Global Research Network on Urban Health Equity (GRNUHE)
URBAN PLANNING/ DESIGN AND HEALTH EQUITY: A REVIEW
June 2010
GRNUHE was financially supported by the Rockefeller Foundation
Warren Smit1, Trevor Hancock2, Jacob Kumaresen3, Carlos Santos-Burgoa4, Raúl
Sánchez-Kobashi Meneses5 and Sharon Friel6
Affiliations:
1. African Centre for Cities, University of Cape Town, South Africa
2. Ministry of Healthy Living and Sport, Victoria, British Columbia, Canada
3. World Health Organization Centre for Health Development, Kobe, Japan
4. National Academy of Medicine, Mexico
5. Directorate-General for Health Promotion, Ministry of Health, Mexico
6. Department of Epidemiology and Public Health, University College London, UK and the
National Centre for Epidemiology and Population Health, The Australian National University
Keywords: urban health, health equity, urban planning, urban design, healthy urban
environments
Suggested citation: Smit W, Hancock T, Kumaresen J, Santos-Burgoa C, Sanchez Kobashi
Meneses R and Friel S (2010). Urban Planning and Design and Health Equity: a Review.
Working Paper Global Research Network on Urban Health Equity.
1
INTRODUCTION
The scope of this paper is the relationship of the physical urban environment and health
equity, and how planning and design of the physical urban environment can reduce health
inequities and facilitate better health for all urban residents. The paper reviews relevant
literature and identifies key gaps in the existing body of knowledge, particularly with regard
to low and middle income countries.
First of all, the literature on the relationship between the physical urban environment and
health and health equity is looked at. Secondly, the literature on healthy urban planning/
design interventions is looked at. Finally, key gaps in the literature and priorities for further
research are identified.
THE RELATIONSHIP BETWEEN THE PHYSICAL URBAN ENVIRONMENT AND
HEALTH EQUITY
Social and economic changes over the past few decades have resulted in increasing spatial,
social and economic inequities in cities all over the world. It was during the 1990s that it
began to be recognised that intra-urban inequities are a central crisis confronting urban policy
in terms of human health and quality of life.1-4 The report of the Commission on Social
Determinants of Health, Closing the Gap in a Generation, highlights the enormous health
inequities that continue to exist in the world today.5 Health inequities are a particular
challenge in cities in low and middle income countries, especially in rapidly urbanizing
regions such as Africa where urbanization has generally occurred without significant
economic gowth and has often not been accompanied by adequate investment in
infrastructure and services for the growing population living in slums.6,7. It has been noted of
health inequities in South Africa that “Despite constitutionally enshrined social and economic
rights and universal and apparent pro-equity policies, deep (and deepening) inequalities
persist”.8(p77) In addition, the global financial crisis of 2009 has further increased the
challenge of addressing health inequities.9
These inequities arise “because of the circumstances in which people grow, live, work, and
age, and the systems put in place to deal with illness”.5(pi) There is thus a strong correlation
between living conditions and health: “Where people live affects their health and chances of
leading flourishing lives”.5(p60) For example, average male life expectancy at birth in Glasgow
(for the 1998-2002 period) ranged from 82 years in the affluent suburb of Lenzie North to 54
2
years in the deprived inner city area of Calton.10 A study of intra-urban health inequities in
São Paulo and Accra compared areas with four different levels of deprivation (in terms of
income, education, overcrowding and access to services) and found enormous disparities: in
Accra, for example, mortality rates per 10 000 people for diseases of the circulatory system
(heart failure, hypertensive heart disease, cardiovascular disease) varied from 7.0 in the least
deprived areas to 16.4 in the most deprived areas, for infectious and parasitic diseases
(cholera, tuberculosis, malaria and hepatitis) the mortality rate varied from 4.7 to 9.0, and for
diseases of the respiratory system (acute respiratory infections, pneumonias and chronic
respiratory conditions) it varied from 4.0 to 7.6.2 Another example is that children living in a
squatter area are nine times more likely to have tuberculosis than non-squatter children in
Manila, Philippines.11 South African studies found that the HIV prevalence of those living in
urban informal areas was double that of formal urban settlements.12 Similar inequities apply
to injuries: young men in the favelas of Brazil are up to five times more likely to die from
homicide than their urban counterparts who do not live in favelas.13
The healthy cities movement that was initiated in the 1980s highlighted the relationship of the
urban environment and health and the role of local government in promoting health at a city
scale.14-21 Although social and economic conditions are important, there is a growing body of
work, across various disciplines, that recognises the role of the physical urban environment in
shaping health and disease and thus in contributing to existing health inequities.22-37
The various ways in which the physical urban environment can directly impact on health and
health equity include the following:

The extent to which the physical urban environment facilitates equitable access to the
benefits of urban life (livelihood opportunities, facilities, etc.)

The extent to which the physical urban environment facilitates access to adequate
housing (shelter, basic services, etc.)

The extent to which the physical urban environment provides a safe living
environment (i.e. with low risk of injuries and few negative impacts on mental health)

The extent to which the physical urban environment facilitates food security and
healthy nutrition

The extent to which the physical urban environment facilitates physical activity
3

The extent to which the physical urban environment facilitates acess to a healthy
natural environment
The literature on the relationship of the physical urban environment and health/ health equity
is discussed below, under these six headings.
THE PHYSICAL URBAN ENVIRONMENT AND EQUITABLE ACCESS TO THE
BENEFITS OF URBAN LIFE
Livelihood opportunities and opportunities to earn a better income are important determinants
of health and improved health equity. There is not much literature about the importance of
income and health outcome at an individual level, but there is vast evidence about these two
variables at an aggregated level.38
The time and effort required in getting to work, which depends upon the nature of the
physical urban environment, is an important issue. The Texas Transportation Institute’s (TTI)
Urban Mobility Report found that traffic congestion cost Chicago $4.27 billion in extra fuel
and person hours in 2003. Travel delay consumed 700,000 million hours in the US in 1982,
increasing to 3.7 billion hours in 2003. 39(p31) A report by the Victoria Transport Policy
Institute states that public transit in cities with large rail systems provides $279 per capita in
congestion cost savings, while transit in bus-only cities provides only $41 per capita. Transit
systems decrease congestion on highways by decreasing the number of vehicles on the road.
39(p31)
Another important issue is access to shops, facilities and community spaces (both outdoor
and indoor) Having shops, facilities and a range of community spaces in a local area can have
many direct and indirect health benefits: “Shops, services and other destinations
can encourage physical activity, social interaction and conviviality… Quite apart from what
is learnt in schools, including life skills and health literacy, there are health benefits
associated with the physical presence of schools within communities”.40(p52)
Access to health care facilities naturally also have an impact on health outcomes.41 Another
potential relationship of the physical urban environment to health care is the impact of
density on emergency response times. Research in high income countries suggests that that
4
people living in more densely populated cities have worse survival from acute cardiovascular
events, perhaps due to the longer response times of emergency medical and fire services.42,43
THE PHYSICAL URBAN ENVIRONMENT AND ACCESS TO ADEQUATE
HOUSING
Adequate housing is a broad concept that includes a range of issues,44 but in terms of health
the key housing issues are:

Location (presence or absence of hazards, e.g. pollution or risk of flooding)

Access to basic services such as water, sanitation and refuse removal; access to an
energy source can also impact on health

