Health Promotion International, Vol. 24 No. S1 # The Author (2009). Published by Oxford University Press. All rights reserved.
doi:10.1093/heapro/dap058
Equity and social determinants of health
at a city level
ANNA RITSATAKIS*
1
Independent Consultant in Health Policy Development, Greece
*Corresponding author. E-mail: annarits@hol.gr
SUMMARY
Equity in health has been the underlying value of the
WHO Health for All policy for 30 years, distinguished
from equality and difference in a commissioned series of
theoretical reports in the early 1990s. This article exam-
ines how cities translated this principle into action. Using
information designed to help evaluate Phase III (1998 –
2002) of the WHO European Healthy Cities Network,
plus documentation from city programmes and websites,
an attempt is made to assess how far stakeholders in cities
understood the concept of equity in health, had the
political will to tackle the issue and the types of action
undertaken. Results show that cities focused mainly on
support for vulnerable groups, and a wide range of
Key words: equity; Healthy Cities; social determinants; health equality
INTRODUCTION
This article examines how cities in the WHO
European Healthy Cities Network (WHO-
EHCN) operationalized the principle of equity
in health during its first three phases, addressing
the challenges to making this an integral part of
long-term policy-making in Phase IV and
beyond.
The origins of the WHO equity movement
stretch back to 1977 (WHO 1981) when the
World Health Assembly formally resolved to
address inequalities in health status observed
between and within countries. The ensuing
‘health for all’ strategy clarified that inequality
in health can only be tackled through intersec-
toral action to influence the broader social
determinants of health.
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actions were being implemented, including lifestyle-
oriented methods or those to improve access to care. Few
cities made the necessary shift towards more upstream
policies to tackle determinants of health such as poverty,
unemployment and housing. There was little experience
of evaluating the impact of interventions to reduce the
gaps. This is partly explained by a frequent lack of local
level data reflecting inequalities in health. The article con-
cludes that although half the cities in the Network needed
stronger action to make equity in health an integral part
of long-term planning, innovative experience was avail-
able to be shared by its members in Phase IV (2003–
2008) of the Network.
This fundamental principle has been
reflected in the work of the wider United
Nations system, with WHO (WHO, 1995)
focusing on poverty as a major cause of ill
health and mortality. The 1995 World Summit
on Social Development made the reduction of
poverty a key concern. The United Nations
Development Programme (UNDP) reiterated
that poverty must be seen not only in terms of
lack of income but also a shorter life, lack of
education and social exclusion; its 2003 report
(UNDP, 2003) presents an ambitious policy to
reduce human poverty, by improving edu-
cation, health and gender equity. The World
Bank has initiated far-reaching efforts for
countries to develop strategies to reduce
poverty and carry out poverty impact assess-
ment (World Bank, 2001).
i81
i82 A. Ritsatakis
The European Union redistributes consider-
able resources to develop disadvantaged regions
of the Union and in Lisbon in 2000 set common
objectives and discussed national plans to work
towards the eradication of poverty by 2010
(EUPHA, 2002). The United Kingdom high-
lighted inequity in health during its 2005 EU
Presidency (Judge, 2005; Mackenbach, 2005).
The quest for equity was given impetus by
Closing the gap in a generation. Health equity
through action on the social determinants of
health, the final report of the WHO
Commission on Social Determinants of Health
(WHO, 2008).
Although the terms poverty and inequality are
often used interchangeably, poverty refers to the
most disadvantaged whereas inequality reflects
the full social gradient. The WHO European
health policy HEALTH21 (WHO Regional
Office for Europe, 1999) recommends that,
although priority should be given to the most dis-
advantaged, the distribution of the determinants
of health among all social groups should also be
addressed. Other researchers have emphasized
the importance of taking into consideration
overall social cohesion when dealing with health
inequalities. (Wilkinson, 1996: Graham, 2004).
In the early 1990s, the WHO Regional Office
for Europe commissioned three discussion
papers (Whitehead, 1990; Dahlgren and
Whitehead, 1992: Kunst and Mackenbach,
1994), indicating what is meant by equity in
health, how inequality might be measured and
what policies and strategies would be most
likely to reduce the gaps. Whitehead distin-
guished differences in health status affected by
fixed factors such as age, gender and genetics,
from factors amenable to change such as life-
styles, personal and family circumstances, social
and community networks and general socioeco-
nomic, cultural and environmental conditions.
