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The Evaluation of Healthy City

Projects in Developing Countries
*University of Sao Paulo, and South Bank University, London, and fSouth Bank
University London, UK


In international public health and other disciplines there is a debate about the
use of process versus impact (sometimes referred to as outcome) indicators
in project evaluations. With growing international and national support for
Healthy City Projects in developing countries it is timely to address the
issue of how to evaluate such projects. This paper briefly describes process
and impact indicators, considers the importance of process indicators given
the role of institutional strengthening and capacity building in Healthy City
Projects and discusses the balance between locally and internationally generated
indicators. A case study of the first Healthy City Project in a developing country
in Asia (Chittagong, Bangladesh) illustrates how the project is linked with
urban management and can enhance co-operation, co-ordination, motivation,
internal organisation, decentralisation and community participation. Finally,
some institutional indicators for evaluation are suggested.


The World Health Organisations (WHO) Healthy Cities Project (HCP) is

a long-term development project that seeks to put health on the agenda of
decision-makers in cities and to build a strong lobby for public health at the
local level. Ultimately, the project seeks to enhance the physical, mental, social
and environmental well-being of the people who live and work in urban areas.*
The Healthy City concept was developed in 1984 and the WHO Healthy Cities
Project was launched in 1986. The underlying aim was to bring the public, the
business and voluntary sectors and the communities together in a partnership
to focus on urban health and health-related issues.3 Since Tsouros4 reviewed the
achievements of the HCP in Europe there has been a growing interest in HCP
in developing countries. With the UN estimating (as of 1995) that 41% of the
developing countries population will live in urban areas by the year 2000, the
WHO, with Dutch Government funding, launched, in 1995 a major new initiative
of HCP in developing countries. It is thus timely to discuss how to evaluate these
projects in an appropriate manner, in particular, what indicators of success to
use. This paper firstly describes the elements of evaluation including process
and impact indicators, then considers the importance of process indicators given
the role of institutional strengthening and capacity building in Healthy City

WE ts:w 629
630 Edmund0 Werna and Trudy Harpham

Projects and discusses the balance between locally and internationally generated
indicators. A case study of the first Healthy City Project in a developing country
in Asia (Chittagong, Bangladesh) illustrates how the project is linked with
urban management and can enhance co-operation, co-ordination, motivation,
internal organisation, decentralisation and community participation. Finally,
some institutional indicators for evaluation are suggested.


There is a sea of literature on evaluation, and, as Elzingas puts it, a veritable

industry of activities connected with it. Although many definitions of evaluation
can be found, the definition used by the United Nations is used throughout this
paper. Evaluation is thus a process which attempts to determine, as systematically
and objectively as possible, the relevance, adequacy, effectiveness, efficiency
and/or impact of activities in the light of predetermined objectives.
In the context of project evaluation, the following elements can be defined:
?? Inputs - The set of means (money, equipment, materials, technical advice,
training, etc.) mobilised to produce the planned outputs.
?? Process - The array of activities displayed by the project and the projects
interaction with the community (e.g. planning systems, management systems,
training programmes).
?? Outputs - The product of the system, which is often service, such as
staff time made available to the community and to patients, in-date drugs
available in health facilities.
?? Outcomes - The effects (potent vaccines delivered to children of correct
age, knowledge conveyed to communities at village meetings and so on) and
coverage (percentages of eligible couples using contraception, attendance
at antenatal care) of the outputs.
?? Impact - Changes in morbidity, mortality, nutritional status or fertility
(such as infant mortality rates). This definition is often given to the term
outcome in the literature.
Although this is a complete picture of the elements of evaluation, most
debate revolves around process versus impact indicators and the remainder
of this section concentrates on these two elements.
There are numerous criticisms of impact evaluations6 which include:

Zmpact evaluations - criticisms

?? The need to establish effectiveness before impact - Health impact evaluations
are unlikely to be of value unless a programme has been reasonably
implemented and unless the services are effectively used. Van Norren
et al.7 state: Too many evaluations appear to be looking for health impact,
merely because it was an objective of the programme, even though the
implementation has been poor. This has been demonstrated in the case
of water supply and sanitation, where step-by-step evaluation models show
that it does not make sense to evaluate the impact before establishing the
functioning and use of the facilities.
?? Impact requires high per capita input - On the other hand, one cannot
expect that low project inputs per capita lead to a substantial improvement
in health impact for a large populations
?? Instant results are unlikely - Impact can only be expected when enough
time is allowed for a particular
intervention to become effective. In
The Evaluation of Healthy City Projects in Developing Countries 631

many cases, this will be longer than the life span of a project. There
is considerable uncertainty about the time-lags for many public health-
oriented interventions.
?? Impact evaluation requires adequate control groups - A comparison
between the situation before and after the intervention may not be
appropriate, because changes may be due to factors outside the programme.
On the other hand, it is difficult to find suitable control groups. Problems
involve ethical considerations, the spill-over of effects, and the doubling
of costs.
?? Impact indicators are not sensitive - Summary indicators do not make
allowance for inequalities in health, risks and access to services.9
Most of the arguments for impact evaluation rest on the political power of the
data.10 WHO argues that countries may wish to define health for all in terms
of general objectives, such as the improvement in the health status of all their
citizens. WHO continues:
Increasingly, development planners and economists are looking for social
indicators such as health status measurements to guide decisions on economic
development strategies . . . it is particularly important to select a small
number of national indicators that have social and political punch in the
sense that people and policy makers will be incited to action by them.11
There is little debate as to whether such indicators should be internationally
generated (to be comparable across countries) or be locally produced.
The debate about impact versus process indicators has quickly entered
discussions about evaluation of Healthy City Projects and is considered in the
next section.