Shelter – protection from the elements, and sufficient living space
There is a vast literature on housing and health.45-52 This literatures highlights the negative
health impacts of damp, poorly ventilated, overcrowded housing.
Poor housing quality has a direct effect on the health of the inhabitants. The World Health
Organization has identified nine features of the housing environment which have important
direct or indirect effects on the occupants’ physical and/or mental health (see Box 1). Table 1
shows the nature of the disease risks arising from specific housing defects. Ensuring that
homes and other buildings are safe and healthy places has long been a concern of public
health, and housing standards relating to the amount of space per person, fire safety, air
quality, heating and so on have always had health as an underlying rationale.
BOX 1: FEATURES OF THE HOUSING ENVIRONMENT THAT AFFECT HEALTH52
1. The house as a structure and shelter (which includes a consideration of the extent to which the
shelter protects the occupants from the extremes of heat and/or cold, insulation against noise and
invasion by dust, rain, insects and rodents).
2. The extent to which the provision of water supplies is adequate, both from a qualitative and a
quantitative point of view.
3. The effectiveness of the provision for excreta, sewage, and solid waste disposal and the
management of their disposal.
4. The quality of the housing site, including the extent to which it is structurally safe for housing and
provision is made to protect it from contamination (provision for drainage being one of the most
important aspects.
5
5. Effects associated with over-crowding, including household accidents and the increasing
transmission of airborne infections: acute respiratory infectious diseases, pneumonia, tuberculosis.
6. Indoor air pollution associated with fuels used for cooking and/ or heating.
7. Food safety, including the extent to which the shelter has adequate provision for storing food, to
protect it against spoilage and contamination.
8. Vectors and hosts of disease associated with the domestic and peri-domestic environment.
9. The home as a workplace - where occupational health questions, such as the use and storage of
toxic or hazardous chemicals, and the health and safety aspects of equipment used needs
consideration.
TABLE 1: THE HEALTH RISKS OF HOUSING DEFECTS52
Housing defect
Health risk
Inadequate heating
Bronchitis, pneumonia, stroke, heart
disease,hypothermia, accidents
Damp and mould growth
Respiratory and other disease
Inadequate ventilation
Respiratory complaints, carbon monoxide poisoning
Lack of hygiene facilities
Infections
Inadequate kitchen facilities
Accidents, food poisoning
Disrepair
Accidents, fire, infections
Structural instability
Accidents
Inadequate lighting
Accidents
Hazardous materials (eg asbestos)
Respiratory diseases, cancer
Overcrowding
Infections, stress
Inadequate means of escape
Injury or death by fire
There is a particularly large amount of research on access to water supply/ sanitation and
health. For example, Esrey and colleagues review 144 articles in peer-reviewed journals on
the impact of improved water supply and sanitation facilities on diseases that are prevalent in
developing countries (e.g. diarrhoea).53 One example of the strong relationship of access to
water with health is that a study in South Africa found that households storing water (i.e. who
have to collect it from a communal water source) are 4.6 times more likely to have diarrhoea
than those who have an in-house water supply and do not have to store water.54
6
Slums are urban areas where problems of insecurity of tenure, poor shelter, overcrowding,
lack of services and hazardous location intersect. Slums can be defined as areas where there
is inadequate access to safe water, inadequate access to sanitation and other infrastructure,
poor structural quality of housing, overcrowding and/or insecure residential status.55 In 2005,
an estimated 810 million people in low and middle income countries, i.e. about 36.5% of
urban residents in these countries, lived in slums.56
The health problems of slum settlements are complex: “The lack of secure land tenure forces
residents to occupy unused or undesirable land… Slum locations may be unused or
undesirable because of their hazardous geography such as landslide- or flood-prone areas, or
unsafe or polluted environments… Poor quality water is a leading cause of morbidity and
mortality world wide and a defining danger of living in slums… Slum housing is densely
packed and poorly built with substandard or even flammable materials”.13(p1562)
Overcrowding can also place residents at risk of respiratory infections, meningitis, can fuel
potentially emerging epidemic diseases like influenza, and can potentially also contribute to
increased domestic violence. Another review of health conditions in slums notes that, in
addition, “The harsh physical and social conditions of urban slum life lead to chronic stress in
slum dwellers”.57(p902)
There are various case studies of health conditions in specific slums. For example,
Amuyunzu-Nayamongo and Taffa examine child health in informal settlements in Nairobi,58
and Riley and colleagues examine a favela in Salvador, Brazil, where they found that “a large
proportion of the residents of this shantytown suffered from a variety of chronic illnesses,
both infectious and non-infectious”.59(p5) Fry and colleagues provide an overview of the the
health of children in slums in Asia.11 Refugee camps have similar conditions of poor shelter
and inadequate access to services, and there are various case studies of health conditions in
specific refugee camps. For example, Zabaneh and colleagues describe the poor living
conditions and associated health problems in an unofficial Palestinian refugee camp in
Lebanon.60
Although there are a number of case studies, there is a lack of comprehensive data on health
conditions in slums. The main conclusion of Riley and colleagues is that “Little is known
about the spectrum and burden of disease morbidity in urban slums of the world”.59(p6)
7
THE PHYSICAL URBAN ENVIRONMENT AND SAFE LIVING ENVIRONMENTS
“Safe living environments” can cover a wide range of issues. For example, the International
Network of Safe Communities’guidelines for membership61 address the following issues:
transport safety; home and leisure safety; children’s safety; safety of the elderly; occupational
safety; crime and violence prevention; suicide prevention; and disaster preparedness and
response. Essentially, however, the issue of safety is concerned with injuries, and the extent
to which the physical urban environment contributes to or prevents injuries.
Injuries can be broadly categorised into two forms – unintentional injuries (or what used to be
called “accidents”) and intentional injuries (deliberate acts of violence against oneself or
others, including both homicide and suicide). The main forms of unintentional injuries are
motor vehicle crashes (with other vehicles or with pedestrians or with the surrounding
environment), drowning, poisoning, falls and workplace injuries, while the main forms of
intentional injury come from male-on-male violence, domestic violence (abuse of women,
children and the elderly), war and civil strife.62 “With more than 5 million deaths every year,
violence and injuries account for 9% of global mortality, as many deaths as from HIV,
malaria and tuberculosis combined. Eight of the 15 leading causes of death for people ages 15
to 29 years are injury-related: road traffic injuries, suicides, homicides, drownings, burns, war
injuries, poisonings and falls”.63
Every year injuries due to violence, traffic crashes, burns, falls or drownings are responsible
for 9% of all deaths and 16% of all disabilities. Common types of injury include:63-65

Violence: In 1998 approximately 2.3 million people died as a result of violence.
About 90% of violence-related deaths occur in low and middle income countries.
Many more people die from homicide than from attack in a war, and even more die
from suicide. For every death due to war, there are three deaths due to homicide and
five deaths due to suicide. However, most violence happens to people behind closed
doors in the family environment and results not in death, but often in years of physical
and emotional suffering.

Traffic crashes: Traffic crashes are the number one cause of death for children and
youth between ages 10 and 24 years. Other vulnerable road users include older
people, pedestrians, cyclists and motorcyclists. About 1.2 million people die every
8
year as a result of road traffic crashes - up to 50 million more are injured or disabled.
About 90% of traffic injury-related deaths occur in low and middle income countries,
and the annual death rate is 20.2 per 100 000 population in low and middle income
countries compared to 12.6 in high income countries.

Burns: Every year over 300 000 people die from fire-related burns. Millions more are
left with lifelong disabilities and disfigurements from such injuries, and often suffer
from resulting stigma. Burns are the only form of injury that kill more women than
men.
A study of injuries in Uganda highlighted that injury rates are much higher rates than those in
most Western countries, and that the urban population is at a higher risk than the rural
population.66 Global statistics confirm this. “Based on 1998 data, 88% of traffic-related
deaths, 86% of suicides and 95% of homicides occurred in low and middle-income countries.
For most types of injuries, people die at a higher rate in low and middle- income countries
than in high-income countries. The poor are at high risk for injury because they are faced
with hazardous situations on a daily basis. For instance, their means of transport are
overcrowded and poorly maintained. As pedestrians on unsafe roads, they are vulnerable to
being crushed by cars and buses. Their workplaces adhere to few safety standards. Their
homes, often poorly constructed, are vulnerable to fire. The poor also have less chance of
survival when injured because they have less access to health services”.62
The physical urban environment has direct links with all of these issues:

There is a link between urban planning/design and crime and violence. – certain
urban layouts facilitate “defensible spaces” while others do not.67,68 Jacobs (1961)
observed that where neighborhoods are configured to maximize informal contact
among residents, street crime is reduced and children are better supervised (the notion
of “eyes on the street”).69 In particular, there is a vast literature on gated communities,
and the extent to which they do or do not provide safety.70

Urban planning/design has a very direct link to the prevalence of traffic accidents. For
example, “woonerven” are streets designed specifically to be safer for pedestrians
through various “traffic calming” measures.
9