Whitehead’s theoretical distinction between
equity and equality has endured, alongside the
social model of health developed with Dahlgren
(Dahlgren and Whitehead, 1991) (Fig. 1). Not
all differences or inequalities are inequitable.
Fixed factors such as age, sex and hereditary
may lead to inequalities which are not perceived
as inequitable. Inequalities which can be reme-
died are inequitable. Adopting the principle of
equity in health requires interventions to tackle
differences that are avoidable and considered
unjust. Judgments on what is unfair vary by
time and place, but one widely used criterion is
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Fig. 1: Main determinants of health.
the degree of choice involved. If people have
little choice in their living and working con-
ditions, the resulting health differences are
more likely to be considered unjust than those
resulting from health risks chosen voluntarily.
Since disadvantages related to education,
income, environment and other factors tend to
cluster together and reinforce each other,
making certain groups very vulnerable to ill-
health, the sense of injustice is increased.
Whitehead suggests that equity in health means
that, ideally, everyone should have a fair oppor-
tunity to attain their full health potential.
Despite contentious debate on the measure-
ment of health inequalities (Regidor, 2004),
there is broad agreement on univariate health
indicators such as quality-adjusted life-years
(QUALYs), premature mortality and self-
reported or objective measures of morbidity.
There is a less agreement on the covariate indi-
cators that classify subject groups and the
measures to differentiate them. Socioeconomic
position is always a major covariate. Though
there is no agreement on how it should be
conceptualized (Mackenbach et al., 2002), it is
characterized mainly in terms of level of
income, education, occupation and, to some
extent, income-related indicators such as home
or car ownership. It is frequently analysed by
gender, age and area-based measures, for which
some countries have developed complex indi-
cators of deprivation. HEALTH21 includes vul-
nerable groups such as women, physically or
mentally disabled people, elderly people, immi-
grants and refugees under the equity in health
label, as do cities in the WHO-EHCN.
Developing her earlier WHO report (with
Dalgren) on policies and strategies, Whitehead
identifies a four-part, theory-based typology of
 Equity and social determinants of health at a city level
actions to tackle social inequalities in health
(Whitehead, 2007). Apart from (a) distal macro-
economic interventions, appropriate for inter-
national agencies or national governments, she
identifies three categories that are within the
broad competences of local governments in
Europe (Green, 1998). Intermediate interven-
tions (b) to ‘improve living and working con-
ditions’ have characterized environmental
health policy in industrialized cities for 150
years. Municipalities and their partners also
have a role in ‘strengthening communities’ (c)
through ‘building social cohesion and mutual
support’, often at a neighbourhood level, and in
(d) ‘strengthening individuals in disadvantaged
circumstances’ to more confidently address
proximal lifestyle determinants of health. This
article reviews Healthy Cities interventions at
all three intermediate and proximal levels.
METHODOLOGY
This article draws on information gathered
during the regular assessment of progress in the
WHO-EHCN during Phases I –III (1987 – 2002)
and available city policy documents and pro-
grammes: (a) network evaluation reports, (b)
self-reporting by member cities, (c) city profiles,
(d) policy and strategic documents and (e)
international bibliography and selected national
level policy documents indicating the context in
which cities are working.
The main source of information was an analy-
sis of replies to the equity section of a question-
naire completed by 41 cities in 25 countries in
2002 for the evaluation of Phase III of the
WHO-EHCN of 56 cities. Regarding equity in
health, questions covered:
† stakeholders’ understanding of the concept
† their level of commitment to reducing the
gaps
† policies and programmes to tackle inequal-
ities in health
† whether health impact assessment (HIA) had
an equity focus
† role of the Healthy Cities project in raising
the equity issue
† measuring and monitoring inequalities.
Open-ended questions facilitated a potentially
rich input from respondents, but the compre-
hensiveness of their replies was vulnerable to
interest and time pressure. This was reflected in
i83
the considerable variation in their responses.
