Cities are playing a growing role in population health improvement and have enormous potential to be health-generating places. However, they also face considerable challenges and need to be governed in a way that gives all citizens the opportunity to enjoy good health.
Drawing on international case studies, this report explores the role of cities in improving population health and the conditions needed for success. It is based on 50 interviews with leaders from 14 cities and includes an extended case study on London that examines the lessons the city might learn from elsewhere.
Our research found that although there is wide variation between cities in terms of governance arrangements, powers and resources, there are also some common themes. One is that improving population health depends on co-ordinated action at multiple levels and ensuring that decisions in areas such as housing, employment and transport planning all have a positive impact on health. This city-wide co-ordination requires effective leadership, robust governance, and adequate investment in central programme management.
The role of political leadership is also critical. Elected mayors and other city leaders have soft powers beyond their formal responsibilities that they can use to drive pro-health policies. Significant improvements in population health are possible when city leaders are willing to invest their own political capital to advocate for change.
In England, debate about the role of cities is closely connected with the devolution agenda, with new ‘metropolitan mayors’ now covering one‑fifth of the country’s population. Policy-makers should explore the case for giving cities further fiscal and regulatory freedoms to enable them to tackle population health challenges more effectively.
Why cities matter for health
Improving population health involves thinking beyond the health care system and taking broader action to shape the environments in which we live. This report argues that cities and their leaders have an important role to play in doing so – and that this role looks set to grow. Cities matter for a number of reasons, including the following.
City leaders have significant influence over the social determinants of health. Most of the actions taken by city governments have an impact on the health of citizens, directly or indirectly, including through decisions about urban planning, the built environment, transport, economic development, housing and other matters.
Cities are where most of the population lives. In the UK more than eight out of every ten people live in urban areas and most of the remainder live in surrounding regions within the economic, social and cultural influence of nearby towns or cities.
Cities contain significant health needs and inequalities. By concentrating people and resources in one place, the urban environment creates hazards for health as well as opportunities for health improvement. For many health conditions, cities are where concentrations are highest and inequalities are greatest.
Cities are playing a growing role in national and international politics and are increasingly exercising leadership on complex social and economic issues, including population health improvement.
Cities are becoming increasingly well connected, with a growing array of networks supporting city-to-city communication. Through these networks, cities are collaborating to share learning on population health and other policy challenges.
While cities are, in some ways, fertile environments for health improvement, they also present considerable challenges. Some of the same characteristics that can make them engines of growth, innovation and creativity can also result in wide inequalities in health. One of the major challenges facing cities in the 21st century is how to reconcile and manage these tensions.
This report examines what a place-based approach to population health might look like in a city context. Drawing on international examples, we explore the range of roles that city governments can play in improving population health and the underlying conditions needed for effective urban health governance. Our research was based on three methodological components:
50 in-depth qualitative interviews, 25 focusing on London and 25 focusing on other international cities
a literature review of relevant evidence and data
an expert roundtable discussion with London system leaders and other invited experts to test emerging findings.
The international cities covered by our interviews were Paris, Berlin, Barcelona, Madrid, Copenhagen, Amsterdam, New York City, San Francisco, Mexico City, Seoul, Tokyo, Curitiba and Auckland. The report also includes an extended case study on London, illustrating the challenges and opportunities for improving health in a complex urban environment.
Our approach included a ‘deep dive’ on four major public health issues, selected to represent a range of challenges that may require different responses from city governments: obesity, HIV, air quality and public mental health.
Conditions for successful health governance in cities
The decisions that affect population health are made in very different ways from one city to another. In some, decision-making is highly centralised, whereas in others power is much more distributed. Each set of arrangements has its own strengths and weaknesses, and overall there is no ideal governance model for health.
Cities also differ in terms of the regulatory and other powers they have at their disposal. Some international cities have made extensive use of these powers to drive health improvements (New York being a notable example). Cities in the UK have less autonomy than those in many other countries, particularly in relation to tax-raising powers.
While the formal governance structures and powers found in the cities included in our research were highly diverse, leadership was seen to be a key issue in all. A common thread was bold political leadership, particularly from elected mayors (or their equivalents), whose visibility and ‘soft’ powers were seen as being crucial in securing support for health improvement measures.
Through our research we identified a number of underlying characteristics that shape the ability of a city to take effective action to improve population health. These characteristics can be grouped into five broad areas: governance; leadership; powers; expertise; and connectivity. Key insights regarding each of these are presented in the table below.
Roles for city governments in population health
City governments and their partners are well placed to play a number of roles in relation to population health. The first of these relates to co-ordination. Complex population health challenges require a co-ordinated response from multiple levels in the system, and city leaders can help bring together all of the necessary partners and ensure there is a coherent approach. International examples such as the Amsterdam Healthy Weight Programme show how important it is for there to be effective co-ordination at city level. Sub-city government also plays a critical role, but there can be significant value in having a consistent, unifying framework for activities across a city.
Cities are often seen as engines of innovation, and another important role for city governments is to promote innovation as part of efforts to tackle the social determinants of health. Some cities have taken steps to create an environment that encourages innovators to develop novel solutions to social policy challenges that affect population health, for example, through the development of urban innovation labs in Mexico City, New York and Auckland. Participants in our research argued that it is often easier to innovate at city level than at regional or national level, with cities sometimes acting as a testbed for policy changes that may be scaled up over time.
Some of the boldest attempts to improve population health in cities have been fuelled by the involvement and leadership of local people. City governments can harness the assets, resourcefulness and creativity of communities by creating the conditions for active citizenship and acting as a catalyst of locally led initiatives. This can be done in many ways, for example, through participatory budgeting in Paris and elsewhere, or through the development of an online citizens’ portal in Madrid.
In addition to co-ordinating system-wide action, promoting innovation and mobilising local communities, city governments can also contribute to population health improvement by using the regulatory and legislative levers available to them and by using their planning powers to create healthy places. Table 2 lists specific actions that city governments can take in relation to each of these five areas, based on our research.
Implications for London
Applying the international insights to London reveals a mixed picture. The city has many assets to draw on in improving population health and has the potential to become a world leader in areas such as healthy transport strategy, but it also faces significant challenges. Chief among these is its complex and fragmented governance arrangements, which can create problems for co-ordinating activities across the city and for accountability.
Priorities for London should include strengthening public health capacity at city level, ensuring that the new pan-London structures for health and care function effectively and making it easier for boroughs to collaborate. The recent devolution agreement provides a platform to build on and should be used to press for further devolution of powers.
The Mayor’s forthcoming health inequalities strategy is also a significant opportunity for London’s partners to work together around a common set of goals. It will provide a key test of whether they are able to demonstrate the kind of leadership needed to deliver positive change in such a complex system.
What is needed now?
The international examples described in the report illustrate the important and distinctive role that cities can play in relation to population health improvement. At their best, cities have the clout to bring about change at scale while managing to retain the local responsiveness and agility that national policy-making can sometimes lack. Policy-makers in the UK should explore the case for giving cities further fiscal and regulatory freedoms to enable them to tackle population health challenges more effectively.
England’s metropolitan mayors are a significant experiment in new forms of governance for large city regions, now covering one-fifth of the country’s population, and there is a need for more information and evidence to inform these changes. As these regions take on new powers through their devolution deals, ongoing learning and evaluation will be crucial and should include analysis of the impact on health and inequalities.
On the current trajectory, it appears that the leaders of cities and city regions are set to become increasingly prominent political actors in the UK and elsewhere. If this continues, there will be growing opportunities for them to exercise leadership in relation to population health. It is important that they are supported to step into this role and fulfil their potential to become influential partners in health improvement.