There is also a large body of literature on childhood burn injuries in low and middle
income countries.71 Childhood burn injuries are generally linked to lack of access to
safe forms of energy.
Other types of injuries may also be linked to the built environment. There is a vast body of
literature on natural and man-made disasters (earthquakes, flooding, etc.) and how urban
planning can reduce and manage these risks. Disasters can have a wide variety of impacts on
health; for example, the health impacts of flooding can include injuries, increased fecal-oral
disease, increased vector-borne disease (e.g. malaria), increased rodent-borne disease and
negative impacts on mental health.72 Resilience towards natural disasters can vary greatly, as
demonstrated by the earthquakes in Port-au-Prince, Haiti, and Santiago, Chile, during 2010.
The Chile earthquake, measuring 8.8 on the Richter scale, resulted in hundreds of deaths,
while the Haiti earthquake, measuring 7.0 on the Richter scale, resulted in more than 230 000
deaths.73 The planning and design of the built environment can contribute towards resilience
to natural disasters, such as flooding and earthquakes (for example in terms of the design of
drainage systems, design of buildings, and so on).
Another important safety issue is the extent to which the urban physical environment
facilitates mobility for people with disabilities, children, women and seniors. There are
considerable bodies of knowledge on these issues, but with a lack of evidence from cities in
low and middle income countries.74-77
Also important, but often neglected, is the extent to which the physical urban environment
facilitates g ood mental health. Characteristics related to the built environment, such as
crowding and noise, can affect people’s health directly and/or impact indirectly through
altering psychosocial processes, such as the development of socially supportive relationships
within the household.78 The overall quality of the urban environment can also effect mental
health. For example, a study in London found higher levels of resident depression in areas
that had “less desirable” built environments (older buildings, evidence of vandalism and
graffiti, few trees and gardens, etc.)79. Access to the natural environment, and clear urban
layouts that facilitate finding one’s way, can also have a beneficial impact on mental health.80
Studies in low-income communities in Chicago have shown there is a relationship between
levels of greenspace and improvements in outcomes such as ADHD symptoms, levels of
10
domestic violence and such psycho-social issues as school performance, girls’ self-discipline,
concentration, the ability to cope and the strength of the community.81 In addition, as noted
above, the design and layout of urban areas may also influence safety and security, which in
turn can impact on psychosocial stresses.
THE PHYSICAL URBAN ENVIRONMENT AND FOOD SECURITY/ NUTRITION
Low and middle income countries are undergoing an urban epidemiological transition in
which non-communicable diseases, such as cardiovascular diseases, are becoming more
prevalent. This is because in rapidly urbanizing and industrializing countries, such as
Vietnam, “the resulting changes in the economy and consequently in society have led to
profound changes in individuals' lifestyles, including the adoption of unhealthy food
consumption patterns, prevalent tobacco use, alcohol abuse and physical inactivity, especially
in large cities like Ho Chi Minh City”.82 These are all well-established risk factors for
cardiovascular disease and all-cause mortality in urban areas.23
An important part of this change in lifestyles has been nutrition transition since the 1970s,
characterized by greater dietary diversity and a shift toward “Western-style diets” of meat,
dairy, less complex carbohydrates, and reduced fruit and vegetable intakes. The relatively
easy access to caloric energy is a major contributor to the two billion adults estimated to be
overweight and obese.83 Since urban areas are much further along in the transition than rural
ones, they experience higher rates of obesity. Fresh fruit, vegetables, meat, eggs and so on
can become more expensive and less available in urban areas than rural areas, especially in
poor urban areas, as has been the case in Mexico, due to differential distribution systems.84
And as more and more women work away from home, they may be too busy to shop for,
prepare and cook healthy meals at home. The fact that more people are moving to the city
compounds the problem.
These changes in food consumption patterns and physical activity have resulted in obesity
becoming a global crisis. In 2005, approximately 1.6 billion adults (age 15+) were
overweight and at least 400 million were obese; it is projected that by 2015 approximately
2.3 billion adults will be overweight and more than 700 million will be obese.85 The number
of people with obesity-related diabetes is expected to double to 300 million between 1998
and 2025, with three-quarters of that growth projected in the developing world.86 Childhood
obesity is also an increasing concern. “The problem [of childhood obesity] is global and is
steadily affecting many low- and middle-income countries, particularly in urban settings.…
11
In 2007, an estimated 22 million children under the age of 5 years were overweight
throughout the world. More than 75% of overweight and obese children live in low- and
middle-income countries. Overweight and obese children are likely to stay obese into
adulthood and more likely to develop non-communicable diseases like diabetes and
cardiovascular diseases at a younger age”.87
The net result is the increased burden of disease associated with non-communicable diseases.
For example, an estimated 17.5 million people died from cardiovascular diseases in 2005,
representing 30% of all global deaths; over 80% of deaths from cardiovascular disease occur
in low and middle income countries.5 The burden of non-communicable diseases in South
Africa, as elsewhere, “disproportionately affects poor people living in urban settings”.88(p934)
Simultaneously, changing global social and economic conditions have resulted in high levels
of food insecurity for the urban poor in low and middle income countries (food security can
be defined as “access by all people at all times to enough food for an active healthy
life").85(p.?) The net result of these changes in diet and nutrition has been a double burden of
malnutrition and obesity for the urban poor (often co-existing in the same households).82
Dixon and colleagues83,90 identify six major determinants of urban nutritional inequalities in
industrializing and industrialized cities: decline in national food self-sufficiency due to
withdrawal of government support for agricultural sectors; displacement of local food
retailers by supermarket and convenience store chains; global food safety policies that impact
negatively on small food producers, retailers, and poorer consumers; producer subsidies,
consumer demand for cheap food, and high levels of foreign direct investment in food
processing firms and convenience food chains encourages the production of high energy
foods; loss of livelihood options in local food systems; and urban planning that contributes to
diet-related disease and to health inequities through its support for “automobility”.
The food environment /urban food system has traditionally received little attention from
planners,91,92 but recent research suggests that, for example, access to supermarkets and
convenience stores has a significant impact on health and diet.93-95 Urban agriculture can also
potentially be important for food security.96 In addition, lack of clean water for drinking can
result in increased consumption of soft drinks, with negative health consequences.97
12
It should be noted, however, that “existing work reporting cross-sectional associations
between the local food environment and dietary habits is prone to the criticism that food
availability may result from dietary patterns, rather than the other way around”.23(p581)
THE PHYSICAL URBAN ENVIRONMENT AND PHYSICAL ACTIVITY
Along with unhealthy food consumption patterns, physical activity is also closely linked to
obesity and chronic disease.98-100 Changing lifestyles have resulted in lower levels of physical
activity.82 In addition, newer urban development has often resulted in fewer, and less
conducive, spaces for physical activity. For example, an analysis in Mexico shows that the
inequity of availability of physical activity spaces has increased rapidly in urban counties,
increasing the gap between the upper and lower quartiles from 1.91 to 2.78 in only five
years.101
There is considerable evidence linking physical activity to health, but “epidemiological
evidence for the health benefits of physical activity stem primarily from studies performed in
industrialized nations”.102( p321) A number of studies in high income countries suggest that
leisure time physical activity has a particularly important effect on health, whereas domestic
physical activity, occupational physical activity and transport physical activity seem to have
less effect.103-105 Again, however, this may be different in low and middle income countries.
There is a large literature based on research in high income countries that suggests that there
is a relationship between the built environment, physical activity and health outcomes (for
example, obesity), and that certain types of built environment can facilitate greater physical
activity and thus result in better health outcomes for residents (for example, reduced rates of
obesity).
The main characteristics of the built environment at a neighbourhood scale can be
conceptualised as: density; land use mix; street connectivity; and the nature of streets.106 At a
larger scale, the metropolitan or regional structure can also be important in determining
movement and activity patterns. All of these are directly infuenced by urban planning.
Neighbourhoods that have a high density, a mix of land uses, a fine-grained street network
and pleasant, human-scaled streets are typically regarded as pedestrian and cyclist-friendly
(i.e. as having a high degree of “walkability”): “Planners often label neighborhoods
‘pedestrian-oriented’ if they have relatively high densities of development, a mix of land
13
uses, a street network with high connectivity, human-scale streets, and desirable aesthetic
qualities in that they make walking both more viable and more appealing. Areas with the
opposite characteristics are labeled ‘automobile-oriented’ in that they make walking, transit,
and other alternatives to the car a practical impossibility or at least a significant
challenge”.106(p66)
There are many examples of studies comparing physical activity/active transport and/or
health outcomes (such as obesity) in neighbourhoods with different types of built
environment (almost all of them are from North America).107-125 These studies typically use
objective and subjective measures of the built environment (quantitative measures of density/
land use mix/ street connectivity/ street scale and questionnaires respectively), and of
physical activity/ health outcomes (accelerometers/ measuring body mass index and
questionnaires respectively) to compare neighbourhoods with different types of built
environment (typically those with different levels of “walkability” as measured by a
“walkability index”). Diez Roux notes that “A large part of existing research linking
residential environments or features of the built environment to health outcomes has been
cross-sectional, relating health behaviors to features of places of residence at a single point in
time”, and that “longitudinal studies that relate changes in area characteristics to changes in
health behaviors are still rare”.23(p581)
Most these studies of the relationship between built environment and physical activity
suggest that residents in neighbourhoods with high density/ high mix of uses/ fine-grained
street networks walk and cycle more than residents of neighbourhoods with a low level of
“walkability”. A review of eleven North American studies found that residents of high
walkability neighbourhoods on average walk and cycle more than 2 times as much (and up to
5 times as much) as residents of low walkability neighbourhoods, thus potentially resulting in
significant health benefits for residents.126 As a further example, another study found that a
relatively small increase in the measure of walkability (e.g. a residential density of 4.4 as
opposed to 3.6 dwelling units per acre) resulted in an average 32% increase in an individual’s
walking time.108 In addition, it has been found that the location and nature of recreation
facilities (parks, playgrounds, etc.) can also influence levels of physical activity: the
availability of walkable green space is associated with greater physical activity and lower
cardiovascular risk.127,128
14
More recent studies, such as the Twin Cities Walking Study in Minneapolis-St. Paul, have
suggested that previous studies may have exaggerated the impact of built environment on