Cultural background and the stage of develop-
ment of equity issues also affect their replies. In
some cases where historical analysis indicates
long-term concern and progress, there is a ten-
dency for more critical reporting than in certain
cities where equity is newly on the agenda.
Furthermore, presentations at the Healthy
Cities conference in Belfast in 2003 indicated
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that more is being done to tackle inequalities,
or to prepare the environment, infrastructures
and processes for doing this, than has been
recorded. Cross-checks with replies to
non-equity questions allowed for some correc-
tion, as did examination of policy and other
documents and city websites.
It is difficult to distinguish between what hap-
pened because of HCP, and what might have
happened anyway since cities were asked to cite
both initiatives of the Healthy Cities project
and other agencies. For the purpose of this
article, both types of action were of interest.
RESULTS
The overall approach of cities in the WHO-
EHCN is based on a theory of change first made
explicit by Draper et al. (Draper et al., 1993) in
his evaluation of Phase I (1988–1992) and
referred to by Tsouros (Tsouros, 2009).
Following ‘realist evaluation’ (Pawson and Tilley,
1997) and ‘Fourth Generation Evaluation’
models (Guba and Lincoln, 1989) context is
regarded as important (de Leeuw, 2009). Indeed,
Healthy Cities projects have sought to change
both the wider municipal processes and struc-
tures and to develop healthy public policy as fra-
mework for specific interventions.
Healthy public policy
The most compelling evidence of the EHCN
cities’ intention to adopt a strategic approach to
equity in health was the declaration by city
mayors supporting Action for Equity in Europe
(WHO Regional Office for Europe, 2000). This
included commitment to ‘a clear and explicit
operational understanding of equity and its full
implications’ and a vision and strategy which
embedded equity as ‘one of its core values and
a key component of its city health development
plan with explicit targets for achievement’
(Green et al., 2009).
i84 A. Ritsatakis
Question 2.1 of the Phase III evaluation
therefore asked whether stakeholders had a
common understanding of equity in health and
its policy implications; and if there were differ-
ing views, why this was so. Of the 33 cities
responding (80% of the total), none covered all
parts of the question and only a handful cited
their definition.
Stakeholders were said to have a common
understanding of equity in health in 18 cities
(44%). The long history of national-level discus-
sion obviously played an important role in cities
in the United Kingdom. This was also mentioned
in Kuressaare, and in Rennes where a 1998
Planning Act to combat social exclusion had
brought the issue onto the agenda. Nine cities
(22%) felt that there was no common understand-
ing. For example, in Dresden perceptions differed
according to political parties and Newcastle
suggested the City Council would think in terms
of poverty, and the local health authority in terms
of access to care. Five cities reported not knowing
whether there was a common understanding.
Twenty-one cities (51%) reported specific
commitment to promoting equity in health in
their city health plans, and a similar number in
overall development plans and/or the plans of
certain sectors. A wide range of policies and
legislation in other sectors were cited as indicat-
ing commitment to reducing the gaps. As might
be expected, the national level policy in
England (Department of Health, 2000) was
reflected at city level. In the words of
Manchester and Stoke-on-Trent, the promotion
of equity was a ‘must do’. Similarly, Liverpool
referred to a central government requirement
that the Director for Public Health give evi-
dence of progress towards closing the gaps.
Camden set its own equity targets. Sheffield
referred to an inclusion or anti-poverty strategy.
Belfast reported that 1998 legislation required
the development of assessment of health
inequality impact. Other cities in the United
Kingdom also mentioned HIA as one indication
of strong commitment and the terms of refer-
ence for city ‘partnerships for health’ clearly
included promoting equity in health. Stockholm
and Gothenburg also referred to such explicit
commitment from county and national levels.
Programmes to promote equity in health
In the 2000 WHO-EHCN Declaration support-
ing Action for Equity in Europe, mayors
committed their cities to ‘clear policies and pro-
grammes and action aimed at reducing health
inequalities’ (WHO Regional Office for Europe,
2000). In this evaluation, respondents were
invited to describe programmes initiated both
by the Healthy Cities project and by other insti-
tutions in their cities. Results ranged from three
‘no replies’ to long lists of projects, programmes
and policies in just about all sectors. The
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majority of policies and programmes cited
referred to actions in support of vulnerable
groups, as referred to in the Declaration. The
following were the main areas of action.
