Healthy Cities Projects in Taiwan

AJPH PERSPECTIVES Healthy Cities Projects in Taiwan The Healthy Cities project, proposed by the World Health Organization (WHO) in 1986, has become a prevailing model of a setting-based approach for health promotion and a paragon for “Health in All Policies.” More than 1000 cities have conducted Healthy Cities–related programs around the world.1 According to WHO, a Healthy Cities project aims to promote comprehensive policies and plans for the health of a city and to reduce inequality in health among groups to achieve the goal of “Health for All.”1 Following this international movement, Taiwan adopted the concept of Healthy Cities projects in 2002. As the main program team, we highlight the development and challenges of the Healthy Cities initiatives in Taiwan in this article. DEVELOPMENT OF HEALTHY CITIES PROJECTS IN TAIWAN Tainan City was selected as the first demonstration city in Taiwan for a Healthy Cities project because of its suitable population size with strong and supportive communities. The project was launched in July 2003 when an interdisciplinary team comprising 16 scholars of public health, nursing, urban planning, architecture, transportation, sports science, and geomatics from National Cheng Kung University received a 3-year March 2020, Vol 110, No. 3 AJPH sponsorship (2003–2005) from the Bureau of Health Promotion of Taiwan. The Tainan Healthy Cities project hereby followed the WHO three-phase and 20step protocol to develop a Healthy Cities initiative. With the guidance from two renowned “fathers of Healthy Cities,” Leonard Duhl and Trevor Hancock, the Tainan Healthy Cities project has accomplished at least five achievements2: (1) making a multilevel framework for running a steering committee, a research group, and three working taskforces; (2) constructing 82 suitable Healthy Cities indicators and 21 demonstration programs; (3) building an effective mechanism for intersectoral collaboration and community participation; (4) setting up Healthy City awards to encourage nonhealth sectors to participate in the Healthy Cities project; and (5) establishing an alliance to help other cities to promote Healthy Cities projects in Taiwan. This successful experience has attracted many other cities and counties to follow the Tainan example to promote Healthy Cities projects since 2006. At the core of the movement, the Taiwan Alliance for Healthy Cities was established in 2008, and, since then, the Alliance has taken the responsibility and given great impetus to promote Healthy Cities projects in Taiwan. The details and achievements of the Alliance were published in related articles.3,4 Assistance was provided to 12 cities or counties and 13 districts or townships in Taiwan to join the international organization, which is affiliated with the WHO Western-Pacific office called Alliance for Healthy Cities. With substantial results, these cities and counties earned many more Alliance for Healthy Cities awards compared with other countries. EMERGING TASKS Because of a rapid growth of the older population, Taiwan became an aged society (those aged 65 years and older ‡ 14%) in 2018 and will soon turn into a superaged society (those aged 65 years and older ‡ 20%) in 2026. Thus, how to keep older adults healthy and active in later life has become an emerging issue in Taiwan. As a consequence, the Taiwan Alliance for Healthy Cities thereby started taking a new role of helping cities and counties to adopt another WHO framework of Age-Friendly City (AFC), as the advanced stage of Taiwan Alliance for Healthy Cities projects. Hence, following the international trend and the WHO guidebook, Chiayi City was selected as the first demonstration city in Taiwan for promoting AFC programs during 2010 to 2011. The Alliance not only delivered the experiences of Healthy Cities projects but also promoted the concepts of Health in All Policies in related AFC issues. Thus, the Healthy Cities movement has hereafter entered into a new phase that incorporated Healthy Cities approaches to deal with the complicated issues of agefriendly cities in Taiwan. By 2013, all 22 cities and counties had consequently received funding from the Health Promotion Administration to promote AFC programs. CHALLENGES FOR HEALTHY CITIES PROJECTS It was not effortless to build a healthy and livable city, nor was it the responsibility of any single sector of a city. Among Healthy Cities approaches, we found that the most challenging tasks included (1) setting up suitable indicators for evaluation and continuously collecting related data, (2) establishing a consonant intersectoral collaboration, and (3) maintaining partnerships between different organizations and ABOUT THE AUTHORS Both authors are with Healthy City Research Center, Research and Services Headquarters, National Cheng Kung University, Tainan City, Taiwan. Susan C. Hu is also with the Department of Public Health, College of Medicine, National Cheng Kung University. Correspondence should be sent to Susan C. Hu, PhD, Director, Department of Public Health, College of Medicine, National Cheng Kung University, No. 1, University Rd, Tainan City 701, Taiwan (e-mail: [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link. This editorial was accepted December 2, 2019. doi: 10.2105/AJPH.2019.305509 Hu and Huang Editorial 299 AJPH PERSPECTIVES experts. For example, compared with cities with previous Healthy Cities experience, those without Healthy Cities experience before but initiating AFC projects