In this section all the arguments regarding the appropriateness of different

evaluation methods refer exclusively to their use within the scope of HCPs.
The section argues that evaluation of the Projects should be strongly based on
process indicators (designed both internationally and locally) with a major focus
on institutional issues. Impact indicators should be used on a complementary
There are at least four different positions in the literature regarding the use
of process and/or impact indicators for HCP:
(i) the sole use of process indicators;12
(ii) the primary use of process indicators supplemented by few impact indicators;13
(iii)parallel use of both types of indicators;14 and
(iv)the sole use of impact indicators.15
However, none of these authors has discussed the reasons for their choice of
impact and/or process indicators. The authors who mention methodological
issues concentrate on the debate between locally generated versus internationally
generated indicators. Such a debate will be analysed below. First, the specific
role of impact and process indicators for HCP will be considered.

Impact versus process indicators

Impact and process indicators are not mutually exclusive, and may be used
together. However, it is usually appropriate to measure the former only after
some years of intervention (e.g. infant mortality rate, prevalence of malaria,
632 Edmund0 Werna and Trudy Harpham

maternal death rate, atmospheric pollution, water quality, extent of green

spaces). Therefore, as noted in the previous section, it is not appropriate to
assess them during the first years of implementation of HCPs.
Although one could argue that long-term outcomes are what really matters,
it is also important to assess the earliest years of HCP in order to keep the
morale of the participating actors high (by demonstrating progress) and/or to
correct potential problems. Donor agencies may also be willing to monitor
the development of HCP from the early stages (for instance, DGIS, the Dutch
bilateral donor agency, criticised a WHO request for funding of HCPs in five
developing countries in 1994 because their proposed evaluation was heavily
based on impact - long-term - indicators).
Thus, there is a need for medium- or even short-term evaluation. A number
of impact indicators can be used in such an evaluation if HCP includes a pilot
project - especially environmental indicator+ (such as water and sewerage
provision, water quality, waste collection, extent of green space, public transport,
living space), and also socio-economic indicators17 (such as unemployment,
homelessness, illiteracy). Pilot projects might play a symbolic role in HCPs, e.g.
the concentration of efforts to improve one specific squatter settlement or one
ward in a city is likely to bring physical/visible results quickly, which, in turn, may
motivate the population and institutions to continue supporting HCP. However,
pilot projects have been extensively criticised for not being sustainable and/or
replicable;ls and they also contradict the broad/holistic approach of HCP.19 Thus,
impact indicators derived from pilot projects are unlikely to have significance for
the city as a whole.
Considering the need for mid- or even short-term evaluation on the one hand,
and the problems of using impact indicators on the other, process indicators
assume a significant role in HCP. Process indicators which assess issues such
as level of community organisation, awareness and participation of different
actors in HCP or co-operation between participating institutions, are able to
spot changes much quicker.
In addition to the above points, process evaluations-especially those focusing
on institution strengthening and capacity binding - are important in assessing
the sustainability of HCP. It is possible to achieve improvements in health,
environmental and socio-economic conditions in a given city via inputs from
external actors - e.g. via international or federal programmes. However, when
such programmes come to an end, the improvements are likely to cease if local
actors have not been prepared to carry them on. Therefore, it is fundamental
to assess the capacities of local actors.
The importance of institution strengthening and capacity building has been
highlighted in the guidelines of HCP,20 as well as in the guidelines of other
United Nations agencies urban agendas and programmes.21 After decades of
investing fundamentally in specific projects, by the mid-1980s the United Nations
agencies most active in the urban field shifted their focus from a project
approach to a process approach. 22 The new approach has entailed a focus on
holistic/long-term processes of urban development, which are likely to generate
more profound and sustainable results. Emphasis is given to the training and
co-ordination of, and co-operation between, local actors; issues which have
been regarded as fundamental to the good management of a sustainable urban
development process. These facts reinforce the importance of using process
evaluation in HCP (the relationship between HCP and the process approach
to urban development will be elaborated in the next section).
In short, for the reasons noted above, evaluation of HCP should be strongly
based on process indicators which focus on the institutional aspects of the
Project. Impact indicators can be used on a complementary basis a few years
after the implementation of HCP. The choice of the specific impact indicators
The Evaluation of Healthy city Projects in Developing Countries 633

will depend on the local circumstances (see next subsection) as well as the timing
of the evaluation (i.e. some indicators may measure change after 2 years, others
will need 5 years). A thorough impact evaluation of HCP requires an extensive
inventory of indicators, whose elaboration is beyond the scope of this paper.
Collin23 provides a good inventory.
In order to define specific indicators to evaluate HCP, it is also important to
review a debate encountered in the HCP literature: whether to use international
indicators, or to generate them locally.