Children
Children were mentioned by the largest number
of cities (18 cities). The type of support ranged
from food and nutrition (e.g. free fruit and
breakfast in United Kingdom cities, dairy pro-
ducts in Zagreb and student meals in Maribor),
summer camps, foster homes, youth hostels,
support for abused children in Athens, and chil-
dren of alcoholic parents (Gyor), lower fees in
kindergartens for disadvantaged children in
Dresden, and a reading recovery programme for
children in Belfast.
Elderly and/or disabled people
Elderly and/or disabled people were mentioned
by 18 cities. The range of support included
improving access to buildings and public trans-
port, summer camps in Athens and Padua,
tele-alarm in Maribor and nursing care in
Jerusalem. Helsingborg reported a strategic
plan for mentally and physically disabled
people.
Immigrants, ethnic minorities and travellers
Fifteen cities mentioned support to these
groups, frequently in the form of translating
information or providing interpretation in
ethnic languages. Padua ensured immigrants are
represented on the City Council, and San
Fernando de Henares had a programme for
intercultural coexistence. Milan referred to a
banking system for poor and migrants and
Camden referred to ‘race equality schemes’.
Women
Cities mentioning women included Athens
(efforts towards gender equality and a hostel for
abused women), Gyor, Vienna and Rennes,
 Equity and social determinants of health at a city level
where single mothers were of particular
concern. In Udine, women in prison were a
concern.
Lifestyles
Several cities cited lifestyles as one way of tack-
ling inequalities. Examples included swimming
classes for disadvantaged young people and
ethnic minority women in Gothenburg, free
access to swimming pools for young people in
Glasgow (which substantially increased the
number swimming), bicycle paths in Sandnes
and cycling and walking projects in Camden,
including safer routes to school. Sandnes also
referred to a volunteer group of adults who
patrolled the streets in the evening to keep
young people safe.
Health care
Ten cities referred to health care, mainly such
issues as free check-ups and other preventive
services for disadvantaged groups, ensuring
transparency in waiting lists in Arezzo, and
lending medical equipment in Jerusalem.
Slightly more than 25% of the cities in the
WHO-EHCN referred to at least some of the
broader determinants of health.
Unemployment
Fourteen cities referred to unemployed people
(including the United Kingdom New Deal pro-
grammes). The focus was mainly on retraining
though Kuressaare made developing infrastruc-
ture to attract new enterprises and jobs a top
priority. Izhevsk reported efforts to reduce
unemployment among women, ex-prisoners and
disabled people.
Housing and the homeless
Housing and the homeless were mentioned by
13 cities. In Izhevsk, for example, the focus was
on ensuring high-quality drinking water by pro-
viding new pipes, and Liverpool mentioned the
stock transfer of social housing.
Overall development
Cities of the United Kingdom formed a distinct
group with integration of their equity-promoting
efforts in programmes for the regeneration of
disadvantaged areas, community strategies,
health action zones, education action zones,
New Deal programmes, neighbourhood renewal
i85
and crime reduction programmes. Cities such as
Athens, Bologna, Gyor, Horsens, Jerusalem,
Seixal and Turku also reported a strong link to
overall development. Maribor elaborated pol-
icies to promote equity in health in support of
the city’s development plan.
Other cities referred to interesting actions
such as an outreach programme in Rotterdam;
to help the poor apply for benefits to which
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they are entitled; the importance of government
reporting on cross-cutting spending, and the
value of a local university ensuring top-level
equity experts on call in Liverpool. In Rennes,
city contracts and local education contracts
focused on disadvantaged areas, and neighbour-
hood councils were established to improve par-
ticipation in decision-making.
CHECKING HOW POLICIES OF OTHER
SECTORS AFFECT EQUITY IN HEALTH
Interest in HIA has increased in recent years.
In a project carried out in close collaboration
with the European Commission, the WHO
Regional Office for Europe proposed that HIA
should focus not only on the aggregate impact
of policies in other sectors on health but also on
the distribution of potential effects (European
Centre for Health Policy, 1999). A review of
HIA in European countries indicated that this
definition has been widely accepted (Welsh
Assembly, 2003).