physical activity as a result of not taking socio-economic differences and/or leisure walking
and cycling sufficiently into account.129,130 In essence, in contexts such as the United States,
rich urban residents tend to live in “low walkability” surburbs, whereas poor people tend to
live in “high walkability” inner city areas, but the differences in walking and other physical
activity may be largely a result of differences in socio-economic status (e.g. car ownership)
rather than differences in the built environment. In addition, many studies focus on purposive
walking and cycling, whereas some studies suggest that people who do little purposive
walking and cycling (e.g. due to a preference for automobile travel) may compensate through
increased recereational walking or cycling. There is also the issue of residential selfselection: people who want to walk and cycle may purposefully choose to live in an area that
is conducive to walking and cycling, whereas “walkability” may not be a priority for
physically inactive people when choosing where to stay. It can be concluded, however, that
characteristics of the built environment do still have at least some independent effect on
physical activity, even though it may be difficult to quantify.109
In addition to the literature on the relationship between the built environment and health at
the neighbourhood scale, there are also a number of studies which examines the relationship
between urban form and health at a city-scale. Low density urban sprawl in American cities is
generally seen as being linked to poor health, mainly because the increased dependence on
automobiles results in increased air pollution and decreased physical activity which in turn
contribute to respiratory diseases and obesity respectively.30,131,132 Other health effects related
to urban sprawl include road traffic injuries and stress due to long commuting times.131,132
There have, however, been no studies of the health impact of urban sprawl in low and middle
income countries.
THE PHYSICAL URBAN ENVIRONMENT AND IMPACT ON THE NATURAL
ENVIRONMENT
The planning and design of the physical urban environment can impact on the natural
environment in urban areas in various ways. For example, allowing noxious industries in
urban areas can result in severe air pollution. In the late 1990s it was estimated that indoor
and outdoor air pollution contributed to 3 million deaths globally per year, with 90% of these
deaths being in low and middle income countries.133 Air pollution by automobiles is a
15
particularly big problem, and there is a strong link between automobile use and asthma.30
Indoor air pollution caused by the use of biomass fuels for cooking and space heating is also
a big problem in low and middle income countries. Loosely related to air pollution, is noise
pollution, which is a common problem in urban areas and can have a number of negative
health impacts.134
Dense urban development can result in high levels of polluted run-off of stormwater which
then pollutes water sources.135 Water pollution (and the scarcity of clean water) is a serious
urban problem, especially in low and middle income coutnries. In the late 1990s, nearly 1.5
billion people lacked safe drinking water, and at least 5 million deaths per year could be
attributed to waterborne diseases.136
The absorbtion of heat by dark surfaces results in the urban heat island effect (i.e. urban areas
having higher temperatures than the surrounding non-urban area).132 Increased reliance on
automobiles (due to urban sprawl) can contribute to air pollution, urban heat islands and
global climate change. Heat can be a major concern in urban areas – it has been associated
with a large number of hospitalizations and deaths every year.137,138 In addition, long-term
climate change has enormous implications for health, for example, in terms of heat stress.139141
A study of healthy urban planning in Europe notes that urban planning can contribute to “an
attractive environment with acceptable noise levels and good air quality” and “reduction in
emissions that threaten climate stability”.142(p56) The first wave of the grassroots
environmental justice movement focused on activism about issues such as these, for example,
the hazards of land uses such as landfills, hazardous waste incinerators, chemical, metal, and
oil production facilities.143
HEALTHY URBAN PLANNING/ DESIGN INTERVENTIONS
The physical urban environment can be shaped through various planning/design processes:
urban planning (integrated city-wide planning/ spatial planning/ land use management), civil
engineering (planning and design of infrastructure e.g. roads and sanitation), urban design/
landscape architecture (design of public spaces), architecture (building design) and transport
planning. It should be noted, however, that the nature, importance and status of these
professions, particularly urban planning, vary considerably between countries (see Box 2). It
16
is important to note that by by use of the term “urban planning” we mean the more flexible
and participatory type of urban planning that focuses on equity and sustainability, and not the
traditional rigid approach to urban planning (and the same would apply for the other built
environment disciplines).
BOX 2: URBAN PLANNING
Urban planning is a crucial activity; it can be defined as “a self-conscious collective (societal)
effort to imagine or re-imagine a town, city, urban region or wider territory and to translate
the result into priorities for area investment, conservation measures, new and upgraded
areas of settlement, strategic infrastructure investments and principles of land-use regulation”.144(p19).
In practice, however, urban planning can mean many different things. In many parts of the world the
traditional “modernist” form of urban planning (top-down and expert-led, and involving the
preparation of rigid master plans) still holds sway. It has increasingly been recognised that modernist
urban planning is inappropriate for current urban realities, and new, more flexible and participatory
approaches to urban planning have emerged.
The importance of strategic economic development planning, of how the planning and design of the
physical urban environment can influence economic activities and flows, has increasingly been
recognized. A typical criticism by business people of the traditional urban planning system is that
although they “understand that hard decisions about economic, social and environmental priorities for
land use will often have to be made in the interests of sustainable development… they are deeply
frustrated by a system that fails to make those decisions consistently in a rational, speedy and user
friendly way, to help deliver genuinely sustainable development”. 145(p1)
The UN-Habitat Global Report on Human Settlements 2009 concludes that “while planning in some
parts of the world has been less effective, it nonetheless remains the central tool available to society to
effect change. For planning to be an effective tool, urban planning systems in many parts of the world
will need to be revised”.144(p211) The report adds that urban planning in low and middle income
countries needs to move “away from objectives that have to do with aesthetics, global positioning, and
ambitions of local elites to replicate American or European lifestyles, to the far more demanding
objectives of achieving inclusive, productive, equitable and sustainable cities”.144(p213)
The first urban planning university course was introduced at the University of Liverpool in 1907.
There are currently 550 university urban planning schools globally. The distribution of this is
extremely uneven, however. For example, the whole of Latin America has only 27 university urban
17
planning schools, compared to 88 in the United States of America. In addition, the approach of urban
planning schools vary considerably – many urban planning schools in developing countries still
produce traditional modernist urban planners.
The case of Mexico demonstrates that addressing urban planning capacity can be a difficult process.146
Since 1933 there have been urban planning regulations in Mexico, and during the 1990s a national
legal framework for urban planning was established. However, there is neither the organizational
structure nor the professional personnel in place for it. Currently, there is an Urban Development and
Territorial Organization Under-Secretariat at the Federal level, and its counterparts at the state and
municipal levels, but these are mainly concentrated on land distribution, financing and construction
supervision. There are only 9 urban planning/ development graduate programmes in the whole of
Mexico, with the oldest one instituted as recently as 1987.
Urban planning and design therefore potentially have an important role in terms of
influencing the urban physical environment, and thus influencing health. Urban
planning/design impacts on the urban physical environment in various ways, for example,
through determining the nature of residential units and infrastructure, the regulation of land
use and density and the location of facilities and open space. With regard to racial health
differences in the United States, it has been noted that “A plethora of recent evidence
suggests that disparities in health… have not narrowed over time, are getting worse, and are
increasingly linked to the physical and social environments that fall under the traditional
domain of planning”.147(p543) As a general rule, it is safe to say that the poor have usually
lived where nobody else wants to live – downstream, downwind, downhill in low-lying land
and floodplain (or uphill if the hills are prone to landslide), in polluted and dangerous
neighbourhoods, near polluting industries and so on. Good urban planning and design can,
however, prevent, or at least ameliorate, these conditions.
Although the disciplines of urban planning and public health share a common origin
(addressing the symptoms of overcrowding and lack of adequate sanitation in the rapidly
growing cities of Europe and North America in the 19th century), there is currently little
overlap between the disciplines.147,148 The importance of re-establishing the link between
urban planning and public health has been recognized in recent decades, though.29,33,147,149-153
For example, Vol. 72 No. 1 of the Journal of the American Planning Association was devoted
to urban planning’s role in building healthy cities.22,148,154-157 The editor of the special issue
concludes that “New, funded, empirical research is yielding fruit”, and that “The growing
18
partnership with health brings the promise of invigorating planning's ability to understand
and enhance the vitality of both places and their people”.22(p8)
The WHO Regional Office for Europe launched its healthy urban planning initiative in 1997,
and this had a number of important outputs. For example, a background report on urban
planning and health, Healthy Cities and the City Planning Process, emphasized the
importance of developing a model of "healthy urban planning" to ensure the health of the
world's increasing urban and poor populations.150 The initiative culminated in Healthy Urban
Planning - A WHO Guide to Planning for People, a set of guidelines which provides 12 key
health objectives for planners (see Box 3).149
BOX 3: KEY HEALTH OBJECTIVES FOR URBAN PLANNERS149
Urban planning policies and proposals should encourage and promote the following:
1. healthy exercise
2. social cohesion
3. housing quality
4. access to employment opportunities
5. accessibility to social and market facilities
6. local low-impact food production and distribution
7. community and road safety
8. equity and the reduction of poverty
9. good air quality and protection from excessive noise
10. good water and sanitation quality
11. conservation and decontamination of land
12. climate stability
There have been a number of experiments at a municipal level with integrating public health
and urban planning. Barton and colleagues142 report on the experiments of the six
municipalities in Europe, members of the City Action Group on Healthy Urban Planning,
with integrating health into their urban planning processes (as part of the the WHO Regional
Office for Europe healthy urban planning initiative). They conclude that “Healthy urban
planning represents a multifaceted field that still needs to be explored to its full conceptual
depths as well as policy and practical implications”, and identify the need “to work with city
politicians, planners, architects, environmentalists and public health professionals to apply
and further explore the concept and principles of healthy urban planning and develop
19
knowledge, skills and tools that can be used in cities across the European Region”.116(p56-57)
Healthy urban planning was one of the three core themes in Phase IV of the WHO European
Healthy Cities Network (2003-2008), and healthy urban design is one of the core themes of
Phase V (2009-2013).158,159
Corburn147 sees a number of key challenges facing the recoupling of urban planning and
public health:

Paying increased attention to the public health effects of “place-making”. Northridge
and Sclar suggest the use of a framework to explicitly consider the public health
implications of planning decisions.160

Developing a coordinated, multidisciplinary approach toward eliminating health
disparities and a clearly articulated strategy to improve the health of urban
populations.

Democratizing urban planning practice to ensure that it is accountable to communities
that have historically been excluded from decision-making but face the greatest
burden in terms of inequalities.
The planning process is also important, as residents’ participation in planning and design can
itself enhance health and happiness.161,162 Lindheim and Syme162 note that there is no one
template for a “healthy” living environment, but that the most healthful urban design may be
one that provides a structure for basic services and facilities and the connectivity to access
them, while providing a range of opportunities for residents to select and/or shape their
homes and neighbourhoods according to their specific needs and preferences. It is important
to note that urban planning and design interventions are crucial both for the planning and
design of new urban developments (“greenfields”developments) and for the redevelopment
(“retrofitting”) of existing built-up areas.
It is important that urban planning and design are seen as a form of urban governance.163
Effective and participatory urban planning and design processes therefore need to be
underpinned by effective and participatory urban governance systems. Urban governance can
be defined as “The sum of the many ways individuals and institutions, public and private,
plan and manage the common affairs of the city. It is a continuing process through which
conflicting or diverse interests may be accommodated and cooperative action can be
20
taken”.163(p14) Evidence from a study of 10 cities in low and middle-income countries suggests
that “Bad governance undermines the position of the poor”.164(p23) For example, oppressive
regulation of the informal sector can destroy livelihood opportunities for the poor, thus
making poor households more vulnerable to health risks. Key preconditions for good urban
governance include:164

Democratic city-level political systems with directly elected mayors and ward
councilors (perhaps with some reservation of seats for women and minority groups to
ensure a more balanced representation).

In addition to periodic elections, a range of mechanism of direct, deliberative and
participatory democracy are required, to enable all citizens to have a voice in
decisions which affect them.

There need to be effective and accessible mechanisms for holding elected
representatives and officials accountable. Transparency of decision-making and
access to information about the resources available and their use are crucial for
challenging patronage and dependency.
Six main sets of interventions related to urban planning/ design and health/ health equity are
discussed below:

Integrated city-wide planning to achieve greater spatial equity

Slum upgrading: ensuring that residents of deprived areas get access to adequate
shelter, services and facilities (without being displaced due to unaffordability)

Facilitating safety from both unintentional injury and crime/violence

Facilitating food security and healthy diets

Facilitating physical activity, i.e. creating urban environments that are conducive to
walking, cycling and recreation activities for all residents