Local versus international indicators

WHO publications recommend indicators (whether process or/and impact) which
should be used in HCP evaluations throughout the world.24 These are here
termed international indicators.
However, the book edited by Davies and Kelly,25 the major publication on
HCP evaluation to date, criticises the use of international indicators, and suggests
that there is a need to develop local indicators for each specific HCP. The local
community should participate in the design of indicators as well as in the process
of evaluation. Such a process would have a value in itself, for involving the
community.26 Evaluation has a political dimension, which should be taken
into account. Evaluation also entails conflict (between the actors involved).
This should be brought to the surface rather than suppressed. Local indicators
and community participation in evaluation have also been emphasised in other
A further advantage of local indicators is that they counterbalance potential
international biases. Evaluations in general and process indicators in particular
are prone to value judgement. To give one example, criteria for assessing good
performance of a given urban agency designed by Western researchers might
differ from those established by local communities. Thus, the inclusion of the
latter in the design of indicators (and in the evaluation process) are likely to
correct the bias.
Davies and Kellys book28 also includes criticisms of inter-city evaluation, due
to the specificities of each individual case. However, this is contentious. Inter-city
comparisons are used widely, for instance, in local government research. They
might not provide an all-inclusive evaluation, but could be worth using in
conjunction with other indicators. It is important to have some control method
for the evaluation. A situation analysis at the onset of HCP would be a good
solution.29 However, when this is not possible, comparisons between different
cities or towns where HCP has been implemented could be used.
Inter-urban comparisons are important to detect problems (and possible
solutions) in different HCPs, and also to feed inter-city/town co-operation
(which is a major issue in HCP). However, the sole use of local indicators in
HCP evaluation is likely to restrict such comparisons - due to the specificity
of the indicators. Thus, international indicators have an important role under
such circumstances.
International indicators also have a further role when the local community
is not prepared to design indicators and evaluate HCP. The authors who
have written in favour of local indicators and community participation base
their arguments on experiences from industrialised countries. However, many
communities in developing countries are not prepared for such an involvement.
It may take a long time for them to absorb the concept of HCP, let alone
to participate in its evaluation or other phases of the Project. This has been
noted, for instance, in preparatory assessment for the implementation of HCP
in developing countries,30 and in the first studies of HCP in these countries.31
634 Edmund0 Werna and Trudy Harpham

However, due to the reasons noted above, it is important to evaluate HCP even
during the process of local capacity building.
In short, both types of indicators analysed have a role in the evaluation of
HCP, and can be effectively used in conjunction. As already noted, many
communities in developing countries are not prepared for such a task. Therefore,
HCP should take this into account in its plan of action, i.e. the Project should
include in its agenda the development of local indicators along with the local
communities. The design of international indicators for HCPs in developing
countries, in its turn, is still incipient. WHO has been working on the design
of such indicators, with contributions from HCP experiences in industrialised
countries, and with comments/criticisms from the donor agencies which are
due to finance HCPs in developing countries. The research community with
expertise in developing countries should be more active in the design of such
indicators, and the present paper constitutes an effort in this direction.
In any case, whether indicators are designed locally or internationally, there
should be an emphasis on processes related to the institutional aspects of the
Project. The next section will present a case study to highlight the importance
of the linkages between urban management and the Project. This reinforces the
need to focus on institutional aspects as a main component of evaluation.



First, this section will show how HCP in general is linked with urban management.
Second, it will illustrate this point with the case of the first HCP implemented
in a developing country in Asia. Finally, the section concludes by presenting
institutional indicators which might be included in a HCP evaluation.

Healthy cities: from public health to urban management

As noted in the introduction, HCP originated from an initial concern with public
health. The Healthy Cities Movement (which generated HCPs) was established
by WHO with the purpose of building a strong case for public health at the local
level, and putting health issues onto the agenda of urban policy-makers. The
original idea of HCP was to apply to urban life the theory and principles of
WHOs strategy of Health For All in the Year 2000. WHO has espoused a view
of health which differs distinctly from the conventional view which emerged in
industrialised societies as from the mid-20th century. In this conventional view
. . . health care (an activity) is often treated synonymously with health (a
state of being) and the determinants of health . . . become diassociated as
causal factors.32
WHOs view, in turn, asserts that health is a state of complete physical, social
and mental well-being, which is much more than the mere absence of disease or
infirmity; and whose attainment, therefore, requires far more than the supply of
health services. Thus,
That health is a state of well-being indicates that health is not an activity . . . ,
rather it is the outcome of all activities which make up the lives of individuals,
households, communities and cities.33
Physical, economic, social, and cultural aspects of city life all have an
important influence on health. They exert their effect through such processes
as population movement, industrialization, and changes in the architectural
The Evaluation of Healthy City Projects in Developing Countries 635