Fourteen cities misunderstood question 2.5
relating to equity-focused HIA or similar pro-
cesses, and provided information on their
regular evaluation of health projects – partly due
to poor phrasing of the question. Fifteen cities
(37%) explicitly stated that they did not
conduct an equity check or audit of policies in
other sectors, but four of these intended to do
so. Replying to a different question, Pecs men-
tioned analysing city documents to assess how
far they incorporated equity in health and inter-
sectoral action and whether such values were
reflected in operation. Brno was monitoring the
impact of the Social Assistance Development
Programme.
The United Kingdom cities were rapidly
developing HIA, supported by the former
Health Development Agency, now part of the
National Institute for Health and Clinical
Excellence (NICE) (http://www.nice.org.uk,
accessed 25 September 2009) which facilitates
i86 A. Ritsatakis
an exchange of information based on experi-
ence in practice, and deals specifically with
addressing inequalities through HIA.
Monitoring and measuring inequality in health
In the 2000 Declaration supporting Action for
Equity in Europe, mayors committed their cities
to ‘systematically measure and monitor inequal-
ities in health that exist between different sub-
groups of the population and areas of the city’
with ‘clear policies and programmes and action
aimed at reducing health inequalities.’ Finally
they agreed ‘The city should have mechanisms
in place to audit existing and new policies,
across and within sectors, for their contribution
towards this overall goal’.
The first evaluation in 1993 of Phase I (1987 –
1992) showed that only a few cities such as
Rotterdam had good experience of developing
small-area information to facilitate the measure-
ment and monitoring of equity in health. On
the whole, information was inadequate (Draper
et al., 1993). It was felt necessary to carry out
population health surveys in Phase II (1993 –
1997) and to address the needs of the most vul-
nerable and underserved social groups. Reviews
of city health profiles in the mid-1990s (Acres,
1997; WHO Regional Office for Europe, 1998)
also indicated that, with notable exceptions,
inequality in health was not adequately covered
and in some cases not clearly identified as an
issue. Sub-city level information was scarce, and
few profiles presented data on lifestyles accord-
ing to socioeconomic groups.
By the end of Phase III, 20 cities (49%) were
monitoring inequality in health at sub-city level.
As might be expected, cities in countries with a
strong tradition of research in equity in health
(the Netherlands, Sweden and the United
Kingdom) reported the most detailed monitor-
ing including ‘deprivation indices’ covering a
range of indicators referring to socioeconomic
determinants of health. Postal surveys in
Sheffield, for example, gathered information
about people’s health status, their perception of
their own health, use of health services and
social factors that may be linked to health and
illness (Sheffield Health Authority, 2000). The
results were presented for each of Sheffield’s
primary care trusts and at the electoral ward
level as well as for the city as a whole, and a set
of 22 socioeconomic indicators at the electoral
ward level were used to compare findings on
the prevalence of particular health problems
with measures of deprivation.
The Social Welfare Department in Pärnu sys-
tematically collected information on employ-
ment, income and residence, and Rennes
referred to ‘social performance’ indicators cov-
ering a wide range of determinants of health.
Brno monitored differences in lifestyles by geo-
graphical area and Ljubljana included the level
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of education.
Eight of the cities monitored by geographical
area referred to vulnerable groups. Vienna, for
example, referred specifically to women and to
migrants. But for the rest, the types of indi-
cators used at the sub-city level were not clear.
Other cities did not monitor at sub-city level
(Kuressaare argued that the small numbers pre-
cluded this; Maribor compared itself with other
cities), but they did monitor vulnerable groups.
When information on income or occupation was
not available, proxies were used to track disad-
vantaged groups, such as those receiving social
benefits. Although Pécs reported that it is not
yet monitoring inequality, it expected to do so
when the CHDP was implemented. Special
surveys were carried out in Camden, Glasgow,
Gyor, Sandnes, Sheffield, Stockholm and Torun,
for example. Strong interest was expressed in
improving monitoring systems. Bologna was
experimenting on how best to do this. Geneva
was about to start a new VISAGE system, and
Belfast was using ‘Noble’ indicators.