Facilitating a healthier natural environment
INTEGRATED CITY-WIDE PLANNING TO ACHIEVE GREATER SPATIAL
EQUITY
Urban planning can be conceptualised as having three key conflicting goals: economic
growth; environmental protection; and equity and social justice.165 The different priorities
lead to different perspectives on the city. “The equity planner sees the city as a location of
conflict over the distribution of resources, of services, and of opportunities. The competition
21
is within the city itself, among different social groups. Space is the social space of
communities, neighborhood organizations, labour unions: the space of access and
segregation”.165(p438)
Urban planning/design can potentially assist in reducing poverty and inequity through
creating more compact and integrated cities in which all residents have more equitable access
to the benefits of urban life such as livelihood opportunities, physical infrastructure and
education (through walking/cycling or through affordable and effective public transport).
This is the notion of ‘spatial justice’ (as pioneered in cities such as Curitiba and Bogota). In
Bogota, a progressive Mayor was able to make a shift in expenditure from freeways to bus
and bicycle systems (see Box 4).166
BOX 4: BOGOTÁ’S BUS TRANSPORT AND BIKE PATH SYSTEMS166
The city of Bogotá, Colombia, has been recognised around the world for its innovative transport
policies, in particular for its bus rapid transit system (Transmilenio) and its bicycle path network
(CicloRuta). The changes were initiated by Mayor Enrique Penalosa during his term as mayor (1998 –
2000). He had 4 goals in mind: to improve the public transport system; to restrict private automobile
use; to expand and improve bicycle paths; and to enhance public space
The Municipality created the company Transmilenio S.A. to plan, organize, and construct the bus
rapid transit system infrastructure, as well as to supervise the bus service. The system, which operates
18 hours every day, has dedicated lanes, large capacity buses and elevated bus stations that allow preboard ticketing and fast boarding. The system has a centralized coordinated fleet control providing
monitoring and communications to schedule services and real-time response to contingencies. Smaller
units offering feeder services to main stations are integrated into the system., and the also links to the
bicycle path network; all main head and stations of TransMilenio have guarded bike parking facilities.
At the end of Phase III the Transmilenio consists of 6 trunk routes for a total of 84.4 kilometers. By
2012 it is expected that Transmilenio will consist of 130 km of new dedicated lanes including new
bus-stations and around 1200 new articulated buses with a capacity of 160 passengers, operating on
trunk routes and 500 new large buses operating on feeder lines. It is projected that 1.8 million
passengers per day will be transported in 2012.
The Bogotá Transmilenio system has attained a very high productivity level averaging 1,600
passengers per day per bus, reducing traveling time by 32%, eliminating 2,109 public-service
vehicles, reducing gas emissions by 40%, and making zones around the trunk roads safer thus
decreasing accident rates by 90% throughout the system.
22
Bogotá’s CicloRuta is one of the most extensive bicycle path networks in the world. It is comprised of
over 340 km of bicycle-only transport lanes and connects citizens to major BRT routes, parks, and
community centers. Led by Mayor Enrique Peñalosa who has a personal commitment to a healthy,
car-free city, a formal plan was structured and extensively implemented all around the city. He
proposed that urban planners "make sidewalks as wide as you value your citizens".
The system is divided into three sections. The Main Network connects the key city centres – its main
educational and work areas - with the most populated residential areas. The Secondary Network
connects housing areas, parks and facilities and attractions with the main network. These paths are
mostly designed to serve as feeders to TransMilenio. The Complementary Network links recreational
networks, and external routes to the system. These paths are located along the river banks which in
turn are part of the system of Linear Parks of the City.
Since the beginning of the construction of the CicloRuta in 2000, bicycle use has increased from 0.2%
in 2000 to 4% in 2007 of the total trips in the City, a 20-fold increase, or up to 320,000 trips made
daily within Bogotá. The number of bicycle users has increased from 22,700 to 83,500 bikers,
meaning a 268% increase in 7 years or 38% per year. Speed is an interesting benefit: average bike
speed is 17 km/h, while public non-massive transport runs at 13 km/h.
CicloRutas play an important role for the poor people of the City. More than 23% of the trips made by
the lowest income group in the city are pedestrian and by bikes. As the income level rises, there are
less people walking or biking.
There has been a 33% decrease in deaths relating to bikes (from 115 in year 2001 to 77 in year 2004),
despite the large increase in CicloRutas trips. In addition, injuries reduced 8.8% (2,754 in 2001 to
2,512 in 2004) despite a 38% annual increase in bike use.
Air quality has improved due to increasing numbers of people using bicycles rather than cars.. It is
estimated that there has been a reduction in greenhouse gases of 36.6 thousand tonnes of CO2e.
CicloRutas also helped to recover public space, along riverbanks, and wetlands - the city’s 13
wetlands were occupied for years by illegal constructors, after construction of the CicloRutas
development stopped in this precious natural environment.
The concept of ‘spatial justice’ builds on the previous concepts of “territorial justice”167 and
“territorial social justice”.168 Spatial justice is essentially about “conceptualising space as a
social product rather than as a context for society”.169(p465) The concept of spatial justice is
related to LeFebvre’s notion of the “right to the city”. Many grassroots struggles in cities
have been about achieving spatial justice and the right to the city.170
23
A key issue in achieving spatial justice is to focus on improving the quality of life for all: .
“Promote opportunities for disadvantaged residents, and seek to reduce economic disparities
by incorporating socially just solutions to regional problems… plan strategically for strong
economic growth, a diversifying employment base, efficient and accessible intra-regional
transportation, and a healthy environment for generations to come.” 171(p10) Another important
issue in achieving spatial justice includes ensuring appropriate spaces for economic activity
in all new developments. To reach these goals, planners should seek to build upon the city’s
economic assets and overcome its challenges. Optimal means to do so are to increase
employment and educational opportunities, facilitate the growth and expansion of industry
and business, improve the quality of life of all residents, grow the tax base, further promote
and develop the downtowns and other areas of the cities, and position the city as a better
place to live and work in.172(p4)
The way in which urban planning decisions are made is also crucial. Participatory integrated
planning processes and participatory budgeting processes (from city scale to neighbourhood
scale) are potentially a way of achieving spatial justice, but power imbalances need to be
overcome, e.g. through the capacity development of civil society.
It should be noted that what spatial justice and spatial equity mean in practice is not always
clear. There have, however, been attempts, using various methodologies, to assess spatial
equity by “comparing the locational distribution of facilities or services to the locational
distribution of different socioeconomic groups”.173(p598)
SLUM UPGRADING
One of the recommendations of the Commission on Social Determinants of Health for how to
put health equity at the heart of urban planning and governance is to upgrade slums and
ensure adequate housing for all residents who currently live in slum conditions: “Manage
urban development to ensure greater availability of affordable housing; invest in urban slum
upgrading including, as a priority, provision of water and sanitation, electricity, and paved
streets for all households regardless of ability to pay”.5(p4) Although it is important to focus on
the upgrading of existing slums, as a large proportion of urban residents in low and middle
income countries live in slums, it should be noted the development of new slums need to be
prevented by the development of new greenfield sites where residents can get access to
secure tenure and basic services and facilities.
24
There is a vast body of literature on slum upgrading, although the health and health equity
aspects are seldom explicitly spelled out. What evidence there is, though, suggests the health
impacts are complex. Better quality shelter generally has health benefits, although these
health benefits are often difficult to quantify. For example, Thomson and colleagues51 review
18 housing intervention studies that measured quantitative health improvements as a result of
improvements in shelter, and they conclude that “many studies showed health gains after the
intervention, but the small study populations and lack of controlling for confounders limit the
generalisability of these findings”.51(p187) Providing basic services is a key objective of slum
upgrading, and the provision of adequate water supply and sanitation can make life
considerably easier for residents and can dramatically improve health conditions. It is
estimated that providing adequate water and sanitation can reduce diarrhoea morbidity rates
by up to 46% and there are strong linkages between improved water supply and sanitation
and significant improvement in the nutritional status of children.174,175 Slum ugrading
sometimes involves electrification, which results in access to a cheaper and safer form of
energy and lighting than, for example, paraffin and candles. Access to electricity enables
residents to purchase refrigerators to store food, which reduces risk of diarrhoea; on the other
hand, this can tend to result in a shift towards an unhealthy diet that increases the risk of
cardiovascular disease.175 Slum upgrading that is not participatory and integrated can also
sometimes have negative impacts in terms of social networks and communal life, with a
corresponding increase in isolation, depression and domestic violence.176,177
In recent decades there has been a shift towards a more integrated and participatory approach
to urban development interventions. This shift has been particularly evident with slum
upgrading programmes. In the past, slum upgrading programmes focused on the provision of
physical infrastructure and were often fairly top-down and unparticipatory, e.g. the Kampung
Improvement Programme, the first large-scale slum upgrading programme, started in
Indonesia in 1969. More recent slum upgrading programmes have tended to have a more
integrated approach and a greater emphasis on community participation - even the Kampung
Improvement Programme evolved in line with the changing trends and became more
decentralized and more participatory, and has started including community development
activities as well as physical infrastructure.178
25
What an integrated approach means in practice is that informal settlement upgrading
initiatives need to have a range of complementary programmes that address physical, social
and economic development needs. Integrated slum upgrading programmes have typically
included the following interventions:179-181

Physical development: roads, pavements, stormwater drainage, water supply,
sanitation, street lighting, solid waste management.

Social/ human development: setting up neighbourhood and women’s groups, youth
activities, forming savings groups, preprimary education, adult literacy, community
health, mother and child care.

Economic development: mobilizing community savings, supporting income
generating activities through vocational training/ skills upgrading and facilitating
access of small businesses to finance and trade.
UN-HABITAT’s Quick Guide for Policy Makers on low-income housing has a useful set of
principles for slum upgrading initiatives based on experiences of successful slum upgrading:
182(p16-17)

Upgrading has to be a participatory process, which addresses first and foremost the
needs of the community, as identified collectively by its members. This is the key to a
project’s sustainability. Without this participation, infrastructure improvements will
not be maintained, conditions will deteriorate, people will become disillusioned with
their local government and the investment in upgrading will be wasted.