and physical environment and in social organization. Health is also affected

in particular cities by climate, terrain, population density, housing stock, the
nature of the economic activity, income distribution, transport systems, and
opportunities for leisure and recreation.34
The above approach has been reinforced by the Ottawa Charter, which is
a founding stone of HCP. 35 The Charter is the product of an international
conference on health promotion held in 1986. It emphasises that policies in
sectors other than health make key contributions to health, e.g. those which
help create supportive environments for health in the economic and social
Therefore, in order to improve the health status of urban populations, HCP
should act upon the multitude of issues which form a city or town. Such actions
have been carried out not via specific projects ,37 but via processes based on the
strengthening of local institutions and support for their co-operationss aiming
at an integrated management of the issues which affect urban health. Such an
aim has led WHO to give the local public authority the status of coordinator of
HCP in every city/town, and also to stimulate and support the participation of
other actors (public, private, voluntary, communitarian and international) who
have been involved with one or many aspects of urban development.
This approach coincides with recent trends in urban governance. Traditional
structures of local government were based on compartmental administration
with few or no horizontal connections between different areas or services, and
with a strong emphasis on the role of the public bureaucracy. However, in the
past few decades there has been a move towards a flexible structure of urban
management, with an emphasis on integration between areas or services as well
as on the co-operation between the public sector and the other actors involved
with urban management .39
In sum, HCPs approach constitutes an integrated process of urban management.
This point will be illustrated with the example of one specific HCP.

HCP in Chittagong, Bangladesh

Chittagong is an ancient city, which remained small until 1960, when it had
an area of 10.24 km2 and a population of 300,000.40 In the last few decades
Chittagong experienced rapid growth. In 1993 it had an area of 183.4 km2, and
the population was between 1.5 and 2.5 million.41 The city is now the second
largest in Bangladesh; it is the main sea port and main industrial centre. However,
similar to most cities in the developing world, the growth of Chittagong has been
accompanied by increasing urban problems. Poverty abounds, and it is estimated
that there are 110 slum areas in the city, with some 1 million inhabitants.42 The
provision of most urban services has been deficient, and the built fabric shows
many signs of decay.
The Chittagong HCP started with a series of meetings and workshops in 1993,
coordinated by WHO. The development of HCP into an integrated process of
urban management in this city is illustrated, for instance, by the type and range
of, and integration between, topics, actions and actors in the Project.
Firstly, the Chittagong HCP is formed by seven task forces which include most
topics related to the process of urban development:
(1) town planning, infrastructure and economic development;
(2) slum improvement;
(3) literacy and unemployment;
(4) water and sanitation;
(5) environmental protection;
636 Edmund0 Werna and Trudy Harpham

(6) drainage and sewerage; and

(7) primary health care and maternal and child health.43
Second, improvements in the aforementioned areas are to be achieved by the
implementation of a plan comprising 73 specific actions as diverse as a transport
development strategy, a mechanism to attract inward investment to Chittagong,
community business investment support mechanisms, extension of technical and
vocational training, legislation to prevent hill cutting, and support for rag pickers
to sell and distribute low cost latrines.4
Third, the task forces and the plan of action are to be implemented under
the co-ordination of the Chittagong City Corporation, and include other actors
involved in urban development. For example, public authorities (Bangladesh
Railway, Chittagong Development Authority, Chittagong Port Authority, Civil
Surgeon, Department of Environment, Department of Forests, Power Develop-
ment Board, Primary/Secondary/Higher Education Departments, ward repre-
sentatives, Water and Sewerage Authority, plus all the departments of the
City Corporation); voluntary sector (Association of Development Agencies
of Bangladesh (ADAB), Concern, Ghashful, NGO Forum, World Vision,
and other NGOs to be incorporated later on); private sector (Chamber of
Commerce, leading banks, Lions Club, Rotary Club); the community (slum
leaders, community associations) and international agencies (UNCHS, UNDP,
The links between HCP and urban management are further illustrated by the
analysis of the onset of the Project in Chittagong.46 This analysis has noted the
potential of HCP to overcome the major problems found in the structure of
urban management in that city. The problems are related to co-operation, co-
ordination, motivation, internal organisation, decentralisation, and community
Firstly, appropriate urban management requires co-operation at various levels.
In addition to the City Corporation, there are some 24 public agencies connected
to eight different ministries involved in several aspects of the administration of
Chittagong and in the provision of its public services. However, inter-agency
and inter-ministry co-operation is faint (let alone the co-operation between
the public, private and/or voluntary sectors). Rivalry between two or more
authorities which share the provision of the same service is frequent.
Interviews after the 1993 workshops unveiled that interactions between several
of the actors had never happened before. Subsequent actions of the Project
entailed further meetings and co-operation. If properly conducted, future actions
might give a great contribution to the harmonisation between the different
actors. Furthermore, considering the incidence of professional rivalry in the
urban management scene in Chittagong, the fact that HCP was brought by an
outside/international organisation (WHO) is beneficial, i.e. WHO may act as a
impartial actor in the local struggle of forces.
The second issue is coordination. According to its establishing ordinance, the
Chittagong City Corporation is responsible for the provision of public services
within the municipal area. 47 However, many services are provided by the other
24 public authorities noted before, which are not under the command of the
City Corporation - and there is no alternative co-ordinating body. As a result,
problems of lack of co-ordination such as overlap of functions in some areas and
deficiencies of provision in others abound.
The orchestration of all the agents and activities involved in HCP requires
fine co-ordination. Considering that the Project is being implemented under the
responsibility of the local government, it is likely to be an excellent opportunity
for capacity-building in co-ordination. HCP can also be helpful in co-ordinating
The Evaluation of Healthy City Projects in Developing Countries 637