directly often faced difficulties and barriers with regard to integrating nonhealth sectors into the projects. This was because building an effective intersectoral collaboration, such as utilizing the government–academia–community framework, indeed needed a great amount of time in practice. Those cities and counties really need to engage in a series of capacity-building activities to establish the platform and mechanism for intersectoral collaboration before implementing advanced AFC programs. The eight domains5 covered by the AFC programs were more complicated than those in the Healthy Cities issues and often neglected by city governments. These eight domains, however, should not be treated separately in the real world of older adults’ daily lives but needed a collective approach and intersectoral collaborations to build related public policies across agencies. Thus, we suggest future Healthy Cities and AFC projects should provide more training courses for capacity building and flexible mechanisms for establishing effective intersectoral collaborations to change the traditional working pattern of bureaucracy in government systems. FUTURE DIRECTIONS In 2015, the United Nations announced 17 sustainable development goals (SDGs) and 169 targets. In the following year, the ninth Global Conference on Health Promotion held in Shanghai, China, with the theme of “Health Promotion in the SDGs” emphasized that cities and 300 Editorial Hu and Huang communities were critical settings for promoting health, and the Healthy Cities approach could contribute at least six SDG goals.6 Echoed widely by public health societies, nearly all Healthy Cities and AFC conferences in 2018 put SDGs as the main theme of their meetings. In Taiwan, the National Council for Sustainable Development thus reorganized its current function groups in 2017 and efficiently established related targets and indicators to the specific United Nations SDGs, in which more than half (65.1%) of the targets were included (Table 1). This action led to a good opportunity for Healthy Cities projects to continuously be implemented in Taiwan, upgrading the system from city level to national level. In addition, the Shanghai Declaration on promoting health in the 2030 Agenda for Sustainable Development has identified three important pillars: good governance, healthy cities, and health literacy.6 According to the definition of United Nations, good governance has eight essential characteristics: participatory, consensus-oriented, accountable, transparent, responsive, effective and efficient, equitable and inclusive, and follows the rule of law. Thus, how to stabilize the so-called “good governance” and develop a methodology for evaluating governmental performance are important issues in future research because many Healthy Cities projects have been affected by frequent mayoral replacements in many countries. CONCLUSIONS Most Healthy Cities projects in Taiwan were conducted at the local-government level. However, when faced with the complexity of city issues, there is a need to establish a vision and long-term goals at the national level to guide local governments’ plans, because the Healthy Cities movement is a strong value-based commitment to improve health.7 To achieve the goals of SDGs, it needs not only the efforts of the central government but also the active involvement of local governments. In all, in the unique Healthy Cities plans, we have experienced that Healthy Cities projects can serve as a practical and effective approach to establish Health in all Policies and help achieve the SDGs in the future. TABLE 1—Sustainable Development Goals’ Indicators of United Nations and Taiwan (With the Same or Similar Definition) Taiwan SDGsa UN SDGs Goals Goal 1: No poverty Goal 2: Zero hunger No. of Targets No. of Indicators No. of Targets (%) No. of Indicators (%) 7 12 6 6 8 14 8 14 Goal 3: Good health and well-being 13 26 11 18 Goal 4: Quality education 10 11 7 7 Goal 5: Gender equality 9 14 5 4 Goal 6: Clean water and sanitation 8 11 8 8 Goal 7: Affordable and clean energy Goal 8: Decent work and economic growth Goal 9: Industry, innovation, and infrastructure 5 6 3 3 12 17 9 2 8 12 0 1 Goal 10: Reduced inequality 10 11 5 5 Goal 11: Sustainable cities and communities 10 15 7 9 Goal 12: Responsible consumption and production 11 13 9 7 5 8 3 4 10 10 8 7 Goal 13: Climate action Goal 14: Life below water Goal 15: Life on land 12 14 9 11 Goal 16: Peaceful, just, and strong institutions 12 23 6 0 Goal 17: Partnerships for the goals Total 19 25 169 242 6 1 110 (65.1) 107 (44.2) Note. SDG = Sustainable Development Goal; UN = United Nations. a Source of Taiwan SDGs: National Sustainable Development Network of Taiwan, Executive Yuan, 2019. AJPH March 2020, Vol 110, No. 3 AJPH PERSPECTIVES Susan C. Hu, PhD Nuan-Ching Huang, PhD CONTRIBUTORS Both authors contributed to the conceptualization of the article, article writing, and discussions of its substance. N. C. Huang wrote the draft. S. C. Hu revised the article and added important intellectual content. ACKNOWLEDGMENTS We would like to give our sincere thanks to Stella Yu, PhD, for her invitation and English edits. We also express our appreciation to Health Promotion Administration, Ministry of Health and Welfare in Taiwan, and all members in Taiwan Alliance for Healthy Cities. CONFLICTS OF INTEREST Both authors have no conflicts of interest. REFERENCES 1. World Health Organization, Europe. Healthy Cities, 2018. Available at: http:// www.euro.who.int/en/health-topics/ environment-and-health/urban-health/ activities/healthy-cities. Accessed October 20, 2018. 