Upgrading has to be done in partnership. Planning and implementing an upgrading
project is always more effective when it’s carried out by the community and the local
government, in close collaboration. NGOs can also play a crucial role in supporting
community organizations, as well as providing them with any technical support they
need in designing housing improvements or developing income generation projects.

Upgrading has to provide secure land tenure. Providing secure tenure is a vital part of
community upgrading. Without it, people’s continued vulnerability to eviction will
make them reluctant to invest further in their housing and living environment.
Sometimes tenure is granted to individual households in the form of title deeds or
lease contracts, after the boundaries have been measured and recorded. Granting
tenure rights to the woman household-head instead of the man can protect her and her
children from the threat of abandonment and homelessness and provide them with an
26
asset they can use for income generation. Land tenure is increasingly being granted
collectively, to communities as a whole, as a means of preventing gentrification and
building stronger community organization.

Communities have to contribute. It is essential that the community contribute to the
cost of upgrading in some way. Experience shows this strengthens a community’s
sense of ownership of the upgrading process. The contribution can be financial (cash
or community loans) or it can take the form of contributed labour or building
materials, or some mixture of these. Upgrading works best when the community’s
contribution is supplemented by some kind of subsidy, from donor grants or public
project funds.

Upgrading must be affordable. The amount that households can contribute will help
determine the scope and content of the upgrading package. If upgrading programmes
come with high taxes or user fees which the people cannot afford, they will probably
not use or maintain the facilities, or may simply move away to more affordable
settlements elsewhere.

Upgrading must be financially sustainable. Sustainability comes in part from how the
upgrading is financed. It is best when funds from several sources are blended,
including community member’s contributions, subsidies and loans from government,
and maybe support from international or local development organizations. To ensure
the upgraded infrastructure is well maintained and managed over time, it is important
that the construction of this infrastructure happen in ways which build community
cohesion and organization and promote local economic development.

Upgrading should be part of a larger urban development strategy. Community
upgrading projects have to be seen as an important part of a city’s larger vision of its
future development. Projects shouldn’t be emergency initiatives implemented in
isolation, but should be part of plans for overall urban management that seek to
address housing problems at city-wide scale.
In addition, it is important that issues of location are carefully considered. Residents of slums
often live there for particular reasons, mainly to be close to livelihood opportunities, and
relocation may negatively impact on their livelihoods and thus ultimately on their
health.176,183
27
URBAN PLANNING/ DESIGN INTERVENTIONS TO MAKE CITIES SAFER
The traditional view of injuries as “accidents” suggests that they are random events, an
unavoidable part of the world in which we live. This has resulted in the historical neglect of
this area of public health. During the past few decades, it has been recognized that many
injuries are preventable.
Creating a safe urban environment has three broad aspects: creating an environment where
unintentional injuries in public spaces and homes are prevented; creating an environment
where harmonious social conditions result in low levels of crime and violence, and where the
planning and design of the built environment makes it easier to avoid crime and violence; and
creating more resilient urban environments that are able to better cope with natural hazards.
As with other health promotion initiatives, this calls for a combination of healthy public
policies, enforcement of health-protective legislation, good urban planning/ design,
community action, and the development of personal and community knowledge, skills and
behaviour. Typical urban planning/design techniques intended to create safer spaces include
designing streets specifically for pedestrians (“woonerven”), using various “traffic calming”
measures. With regards to reducing violence, one of the recommendations of the Commission
on Social Determinants of Health is to “reduce violence and crime through good
environmental design and regulatory controls, including control of the number of alcohol
outlets”.5(p66) There are a number of sets of guidelines on urban environmental design to
reduce crime and violence.184
There has also been increasing recognition in recent years of the importance of creating more
resilient urban environments that can better deal with a range of expected and unexpected
hazards. Resilience has been defined as meaning that “a locale is able to withstand an
extreme natural event without suffering devastatin losses, damage, diminished productivity,
or quality of lifeand without a large amount of assistance from outside the community”.185(p3233)
Resilience is an important goal because the vulnerability of technological and social
systems cannot be predicted completely, and planners have to cope with great uncertainty
regarding the impact of hazards. Resilience – “the ability to accommodate change gracefully
and without catastrophic failure” - is therefore critical in times of disaster, to ensure that
people and property will fare better when struck by disasters.186(p138) Strategies for creating
more resilient urban environments include, for example, ensuring that infrastructure networks
28
consist of small, autonomous units that are easy to maintain and use standardized
components.186
UN-Habitat, as part of its Safer Cities Programme in African cities, has developed a number
of planning and design suggestions. These include planning for mixed use and activity in
public places; signage and lighting; access to help; CCTV surveillance and patrols,
particularly by communities; cleaning and waste removal; management of markets and public
ways; and urban renewal schemes.187
The planning process is also important. The International Conference on the State of Safety
in World Cities held in Monterrey in 2007 made the following recommendations regarding
the processes of planning for safer cities:188
 It is critical to involve key sectors and stakeholders, including communities and
vulnerable groups. Further, it is important to promote links between practitioners in an
effort to avoid fragmented interventions by different urban management sectors such as
safety, transport, planning, criminal justice and urban design.
 Urban planning should be recognized and used as a mechanism for creating safer cities,
with a special focus on the needs of women and children; planning approaches that
recognize issues of the quality and management of public space, and use participatory
mechanisms to engage communities and stakeholders, are among the most promising
options for safer cities.
There have been attempts at planning cities that are safe for specific vulnerable groups, such
as women and children and people with disabilities. It has been argued that planning for
child-friendly cities is particularly important: “manipulation of the urban environment rather
than the child offers the best prospects for creating cities that are healthier-for children and
consequently for other vulnerable users”.189(p107) For all these recommendations, involvement
by vulnerable groups in planning and design processes are seen as crucial.
URBAN PLANNING/ DESIGN INTERVENTIONS TO FACILITATE FOOD
SECURITY/ HEALTHY DIETS
29
Urban populations are characterised by a large proportion of residents being dependent on the
cash economy and wage labour, and the best way for urban households and individuals to
achieve food security is thus through securing an adequate and reliable source of income.190
Nonetheless, urban planning and design and contribute to food security and healthy nutrition.
For example, a study of healthy urban planning in Europe notes that planning can contribute
to “opportunity for local food production and healthy food outlets”.142 Similarly, one of the
recommmendations of the Commission on Social Determinants of Health is to “encourage
healthy eating through retail planning to manage the availability of and access to food”.5(p66)
Pothukuchi and Kaufman suggest that urban planners need to analyse the impact of current
planning on the urban food system, and need to explicitly put food security at the centre of
community goals, i.e. to ensure that “all residents have access at all times to affordable, high
quality food through conventional (and not charity-based) sources and through means that are
environmentally, economically and socially sustainable”.88(p121)
There are a number of possible urban planning interventions aimed at stimulating access to
healthy food.

Location and design of local markets. For example, the food and small goods markets
in Sam Chuk, Thailand, were redesigned to provide greater availability of foodstuffs
and to be more welcoming and accessible to city residents.5

Ensuring space for urban agriculture, either communally or on individual plots.191

Regulations regarding location, nature and size of food outlets. “One regulatory action
that local government can effectively adopt in order to reduce access to foods high in
fats and salt is the utilization, or strengthening, of planning regulations to manage the
proliferation of fast food outlets in particular areas, for example, near schools and in
socially disadvantaged neighbourhoods”.5(p68)

Street foods are important for urban food security as they provide a cheap source of
food for the urban poor.190 Facilitating the provision of suitable space for the cooking
and selling of street food could thus also have a positive impact on food security and
nutrition.
URBAN PLANNING/ DESIGN INTERVENTIONS TO INCREASE PHYSICAL
ACTIVITY
30
One of the recommendations of the Commission on Social Determinants of Health is to “plan
and design urban areas to promote physical activity”.5(p66)
There are a number of manuals for promoting physical activity in cities in high income
countries.192-194 For example, the World Health Organisation Regional Office for Europe’s A
Healthy City is an Active City: A Physical Activity Planning Guide “provides a range of
ideas, information and tools for developing a comprehensive plan for creating a healthy,
active city by enhancing physical activity in the urban environment”.193(pii) In addition, the
Heart Foundation in Victoria, Australia, has developed the Healthy by Design planning tool
to promote walking, cycling, and public transport use. The tool consists of guidelines for and
case studies of potential solutions such as networks of walking and cycling routes.5
Interventions to increase physical activity include:195

Community-scale urban design and land-use regulations, policies, and practices. The
interventions use policy instruments such as zoning regulations and building codes,
e.g. policies encouraging transit-oriented development, and policies addressing street
layouts, the density of development, the location of more shops, jobs and schools
within walking distance of where people live. Comparisons of different types of
neighbourhoods suggest that these interventions (increasing density, land-use mix and
street connectivity) can result in a significant increase in physical activity, with
associated health benefits.113,126 The trade-offs between physical activity priorities and
other health and wellbeing priorities may be complex, however. For example, street
grid layouts are believed to facilitate purposive walking; on the other hand, cul-desacs are believed to provide a safer place for children to play in.33 In this case,
therefore, a trade-off needs to be made between facilitating walking and facilitating
outdoor play by children.