campaigns such as sensitising the private sector and special authorities which
have space capacity to provide given services.
The third issue is motivation. Cases of public officials with little interest in
(and even with little knowledge about) their duties have been frequent in
Chittagong. According to statements gathered in interviews, the work carried
out in the first phase of HCP has succeeded in raising the motivation of the
participants towards the fulfilment of its goals. Considering that HCP goals are
intertwined with the day-to-day activities of the participants, such motivation
is likely to have multiplier effects. Thus, it is important to devise ways of
keeping the momentum which was generated by the implementation of the
Chittagong HCP.
The fourth issue is internal management of the public authorities. Problems
include weak inter-departmental co-ordination, lack of performance monitoring
and reporting systems, wide variation of managerial structures for analogous
kinds of services, weak tradition of team work, among others. One of the basic
premises of HCP is to generate institutional change.48 In a speech given at
a 1993 Workshop, Greg Goldstein (from WHO) identified the Project with
a new form of local government. Indeed, the implementation of HCP is
based on institutional arrangements which are innovative to Chittagong. This
may not change the institutional organisation of its authorities. However, it may
introduce fresh managerial ideas for the participants.
The next issue is decentrulisution. Although decentralisation has been adopted
as a key item in the public policy agenda in Bangladesh,@ its implementation
is still far from true devolution to local governments. As already noted, many
services in Chittagong are still outside the realm of the City Corporation, and
are controlled by agencies directly linked to central ministries. However, on the
one hand, the Chittagong HCP is co-ordinated by the City Corporation. On the
other hand, the Project includes areas of action which are outside the realm of
that authority. Therefore, the intervention of the Chittagong City Corporation in
the overall management of urban development is likely to increase with HCP.
Finally, HCP might boost community participation in Chittagong. This is
one of the basic propositions of the Healthy Cities Movement.50 Popular
participation has been regarded as fundamental for a sound urban management
process. However, although with some rhetoric and tentative actions from the
government, popular participation in Chittagong (as well as in the rest of
Bangladesh) is far from satisfactory .si Thus, HCP may also make a substantial
contribution on this issue.
In short, HCP has potential to ameliorate the major problems found in
the structure of urban management in Chittagong. It is worth noting that
the Chittagong HCP has its own problems, which need to be addressed if
the potential contribution of the Project is to be fully realised.52 At any
rate, the above analysis has confirmed the links between HCP and urban
management. This reinforces the case for designing institutional indicators for
a process evaluation of HCPs.

Institutional indicators for the evaluation of HCPs

These indicators can be divided into two broad categories: (i) the relationship
between HCP and existing institutions, and (ii) the institutional aspects of

Existing institutions. The evaluation should cover all the institutions active
in urban development: the public, private and voluntary sectors, community
organisations and international agencies.
638 Edmundo Werna and Trudy Harpham

In relation to public institutions, the evaluation should assess whether/how

HCP has: (i) contributed to strengthen the institutions; (ii) influenced their
policies and actions; and (iii) induced cooperation.
Firstly, good organisation and management structures in public authorities
are fundamental for a sound process of urban management. Considering the
existence of overwhelming problems in urban management in developing
countries, an in-depth study of the internal dynamics of the institutions is
necessary. Thus, the first item of the evaluation (strengthening) should include
issues which indicate changes in the level of organisation and management
efficiency in an institution. This paper has used a research on urban governance
carried out by the Development Administration Group (University of Birmingham)
in a number of developing countries as a guideline for assessing these changes.53
The bases of such an assessment should be changes in equity in provision
of services, in accountability, transparency, technical efficiency, economic
efficiency and autonomy.54
Secondly, the degree to which HCP has been able to influence changes in
the policies of the different actors involved in the development of a given
city or town is a major indicator of the Projects success. Actions derived
from these changes may be more sustainable than those derived from HCPs
institutional organisation (i.e. the Projects office, working groups and the
partnership task force). Virtually all local actors involved in the development
of a city/town are represented in the HCP organisation. However, this does
not guarantee that policy recommendations and actions put forward by HCP
will be internally incorporated by the local institutions; and the institutional
organisation of HCP may eventually dwindle. Thus, it is important that the
local institutions take on board the HCP aims, through internal changes in their
policies. The evaluation of these issues could be carried out through assessment
of changes in policy recommendations and actions. This should be accompanied
by interviews with key actors involved in policy making and implementation in
order to check whether/how the changes in actions and decisions have been
influenced by HCP.
Thirdly, co-operation between all the actors involved in the planning and
management of a city/town is a major goal of HCP - and it is indeed a major
requirement for an integrated process of urban development (this includes not
only co-operation within the public sector, but also between public authorities
and private, voluntary, international and/or community organisations). HCP
working groups and partnership task force entail strong co-operation. However,
as with the previous item (policies), it is important to go beyond the scope of the
HCP institutional organisation in relation to co-operation, i.e. it is necessary to
influence intrinsically the behaviour of the existing institutions in each city/town.
These issues could be evaluated through assessment of the evolution of joint
programmes and of the attitude of officials regarding co-operation. Similar to
the previous item, it is fundamental to assess whether (and how) changes have
been influenced by HCP or not (through interviews with key actors).
In relation to the private and voluntary sectors and international agencies, the
evaluation should also assess whether/how HCP has: (i) influenced their policies
and actions; and (ii) induced co-operation (within and between sectors/agencies).
The procedures to carry out such an evaluation would be similar to those noted in
relation to the public sector. The rationale for focusing on private, voluntary and
international actors is based on the fact that they have beerrplaying an important
role in urban development. Due to the worldwide support for neoclassical
ideas and its emphasis on the private (for profit and not for profit) sector, and
due to the large number of multilateral and bilateral agencies funding urban
development programmes in developing countries, the role of these actors is
likely to remain important.
The Evaluationof Healthy City Projects in Developing Countries 639