2. Hu SC, Huang NC, Hsu TT, Hong CC. The achievement of Healthy City Tainan 2003–2006. Tainan City, Taiwan: National Cheng Kung University and Tainan City Government; 2008. 3. Hu SC, Kuo HW. The development and achievement of a Healthy Cities network in Taiwan: sharing leadership and partnership building. Glob Health Promot Educ. 2016;23(suppl):8–17. 6. World Health Organization. The mandate for healthy cities. The 9th Global Conference on Health Promotion; 2016; Shanghai, China. Available at: http:// www.who.int/healthpromotion/ conferences/9gchp/healthy-cities/en. Accessed November 10, 2018. 4. Huang NC, Kuo HW, Hung TJ, Hu SC. Do Healthy City performance awards lead to health in all policies? A case of Taiwan. Int J Environ Res Public Health. 2019;16(6):e1061. 7. de Leeuw E. From urban projects to healthy city policies. In: de Leeuw E, Simos E, eds. Healthy Cities: The Theory, Policy, and Practice of Value-Based Urban Planning. New York, NY: Springer; 2015:407–437. Building Up Housing to Break Down Health Disparities When the foreclosure crisis struck the United States in 2007 to 2008, millions of homeowners lost their homes, greatly limiting economic opportunity and wealth-building potential.1 Subsequently, a new calamity arose: the affordable housing crisis. As the availability of affordable apartments declined by more than 50%, the search for affordable housing led many middle- and upper-income individuals to migrate to lowincome communities where rents were more reasonable. This trend, gentrification, placed low-income communities at further risk for residential displacement.2 With stagnant wages and diminished housing affordability, many could no longer meet costly rent requirements and were faced with a sobering and precarious reality— homelessness. HOUSING AS A FUNDAMENTAL CAUSE Substandard housing and the lack of housing are associated with high rates of respiratory infections and tuberculosis. In March 2020, Vol 110, No. 3 AJPH addition, chronic diseases such as asthma and cancer have been linked to poor housing and the absence of housing in general. It is expected then that individuals who are homeless are at disproportionate risk for a variety of health disparities in comparison with the general population. Without a consistent and adequate nighttime residence, other ailments such as physical disability are also frequently observed in individuals who are homeless. While the compounded impact of poverty and health issues may precipitate homelessness, the experience of homelessness can also worsen health or introduce illness, attributable to novel hurdles in accessing health care.3 Reducing resource inequality is a health policy implication tied to Link and Phelan’s fundamental cause theory. The role of housing as one of the fundamental causes of homelessness and poor health cannot be ignored and should be recognized as a health-relevant policy.4 If the public health field is to address the fundamental causes of illness in populations who are unstably housed and homeless, health disparities in these communities can no longer be perceived as irrevocable norms 5. Global Age-Friendly Cities: A Guide. Geneva, Switzerland: World Health Organization; 2007. but rather as a reflection of improper and inconsistent shelter and an indicator of a failing housing system. EXPANDING THE SCOPE OF PUBLIC HEALTH Housing is a foundational human right. As such, it belongs in the forefront of the research, policy analysis, and intervention development undertaken by public health practitioners. Housing First is a promising programmatic model that prioritizes permanent housing instead of standard emergency shelter for individuals who are homeless. The Housing First approach can serve as platform for developing innovative social policies and has already demonstrated great potential in places including New York City, California, Pennsylvania, and Washington. Housing First does not require that individuals who are homeless address behavioral health–related problems before “graduating” through a series of programs or services to obtain shelter. Instead, this model shifts the paradigm by recognizing that housing is a human right that should not be withheld from anyone.5 Importantly, evidence of its impact can be found across a plethora of studies and has been associated with positive residential and health-related outcomes, including improved housing retention rates, decreased criminal justice system involvement, fewer psychiatric hospitalizations, less emergency department utilization, and fewer costs incurred over time to hospitals.6 Hospitals and health care organizations are uniquely positioned to engage in this housingcentered work. Precipitated by the housing crisis and perhaps inspired ABOUT THE AUTHORS Selena M. Gonzalez is with the Collaborative for Homeless Healthcare, New York, NY. Robert E. Fullilove is with the Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY. Correspondence should be sent to Robert E. Fullilove, Professor, Mailman School of Public Health, Columbia University, 722 West 168th St, Room 530, New York, NY 10032 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted December 14, 2019. Note. The opinions expressed in this article are those of the authors. They do not purport to reflect the official views or positions of the Collaborative for Homeless Healthcare. doi: 10.2105/AJPH.2019.305521 Gonzalez and Fullilove Editorial 301