Street-scale urban design and land use approaches use policy instruments and
practices to support physical activity in small geographic areas, generally limited to a
few blocks. These policies and practices include features such as improved street
lighting or infrastructure projects that increase the ease and safety of street crossing,
ensure sidewalk continuity, introduce or enhance traffic calming such as centre
islands or raised crosswalks, or enhance the aesthetics of the street area, such as
31
landscaping. Examples include relighting streets,196 redesigning streets197,198 and
improving street aesthetics.199,200

Transportation/travel interventions of interest to promoting physical activity include
interventions that strive to improve pedestrian, transit and light rail access, increase
pedestrian and cyclist activity and safety, reduce car use, and improve air quality.
A review of 18 studies of interventions (all in high income countries) found “sufficient”
evidence that community-scale and street scale urban design and land use policies and
practices were effective in increasing physical activity.195 There was, however insufficient
evidence to determine effectiveness of transportation and travel policy and practice
interventions in increasing physical activity because of an insufficient number of studies.195
More recently, the concepts of social justice and environmental justice have been used as
frameworks for advocating for urban planning/design that creates environments that facilitate
walking, cycling and outdoor activity.143,154,201
URBAN PLANNING/ DESIGN INTERVENTIONS AND THE NATURAL
ENVIRONMENT
Urban planning/ design interventions can contribute to better air and water quality. For
example, restrictions on the location of industrial activities that contribute to air pollution can
help create cleaner air in urban areas. “Sustainable urban drainage systems”can help reduce
run-off from precipitation while simultaneously improving the quality of run-off so that it can
potentially be re-used for certain purposes. Sustainable urban drainage systems typically
include the following options: green roofs, rainwater harvesting systems, rain gardens
(bioretention areas), permeable paving, road medians, swales and ponds. Urban heat islands
can be minimized in various ways (for example, through greening) in order to reduce risk of
heat stress in urban areas.
Climate change adaptation and mitigation are also important for urban planning/design, for
example, coping with more frequent and more intense extreme weather events and reducing
emissions that contribute to climate instability. Bulkeley and Betsill examine how climate
protection policies have been put into practice through urban planning/ design (especially
land-use planning and transport planning) in six local governments (all in high income
countries).202
32
The case study of addressing Mexico City’s fight againsts air pollution (see Box 5)
demonstrates the importance of good governance in addressing health challenges such as
these.
BOX 5: DEALING WITH MEXICO CITY´S AIR POLLUTION203-205
Mexico City’s fight against air pollution has been widely documented. The air pollution problem in
Mexico City was a result of inadequate planning, uncontrolled growth of motor vehicle transportation
in a closed high altitude basin, a lack of housing policies, and the dispersion of jobs, services and
industries. All of this led to large amounts of time spent on commuting and the disruption of family
and social life in a city that concentrates less than 20% of the country’s population but generates more
than 40% of the Nation’s GNP.
It was estimated that air pollution in Mexico City resulted in about 3000 premature deaths per year. In
addition, there was also chronic exposure and diseases (so called chronic mortality) specifically
related to air toxics and particulates. It was estimated that a reduction of 10% in inhaled particles
would save 1000 lives a year; the population most exposed to particles were in the industrialized
north, north-east and the historical city centre where the highest density population existed (about
65% of the population) and some of the neighborhoods with less economic development. A similar
reduction in diesel and other air toxics would reduce 30-40 cancer deaths per year.
In response to the air pollution problem, in 1993 the Mexico City metropolitan area authorities
established a Metropolitan Commission, including the federal and local government’s health
departments, transport authorities, industry representatives, academia and civil society representatives.
Three metropolitan plans were developed (and a fourth is being prepared). Decisions have been
supported by evidence generated locally as well as internationally, and a research programme was
financed by the Commission. Decisions have been taken on elimination of leaded gasoline, the
avoidance of manganese methylated gasoline, emission control devices, financial incentives for new
car acquisition, stringent industry emission inspections, twice-yearly inspection programme, the
building of the “Metrobus” (a mass bus system), and the expansion of the electric underground
subway (Metro). This has helped to reduce air pollution, going from a mere 15 days a year under the
air quality standards to 250 days in 2009. Mexico City is being transformed into a mainly service
city; its population growth has almost halted, and much of the most toxic industry has left the city.
CONCLUSIONS
With a few exceptions, such as the studies of São Paulo and Accra undertaken in the 1990s,3
there has been little comprehensive, longitudinal analyses of intra-urban health inequities in
cities in low and middle income countries. With the exception of some research on health
33
conditions in slums and on the health impacts of shelter and services, there also has been little
research on the built environment and health in low and middle income countries.
A big gap in our understanding is the relationship of access to employment opportunities and
other livelihood opportunities to health-related behaviours and health outcomes in cities in
low and middle income countries.
The health impacts of access to shelter and services are generally well understood, but there
are also some gaps in our understanding here as well: “We know little about the mechanisms
of interaction of social factors and the effects of poor housing over the lifecourse. There is
also a lack of comparative information on the costs and effects of specific housing
improvements”.57(p189) The health impacts of slum upgrading in general have also not been
well documented. There is thus scope for future research on this (and it should be noted that
the health impacts of slum upgrading include a range of issues, such as safety, mental health,
food security/ nutrition and physical activity).
There has been some research on the built environment and food in high income countries,
but little or no research of this type in low and middle income countries (with the exception
of some work on urban agriculture and food markets). There is thus scope for research on the
built environment and food security/ nutrition in low and middle income countries, and on
how urban planning/ design can promote increased food security and better nutrition in these
countries. Urban agriculture and informal markets/ street vendors are likely to be much more
important issues in low and middle income countries than in high income countries.
There is a large amount of research on the built environment and safety and on the impact of
urbanization on the natural environment. Little of this research in low and middle income
countries relates specifically to health, though, so documenting the impact of violence, traffic
accidents, air pollution and water pollution in cities in low and middle income countries is
important. There has also been little or no research on the built environment and mental
health in low and middle income countries, and there is thus scope for this (ideally as part of
holistic studies examining the impacts of slum upgrading).
There has been a considerable amount of research on the relationship of the built environment
and physical activity, but almost entirely in North America. There has been little or no
34
research on the relationship of the built environment and physical activity in low and middle
income countries, and there is thus scope for research on this, comparing physical activity
patterns and health outcomes among residents of similar socio-economic status in different
types of built environment (tools such as indices of “walkability” would, however, need to be
adapted in order to be more appropriate to the urban contexts of low and middle income
countries). It should be noted, however, that urban form cannot be solely dependent on the
need to provide a conducive environment for physical activity (although it should also be
noted that the health and wellbeing benefits of creating pleasant urban environments that are
conducive to walking, cycling and outdoor recreation activities go far beyond just increased
physical activity).
There is a general shortage of longitudinal studies, so it is important to prioritise longitudinal
studies that track changes over time. In addition, there is a clear overlap between many issues
(e.g. safety and security, physical activity, mental health), so holistic studies that
simultaneously examine a range of issues relating to health and wellbeing are particularly
important.
Finally, there is a need for more empirical evidence on the relationship between urban
governance systems and urban planning/design in cities in low and middle-income countries,
and what the governance blockages to, and preconditions for, achieving healthier urban
environments are.
35
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