Finally, as already noted, community participation has been regarded as a

central issue both in HCP documents and in the urban development literature.
The evaluation of this issue should assess whether/how HCP has: (i) strengthened
community organisations; and (ii) involved them in the Projects activities. These
issues should be pursued through interviews with key informants to trace the
history of the organisation of communities and of their participation in HCP.

Institutional aspects of HCP. Although the achievement of the HCP aims via
the actors analysed above is more sustainable in the long run, the institutions set
up by the Project (i.e. the local and partnership task forces, steering committees
and working groups) are important to reach short-term and/or partial objectives
(which generate multiplier effects), and also to influence the above actors. The
evaluation should assess the implementation and development of the HCP
institutions. It is likely to overlap with many points of the previous set of
evaluation, because the key persons involved in HCP are all members of existing
institutions. Thus, each one of the two sets of evaluation can be used to cross-
check a number of points of the other.


This paper reviewed the debate about process and impact indicators both in
general terms and particularly in relation to the evaluation of Healthy City
Projects. It stressed the importance of the former set of indicators, and the
need to focus on the institutional aspects of the Project.
A central point of the paper, illustrated both in conceptual terms and with
the Chittagong case, is that WHOs Healthy Cities Project has evolved from an
initial and specific approach to public health to an integrated approach to urban
management - which, in its turn, has a broader/longer-term impact on health.
However, such a change has not been fully grasped yet (e.g. most papers written
about the HCP still have a public health rhetoric). Therefore, it is important
to clarify the current connection with urban management. Otherwise, Healthy
Cities may not be able to realise its broad potential (e.g. if the people involved do
not understand its extended scope). Consequently, the set of indicators suggested
in the paper aim at assessing such a broad approach of the Project.
Finally, it is important to note that the evaluation of the first HCP experiences in
developing countries has detected problems of implementation. The Healthy Cities
Movement originated and evolved conceptually and empirically in industrialised
countries. These countries differ from developing countries in many respects,
and the implementation of HCPs in the latter still needs refinement - for
instance, WHO has to take into account the specific difficulties of the local
institutions and communities in each city to implement the Project. The training
of a local team to co-ordinate the Project and the preparation of the local actors
to fully participate might require more time and resources than in industrialised
countries. Considering its present financial limitations, WHO needs to find
partners to implement Healthy City Projects in developing countries, and/or to
adapt the aims of the Project, taking into account the existing constraints. This
paper noted the importance of setting up a scheme to compare the development
of HCPs in cities in developing countries. This could help each Project to address
its problems based on similar experiences.

1. In this paper, the terms HCP and Project are used interchangeably to refer to the Healthy Cities
640 Edmund0 Werna and Trudy Harpham

