Mainstreaming health in urban design and planning: advances in theory and practice

That urban environments influence health is not a recent discovery, nor is concern for health among urban planners a novel development. Public health practitioners, too, have long advocated for interventions in the urban fabric to address pressing health issues. The origins and evolution of these fields are, indeed, closely interwoven. The ‘sanitary revolution’ of the 19th century recognised the environmental origins of many major urban health threats, and well over a century has elapsed since the birth of the corresponding public health movement focused on improving urban living conditions. Early exploration of the possibilities of urban space for elevating wellbeing included ‘model’ experimental housing projects, as in the industrial company towns of New Lanark and Saltaire (Minnery 2012), and planning theory sowed the seeds not just for research and practice on healthy cities, but also for a deeper examination of the relationship between human and natural systems, for example, through the Garden Cities movement.

Today, we have moved far beyond isolated experimental prototypes of healthy urbanism. The WHO Healthy Cities project was founded in 1986, drawing on the principles of Health for All laid out in the 1978 Alma Ata conference, and has achieved many practical successes while expanding to thousands of communities around the world. In parallel, since the 1990s there has been a burgeoning effort to shed light on the interrelated nature of people, health, and the environment at various geographical scales (Lawrence 2021). Indeed, in the modern age, humanity’s impacts on the environment have become so significant that we now know our era as The Anthropocene (Steffen et al. 2007), and we recognize the preservation and flourishing of natural resources as inextricably linked to human health – for example, in the emerging rubric of planetary health. Peer-to-peer city networks, to be sure, increasingly concern themselves with issues of health and environment. Thus, it is now well established that effective urban planning and design can support human and planetary health and that, conversely, poorly designed and managed cities – as often seen in contexts of rapid, unplanned urban growth and limited resources – generate threats to health and environmental burdens. As Lawrence (2004) articulated, health should be seen as ‘a dynamic, holistic and positive concept that should be understood and included in programs, projects and plans about built environments’.

Yet, while research, policy, and practice on healthy cities have surged in recent decades, the status of urban health globally remains suboptimal: for example, though city dwellers generally enjoy better health than their rural counterparts, almost 40% have no access to safely managed sanitation services and an estimated 91% of people in urban areas breathe polluted air (WHO 2021). With 68% of the population predicted to live in urban areas by 2050, a failure to incorporate health more decisively into urban planning and management will inevitably lead to growing – and in some cases, locked-in and self-perpetuating – health and environmental burdens.

One factor that has limited progress on urban health is underappreciated urban complexity. Cities play host to multifaceted and sometimes paradoxical outcomes. For example, their density can enable more efficient use of resources – an environmental benefit – but they are nonetheless responsible for over 60% of greenhouse gas emissions (WHO 2021). Likewise, they generally offer good access to employment, education, and services like health care and housing (collectively, the key social determinants of health), but also concentrate health risks and hazards such as air and noise pollution and numerous determinants of communicable and non-communicable diseases, injuries, malnutrition, and mental health issues. These risks and outcomes are, of course, distributed unequally between and within cities.

Urban complexity demands systems thinking to understand and advantageously co-create our urban environments. Leveraging synergies across urban planning, design, management, and governance requires dealing with the interactions of cities, their infrastructures, agents, formal governing bodies, and informal processes of development that give rise to complex or unexpected outcomes. Systems thinking can help characterize this complexity and facilitate the implementation of intersectoral policies, enabling practitioners to model and understand interconnected and interdependent factors and bringing together diverse forms of knowledge to support action. It can foster development of healthy, productive urban spaces, support delivery of essential services, and protect planetary health, including by illustrating the value of green architecture, sustainable mobility, renewable energy, and nature-based solutions in spatial and land use planning (WEF 2022).

Systems approaches have been identified as valuable for the implementation of health-in-all-policies (HiAP), a methodology that, in defining the fundamental conditions for health, situates responsibility for health promotion beyond the health sector (WHO 1986, Shankardass et al. 2018). They have been singled out as critical to achieving the SDGs, including through the lens of urban health (Tan et al. 2019, Ramirez-Rubio et al. 2019). In the post-pandemic world, a systems approach can also leverage the momentum of COVID-related urban change, helping to ensure that intersectoral action becomes standard, enabling an all-hazards view of urban threats, and maximising co-benefits for environment and health. In each of these contexts, the involvement of extra-governmental actors – including citizens, academic experts, third sector and the private sector – is paramount, and transdisciplinarity, involving broad cooperation across disciplines and domains of knowledge and practice, participatory collaboration between decision-makers, researchers and practitioners, and the co-creation of built environments with lay users, is one key aspect of a systems approach (OECD 2020).