DISCUSSION
Understanding and monitoring inequalities
in health
Though many cities wished to emphasize
inequalities in health rather than in illness or
death, most relied on their public health depart-
ments to provide conventional univariate data
on morbidity and premature mortality. Cities in
Phase III of the Network conceived inequality
in health largely as manifest in:
† geographical differentials
† vulnerable groups
† socioeconomic differentials
Geographical differences cited most commonly
referred to the economic development of
sub-city areas, geographical differences in
health status and availability of care. Second,
 Equity and social determinants of health at a city level
vulnerable groups, including children, elderly
people, disabled people, women, migrants and
ethnic minorities, were referred to either in
relation to the understanding of the concept or
in relation to action taken. The third category
deals with socioeconomic circumstances, includ-
ing poverty, education and social inclusion and
exclusion. A fourth concept cited by cities is
that of equal access to health care or other ser-
vices. In a number of cases, however, it is
assumed that, if services are equally available,
they will be equally utilized, whereas inter-
national research has shown that this is fre-
quently not the case (Mielcke et al., 1994).
The main focus of mainstream academic
studies is on inequalities in health associated
with differences in socioeconomic circum-
stances. However, outside the United Kingdom,
Scandinavia and the Netherlands, few cities
have access to data relating to income, edu-
cation and employment. Consequently in
measuring and monitoring inequalities,
Network cities tended pragmatically to empha-
size either the health status of vulnerable
groups and/or neighbourhood differentials in
health status. Rotterdam was one of the excep-
tions, collecting socioeconomic data annually at
the level of the neighbourhood. The Rotterdam
Local Health Information System identified six
clusters of neighbourhood characteristics:
health, safety, quality of the environment,
demographic, social status and lifestyles, scored
on a range from 1 –10 to form the health barom-
eter which indicated the effects of specific pol-
icies in the coming years.
Interventions to address inequality in health
An examination of policies for equity (Obertop,
1999) indicated that although all cities in Phase
II of the Network were making efforts to tackle
inequality in health, their effectiveness had yet
to be proven, and cities had yet to move from a
traditional health education focus on proximal
lifestyle determinants to more strategic inter-
vention on distal and intermediate determi-
nants. This reflected similar findings at the
national level (Ritsatakis and Barnes, 2000).
In reviewing Phase III, cities cited a huge
diversity of programmes and policies as contri-
buting to closing the gaps in equity. The typo-
graphies of Benzeval et al. (Benzeval et al.,
1995) and Whitehead (Whitehead, 2007) are
helpful in distinguishing interventions at a
i87
macroeconomic level appropriate for national
governments, from those at a proximal or inter-
mediate level which are within the competence
of municipalities and their partners. Most
actions can be classified as ‘strengthening indi-
viduals’ in vulnerable groups or disadvantaged
circumstances to enhance proximal lifestyle
determinants of health. These actions might
previously have been labelled ‘welfare pro-
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grammes’. Fewer actions can be classified as
‘strengthening communities’ and even fewer
addressed ‘living and working conditions’ which
have traditionally been a major competence of
municipalities, eradicating many of the causes
of infectious disease.
However, the huge array of possible interven-
tions is classified, there is little evidence, either
from this evaluation or from other reviews on
what are the most effective interventions at a
local level, or indeed on the mechanisms of
change referred to by realist evaluators. Clearly
inequalities in health would be reduced by the
structural transformation of societies to reduce
disparities in socioeconomic status. However,
such a transformation is unlikely and in any
case requires macroeconomic policies that are
beyond the competence of local government.
However, national policies can assist actions at
a local level to ameliorate the health status
of vulnerable groups. Sweden’s national policy
Health on Equal Terms (Swedish National
Public Health Commission, 2000) suggested
strengthening social capital; providing a satisfac-
tory environment in which children can grow
up; improving working conditions and the phys-
ical environment; stimulating health-promoting
habits; and providing satisfactory infrastructure
for health issues. In England, where targets
were set to reduce gaps in life-expectancy and
infant mortality, the Department of Health
suggested that the inequality cycle be broken by
giving top priority to healthy pregnancy and
early childhood and improving opportunities for
children and young people. In the event, the
gaps have increased although there has been an
improvement in some indicators, indicating the
difficulty of the task and need for far-reaching
action (Department of Health, 2005).