2. A. Tsouros (ed.), World Health Organization Heahhy Cities Project: A Project Becomes a Movement,
Review of Progress 1987 to 1990 (WHO, Copenhagen, 1990), p. 11.
3. Y. Von Schirnding and N. Padayachee, Healthy Cities for a Future South Africa, South African
Medical Journal 83 (1993), pp. 718-719.
4. Tsouros (1990), see note 2.
5. A. Elzinga, Evaluating the Evaluation Game: on the Methodology of Project Evaluation, with
Special Reference to Development Co-operation, Sarec Report, Stockholm (1981).
6. See A. Shrettenbrunner and T. Harpham, A Different Approach to Evaluating PHC Projects in
Developing Countries: How Acceptable is it to Aid Agencies ? Health Policy and Planning 9, 2
(1993), pp. 128-135.
7. B. Van Norren, J.T. Boerma and E.K.N. Sempebwa, Simplifying the Evaluation of Primary Health
Care Programmes, Social Science and Medicine 26(1989), pp. 1091-1097.
8. Van Norren et al. (1989) see note 7.
9. D.R. Gwatkin, J.R. Wilcox and J.D. Wray, The Policy Implications of Field Experiments in Primary
Health and Nutrition Care. Social Science and Medicine 4. C (1980). DD. 121-128.
10. See, for instance, Schrettenbrunner and Harpham (1993), note6. n*
11. WHO, Development of Indicators for Monitoring Progress Towards Health for all by the Year 2000,
Health For All Series No. 4 (WHO, Geneva, 1981).
12. e.g. A. Blankers, Accra Healthy Cities Project/Urban Primary Health Care - One Year After its
Initiation, Research Report, Faculty of Health Sciences, University of Limburg, The Netherlands
(July 1993); J.K. Davies and M.P. Kelly, (eds), Healthy Cities - Research and Practice (Routledge,
London, 1993); E. de Leeuw and M. Goumans, Current Research and Evaluation on Healthy
Cities Programs - A Focus on Community Research Priorities and the Producers and Users of
this Research, paper presented at the International Healthy Cities and Communities Conference,
San Francisco, December, 1993.
13. e.g. F. Baum, Healthy Cities and Change: Social Movement or Bureaucratic Tool? Health
Promotion International 8, 1 (1993), pp. 266-285; F. Baum and R. Cooke, Healthy Cities
Australia: the Evaluation of the Pilot Project in Noarlunga, South Australia, Health Promotion
International 7, 3 (1992), pp. 181-193; F. Baum, R. Cooke, K. Crowe, M. Traynor and B. Clarke,
Healthy Cities Noarlunga Pilot Project Evaluation, Southern Community Health Research Unit,
Noarlunga (1990).
14. R. Draper, L. Curtice, J. Hooper and M. Goumans, WHO Healthy Cities Project: Review of the
First Five Years (1987-1992) - A Working Tool and a Reference Framework for Evaluating the
Project (World Health Organization, Regional Office in Europe, 1993); WHO, Building a Healthy
City: A Practitionerss Guide, a manual prepared by the Unit of Urban Environmental Health, Office
of Operational Support (WHO, Geneva, Draft dated 19 July 1994).
15. J.F. Collin, (coordinator), Guide Notes for the Healrhy-Cities Indicators (WHO, Copenhagen, 1992);
Working Group on Indicators of Healthy Cities, Summary Report (WHO: Copenhagen, 1990).
16. See Collin (1992), note 15.
17. See Collin (1992), note 15.
18. See N. Harris, (ed.), Cities in the 2990s - The Challenge for Developing Countries (UCL Press,
London, 1992); E. Werna, United Nations Agencies Urban Policies and Health, paper presented
at the Conference Urban Health Research: Implications for Policy, London School of Hygiene and
Tropical Medicine, December 1994.
19. E. Werna, Urban Management, Provision of Health-related Services and the Healthy City Project
in Chittagong, Bangladesh, Research Report, Urban Health Programme, London School of Hygiene
and Tropical Medicine, 1994.
20. e.g. WHO, Twenty Steps for developing a Healthy Cities Project, WHO Regional Office for Europe
(WHO, Copenhagen, 1992); WHO (1994), see note 13.
21. See UN (United Nations), Agenda 21 - Rio Declaration, Proceedings of the United Nations
Conference on Environment and Development, Rio de Janeiro, 3-14 June, 1992; UNCHS, Global
Shelter for the Year 2000 (UNCHS, Nairobi, 1988); UNCHS-World Bank-UNDP, Urban Management
Programme Annual Report 1993 (World Bank, Washington, 1994); UNDP, Cities, People and Poverty:
Urban Development Co-operation for the 1990s. Strategy Paper (UNDP, New York, 1991); UNICEF,
UNICEF Programmes for the Urban Poor, Policy Paper (UNICEF, New York, 1993); World Bank,
Urban Policy and Economic Development - An Agenda for the 1990s. World Bank Policy Paper
(World Bank, Washington, 1991).
22. See Harris (1992) and Werna (1994), note 18. Five of the most active agencies in the urban field
are the following: UNCHS (United Nations Centre for Human Settlements), the World Bank, UNDP
(United Nations Development Programme), UNICEF (United Nations Childrens Fund), and WHO
(World Health Organisation).
23. Collin (1992), see note 15.
24. Collin (1992), see note 15; Draper et al. (1992) see note 14; WHO (1994) see note 13; Working
Group on Indicators of Healthy Cities (1990), see note 15.
See note 12.
;:. This is analogous to John Turners approach to community involvement in housing provision, which
has been widely applied in developing countries - see J. Turner, Introduction, in B. Turner (ed.),
Building Community - A Third World Case Book (Building Community Books, London, 1988),
pp. 13-18; J. Turner and R. Fitcher (eds), Freedom to Build: Dweller Control of the Housing Prices
(Macmillan, New York, 1972).
27 Baum (1993), see note 13; Baum and Cooke (1992), see note 13; Baum et al. (1990), see note 13;
de Leeuw and Goumans (1993), see note 12.
28. See note 12.
The Evaluation of Healthy City Projects in Developing Countries 641