Articles in this special issue of Cities & Health confront the crucial question of how we can best mainstream health into urban design and spatial planning. This is not the first attempt at this target: the Adelaide Statement on Health in All Policies (WHO 2010) aimed to promote health not simply across different sectors but also as an intersectoral approach, recognising the influence of numerous factors beyond healthcare and traditional public health practice (Leppo et al. 2013). And health has indeed been more prominent in planning policy and urban design at various scales over recent decades. However, leaders and policy makers have rarely been driven to embed it in planning in such a way that health, wellbeing, and equity are integrated into the development and implementation of policies, master plans and regeneration or design projects.

The COVID-19 pandemic has in some ways changed the game. It has ‘popularised’ public health and forced governments to strengthen communication between health authorities and other policy sectors (Green et al. 2021), while also highlighting relationships between health and the built environment (e.g. housing, access to green space, transport infrastructure). Wholesale transformations in the use of urban space for work, leisure, and essential services are emerging in ways that seemed impossible just a few years ago. In this way, the pandemic offers an opportunity to accelerate intersectoral collaboration for health. Stimulating other sectors to consider and measure their health and environmental impacts has traditionally been challenging, and immediate economic priorities often override longer-term environmental and health considerations (even within the health sector itself); yet, COVID-19 demonstrates that in the face of an exceptional perceived health threat, intersectoral responses at large scale can became standard practice (Greer et al. 2022). We face this new future, therefore, with a sense of expanded possibilities for urban and planetary health.

About articles in this collection

This collection gathers a series of articles that take a holistic, high-level view of healthy planning while focusing on equity and inclusivity. Explicitly or implicitly, they aim to ensure that research is translated into practical, effective tools for decision-makers and practitioners to incorporate health in their design and planning practice. Thematically, they range from conceptual and methodological exploration to tool development to evaluation of specific issues in urban health and health equity. These themes are of vital importance not only for theoretical understanding of healthy planning, but also for advancing from research to the sustained practice of healthy urbanism across different scales of policy, design, implementation, and evaluation. Some of the articles are broad in scope, reflecting the strategic mainstreaming of health across urban design and planning; others are more focused, reporting case studies or the outcomes of specific projects and providing examples of how healthy planning is applied at specific scales or in specific contexts.

One empirical (Pineo et al. 2020) and one conceptual paper (Pineo 2020) describe the development, testing, and final design of a new conceptual framework: Towards Healthy Urbanism: Inclusive, Equitable and Sustainable (THRIVES). The THRIVES framework builds on the idea that healthy urbanism requires participation and local knowledge, and seeks to clarify which determinants of urban health can be influenced by planning and design across different spatial and temporal scales. It is an evolutionary refinement of previous frameworks in response to advances in knowledge and novel challenges. In particular, it gives central position to planetary health, reflecting growing concerns about the impact of the climate crisis on health and new evidence on the impact of the environment as a health determinant – a significant shift compared to previous frameworks, and in particular to the Settlement Health Map (Barton and Grant 2006).

Complementing the novel perspective of the THRIVES framework, Jano Reiss and colleagues (2022) likewise argue for a paradigm shift in meeting complex urban health challenges, from siloed operations to a collaborative, interdisciplinary approach, as embodied in a collective impact model. They describe the key elements needed for implementation of this model and its application in Jerusalem in the context of the local effort to achieve the SDGs – particularly SDG3 on Health and Wellbeing. They further trace its impact on local municipal institutions.

Several papers focus on methods for mainstreaming health in urban policy and planning. Sharpe and colleagues (2021), for example, explore the implementation of Health Impact Assessments (HIA) as an important aspect of spatial planning. They comment on the new ‘Health Impact Assessment in Spatial Planning’ guide, published by Public Health England in 2020, highlighting its value in supporting local authorities in a range of activities, from developing local HIA policy to integration, quality control, and other key processes, emphasizing the value of HIA even where there is no statutory requirement.

Two additional articles focus on methodologies for stakeholder engagement. Zengarini and colleagues (2021) report results from an action-research process in Turin designed to address health inequalities by using scientific evidence to facilitate decision-making. They highlight the value of mutual learning spaces, collaborative networks, and longitudinal engagement, as well as the specific utility of health equity as a common impact metric to motivate collaboration and open policy windows for action. In a commentary piece, Liu et al. (2021) report on the outcomes of a stakeholders’ workshop on the health co-benefits of urban green space in Guangzhou, in which Collaborative Systems Modelling was employed to enable the joint characterization of systemic variables and structures. The authors note the potential for such stakeholder-oriented collaborative modelling processes to surface novel solutions for complex problems.

