, in 2011, WHO’s Western Pacific Regional Office published Healthy urbanization: regional framework for scaling up and expanding healthy cities in the Western Pacific (WHO, 2011), which called for a systems-wide approach to urban health, recognizing the need for strong support from national governments (WHO, 2010). This action-oriented framework adopted the Kobe Centre’s definition for healthy urbanization as ‘the process of enabling people to gain greater control over their health and their determinants through good urban governance that creates equal social opportunities for health for all’ (WHO KOBE, 2008). With similar intent, the Pan American Health Organization recently launched a Healthy Municipalities, Cities, and Communities initiative to promote intersectorality, community participation, and an approach centred on health equity. The WHO’s European region, outlined above, has just celebrated 35 years of progress under its Healthy Cities Network initiative.

5.1 Urban health observatories

Given the significant health implications of urban environments and urbanization, cities and other urban health actors need detailed information on health needs and outcomes linked to demographic, economic, cultural, physical, and environmental data (WHO, 2023a). Establishing effective mechanisms for monitoring urban health and health equity is essential (Caiaffa et al., 2014). Robust data, used wisely, can help integrate actions across existing systems in both health and non-health sectors (e.g., urban planning, urban resource and infrastructure investment, city development, transport, trade, food systems, etc.).

One approach to addressing the obstacles presented by the wide range of factors that influence health, and the dispersed and uncoordinated nature of relevant data (Dias et al., 2015), is the ‘public health observatory’—or in urban settings, the ‘urban health observatory’. The idea of health observatories dates back to the late 19th and early 20th centuries. Early efforts included the establishment of local health boards and the collection of key statistics in cities like London, Liverpool and New York. This idea of health observatories gained momentum in the latter half of the 20th century, coinciding with advancements in epidemiology, data collection, and computing technologies. The focus on urban health observatories specifically, emerged in the late 20th and early 21st centuries, driven by increasing urbanization and the recognition that cities face unique health challenges (see Box 1).

Key milestones in this development include: WHO support in 1998, through launching the Health Metrics Network to improve health information systems globally and the European Urban Health Observatory (EURO-URHO), established in the early 2000s. In 2006, UN-Habitat reported the existence of 119 local urban observatories, its Global Urban Observatory Unit oversees and coordinates approximately 374 today and focuses on monitoring urban conditions and trends, including health indicators, to support sustainable urban development. Urban Observatories are now commonly found in sector outside the health sector, with providing a potential for combined work within a broad urban health paradigm.

In many areas, including but not restricted to informal settlements, regularly collected, reliable data does not exist. However, a wealth of new data is now available from modern technologies like earth observation, mobile phone, and other spatial sources (Thomson et al., 2019), among others. In recent years, the rise of big data, advanced analytics, and geographic information systems has further enhanced the capabilities of urban health observatories. Urban health observatories now integrate diverse data sources, including electronic health records, environmental data, and social determinants of health, to provide a comprehensive view of urban health. AI and agent based modeling will no doubt lead to new and emergent capacities.

5.2 Micro- data, meso-data and digital urban health

At the other end of the scale from advances in Big Data, we must not ignore the continual evolution of micro-data, including remote sensing and socially sourced data (Xing et al., 2024). Both collection of data, and delivery of analysis are advancing at local place-based and individual/community scales.

On the positive side there may be the potential, through this micro-data for individuals to help balance gaps in healthcare access and exposure to health risk in urban areas, where both ‘unhealthy’ and ‘healthy’ infrastructure is unevenly distributed, often leading to health inequities. For example there are now mobile phone based apps being developed showing walking routes with good air quality, locating free water points, and how be more independent in the public realm through showing location of access to local toilet facilities. However, these developments may not align well with ‘Health for All’, vulnerable populations often lack the required technology, or the digital literacy required, to access such digital analysis. Digital access influences and is influenced by the social determinants of health in self-perpetuating cycles (Acuto et al., 2025). Significant digital gaps exist also within and between cities and countries, contributing to marked urban health inequities.

Institutionally, digital technologies are increasingly applied to improve the design, effectiveness, and efficiency of urban systems that affect health, including by increasing the quantity and quality of information available to decision-makers and improving the quality of communications and citizen engagement. Through these and other emerging digital technologies, public actors can shape urban areas to support the health of urban dwellers (Siri et al., 2025).