29. See Werna (1994) see note 19.

30. F. Barten, T. van Naerssen, J. de Koning and G.T. Heikens, Urban Poverty and Health, Discussion
Paper for the WHO/DGIS workshop, WHO Headquarters, Geneva, 4-6 October 1993.
31. Blankers (1993). see note 12; Werna (1994). see note 19.
32. CCC-WHO (dhittagong City Corporation and World Health Organization), Chittagong Healthy City
Project - Health for All-All for Health (CCC-WHO, November 1993), p. 3.
33. CCC-WHO (1993) see note 32.
34. WHO, The Urban Health Crisis - Strategies for Health for AN in the Face of Rapid Urbanization
(WHO, Geneva, 1993), pp. 10-11.
35. Baum et al. (1990), see note 13; CCC-WHO (1993) see note 32.
36. CCC-WHO (1993) see note 32.
37. Although many HCPs include pilot projects, these do not constitute the core of the Healthy Cities
38. Thus following the current approach (i.e. the process approach) adopted by the United Nations
agencies which are most active in the urban field (see previous section).
39. See N. Devas and C. Rakodi, (eds), Managing Fast Growing Cities - New Approaches to Urban
Planning and Management in the Developing World (Longman Scientific & Technical, Harlow, 1993);
Harris (1992). note 18; G. Stoker, Regulation Theory, Local Government and the Transition from
Fordism. in D.S. King, and J. Pierre, (eds), Challenges to Local Government (SAGE, London, 1990),
pp. 242-264; E. Werna, Urban Management and Intra-urban Differentials in Sao Paula, Habitat
International (1995). 9(l), pp. 123-138. These trends are currently more advanced in industrialised
countries. However, there is evidence of moves in this direction in developing countries. There is also
strong support for them in the development literature and in policy/position papers of international
donor agencies - facts which suggest that they are likely to expand in the developing world.
40. CCC-UNICEF (Chittagong City Corporation and United Nations Childrens Fund), City Plan of
Action on Some Basic Services for Women and Children (CCC, Chittagong, June 1993).
41. CCC-UNICEF (1993), see note 40; CCC-WHO (1993) see note 32.
42. CCC-WHO (1993), see note 32.
43. CCC-WHO (1993), see note 32.
44. CCC-WHO (1993), see note 32.
45. CCC-WHO (1993), see note 32.
46. Werna (1994), see note 19.
47. S.L. Rahman, (ed.), Pourasawa and Municipal Corporation Law Manual (Soilur, Dhaka, 1982).
48. e.g. Draper et al. (1993), see note 14.
49. M.M. Khan, Paradoxes of Decentralization in Bangladesh, Development Policy Review 5 (1987),
p. 407.
50. Blankers (1993), see note 12; Draper et al. (1993), see note 14.
51. M.M. Khan and H.M. Zafarullah, The Decentralized Planning Process in Bangladesh, Studies in
Rural Regional Development Planning in Asia HSD Research Report 19 (1988).
52. Werna (1994) see note 19.
53. The findings of this research are presented in a series of case studies and working papers entitled
The Institutional Framework of Urban Management (Development Administration Group, School of
Public Policy, University of Birmingham). The case studies are the following: P. Amis, Urban
Management in Uganda, Survival Under Stress (1992); R. Batley, Urban Management in Brazil
(Vol. 1, General Characteristics; Vol. 2, Recife; Vol. 3, Porto Alegre) (1992); R. Batley and
S. Dutta, Urban Management in India (Vol. 1, Common Characteristics; Vol. 2, Ahmedabad
in Gujarat; Vol. 3, Anand in Gujarat) (1992); R. Batley, Urban Management in Mexico (Vol. 1,
General Characteristics; Vol. 2, Hermosillo; Vol. 3, Campeche) (1992); I. Bore, Calcutta: Two Small
Municipalities in a Large Metropolis (1992); M. Norris and P.S. Nooi, Urban Management in Penang
Island, Malaysia (1992); D. Pasteur, Good Local Government in Zimbabwe: Bulawayo and Mutare
(1992); D. Pasteur, Lending for Municipal Development in the Phillipines, the Institutional Impact
of World Bank Projects, 1976-1990 (1991). The working papers are the following: No. 1: K. Davey,
The Structure and Functions of Urban Government; No. 2: D. Pasteur, Internal Organization
and Management; No. 3: M. Norris, The Staffing of Urban Government; No. 4: K. Davey and
N. Devas, Urban Government Finance; No. 5: K. Davey, Central Local Relations; No. 6:
R. Batley, Public, Private and Community Organization; No. 7: K. Davey, Urban Government
54. It is beyond the scope of this paper to elaborate on the indicators for these issues, as well as
for the following issues to be presented. The indicators are fully elaborated in E. Werna and
T. Harpham; Notes on the Evaluation of Healthy City Projects in Developing Countries, paper for
the World Health Organization, Urban Health Programme, London School of Hygiene and Tropical
Medicine (1994).