Pineo and Moore (2021) also focus on stakeholder engagement, in this case from an empirical perspective, reporting the results of semi-structured interviews with built environment and public health professionals across a range of countries, focused on the application of healthy design principles in practice. They show that risk management, responsibility, and economic constraints are perceived as important factors in the adoption of such principles, and report on perceived barriers to healthy placemaking.

As noted in the THRIVES framework, environmental justice and equity go hand in hand with urban and planetary health, given the disproportionate impact of climate change and environmental degradation on the most vulnerable population groups. Two papers in this collection focus on this intersection. Oscilowicz and colleagues (2022) provide an insightful commentary on green gentrification and its impacts: discussing the Policy Tools for Urban Green Justice report, they call for a more exhaustive and intersectoral planning approach to avert the emergence of ‘green privilege’ and deliver strategic and equitable greening interventions. Drawing on empirical research in Baltimore, Hindman et al. (2020) highlight that access to green space is not solely determined by proximity, but also by perceptions and subjective factors shaped by socio-economic realities and inequities. As such, they support the assertion that understanding and addressing complex urban health and health equity challenges requires a multidimensional approach.

Ige-Elegbede et al. (2020) pull back to provide a bird’s eye view, expanding the evidence base in their systematic review of the impact of neighbourhood design on health and wellbeing. They highlight important associations between health and design principles like access to green space, walkability, access to public transport and amenities, and neighbourhood quality. While the authors reemphasize the importance of integrating health and wellbeing into neighbourhood design, they also highlight inconsistencies in the evidence and areas for future research.

Finally, three book reviews point to further scholarship related to the mainstreaming of health in urban planning and policy. Banerjee (2022) reviews Corburn’s (2021) ‘Cities for life: how communities can recover from trauma and rebuild for health’, exploring the differential impacts and consequences of urban trauma and emphasizing the value of Inclusive Planning involving stakeholder participation, particularly at the grassroots level. Besser (2020) reviews Lovasi's et al. (2020) ‘Urban public health: a research toolkit for practice and impact’, a broad text covering both introductory and advanced topics, and thus useful for novices and more experienced researchers in this critical field. Lastly, Kinder (2022) reviews Botchwey's et al. (2022) ‘Making healthy places: designing and building for well-being, equity, and sustainability’, the second edition of the authoritative reference exploring the relationships between the built environment and health and offering practical guidance.

Few issues are as critical to the health and wellbeing of present and future generations as the design and planning of cities. The articles collected here usefully advance our understanding of these issues at both conceptual and granular levels and provide methodological insights for researchers and practitioners. They also reemphasize the significant impacts that urban design and planning can have on health equity and the importance of participatory, cross-sectoral, and multi-domain processes – and more broadly of a systems approach – in managing these complex systems. We hope they will be of value to readers and a spur to further work in this critical space.

Additional information

Notes on contributors

José G. Siri

José G. Siri is an epidemiologist and urban specialist. Over a career in research and policy, he has developed and applied systems approaches to urban and planetary health, focusing on leveraging science for healthy development, devising simple systems tools to catalyze better decision-making, and improving understanding of complex challenges. His experience spans five continents and extensive engagement with researchers, practitioners, and policymakers, and has touched on urban studies, climate and health, sustainable development, systems thinking, transdisciplinarity, epidemiology, ecology, infectious disease, public health, and malaria control. He currently consults for the World Health Organization.

Ilaria Geddes

Ilaria Geddes is a Special Scientist at the Department of Architecture at University of Cyprus. She is the Research Coordinator of the Erasmus+ project Knowledge Alliance for Evidence-Based Urban Practices (KAEBUP) and contributes to teaching courses on Mediterranean Cities and Research Methodologies. Her research focuses on diachronic analysis of city development, urban theory, urban planning and the integration of diverse methodologies in urban studies. She is the co-president of the Cyprus Network of Urban Morphology (CyNUM) and an Editorial Advisor to the journal Cities & Health. As a Research Fellow at the UCL Institute of Health Equity, she contributed to the Strategic Review of Health Inequalities in England Post-2010 (Marmot Review) and authored the report The Health Impacts of Cold Homes and Fuel Poverty. She previously worked in urban design practice as a Project Consultant for Space Syntax Limited.