Long-term commitment to reducing the gaps
If reducing the health gaps remains solely in the
domain of the health sector, it is difficult to
envisage long-term commitment. A small
i88 A. Ritsatakis
number of CHDPs indicated, however, that
economic development and the reduction of
unemployment were high on their agenda for
improving health. These included cities as dis-
parate as Kuressaare, Liverpool and Lodz.
There were examples of city health plans such
as that for Seixal, where housing conditions,
poverty (including unemployment) and life-
styles and behaviour were expected to have the
strongest impact on family health (MH Seixal,
1998). The Newcastle Partnership brought
together strategies and plans of different organ-
izations to tackle deprivation and discrimination
and create ‘a prosperous city attracting invest-
ment and jobs, but also a safe and caring city
where people want to live and work and where
everyone is helped to achieve their full poten-
tial’ (Newcastle City Council, 2002).
HIA could be a potentially powerful tool for
promoting the long-term reduction of inequality
in health (Judge, 2005). Liverpool and
Manchester have pioneered HIAs in the United
Kingdom. Belfast has been in the fortunate pos-
ition of being able to take advantage of recent
legislation requiring public authorities to carry
out equality impact assessments of their policies
and to draw up equality schemes to demonstrate
how they intend to promote equality of oppor-
tunity in their activities. Such schemes must be
approved by the Equality Commission (Equality
Commission, 2003).
In addition, six cities seem to have developed
similar approaches such as checking for the
impact of poverty in Dublin and of segregation
in Helsingborg. Although Gyor stated that they
did not systematically carry out HIA, in a very
practical approach, they indicated that funds
under the present tender system were to be
awarded only to proposals that affected
inequality.
CONCLUSIONS
There has been an undeniable shift from rheto-
ric to action in at least half the cities in the
WHO-EHCN, bringing the value of equity in
health firmly into the planning process. But by
the end of Phase III, half still needed additional
work to clarify the concept of equity in health
and its implications for policy development.
In countries where there is a long tradition of
mapping out inequality in health and its causes,
cities have developed information bases capable
of creating political discussion for action. On
the evidence of the evaluation, most cities need
to improve information on inequality in health,
reflecting socioeconomic differences. The utiliz-
ation of data available in sectors other than
health (including the private sector) could poss-
ibly be useful in giving a clearer picture of the
covariates of inequalities in health.
The challenge is not only measuring and
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monitoring but also analysing the data and pre-
senting the policy implications in a manner
easily understood by policy-makers and the
public. Policies to promote equity in health are
frequently long term, and it is difficult to disen-
tangle the impact of single strands of policy on
the health of specific groups. Commitment must
be retained and renewed as policy-makers come
and go. Improving the use, analysis and presen-
tation of available knowledge might be the
trigger to clarify the equity concepts and their
implications and to push equity higher on the
agenda. Examples of resource material and
training for the understanding of this complex
process remained available in the EHCN during
Phase IV.
Few cities have shifted from support for vul-
nerable groups to upstream action to tackle the
intermediate determinants of health. If other
sectors are to accept their responsibility for
tackling inequality in health and to be given
recognition of their contribution, then urgent
attention must be paid to evaluating the effec-
tiveness of upstream interventions to promote
equity in health.
Strong potential is offered by the develop-
ment of HIA which was a key theme of Phase
IV. The EHCN includes global level pioneers in
this area and work is already underway to
assess the implications of HIA in terms of
equity, effective structures, information, human
resources and training.
Innovative work continues to be undertaken
in EHCN cities, including target-setting to raise
equity in health on city agendas. Greater rep-
resentation of vulnerable groups is being
achieved through structures such as older
people’s councils. Although the methods for
community participation based on modern tech-
nology (web sites) favoured by many cities are
not conducive to the participation of vulnerable
groups, some cities have gone to great lengths to
listen to the voices of the people (Liverpool
Partnership Group, 2002). There is still a long
way to go, but EHCN cities are building on their
 Equity and social determinants of health at a city level
experience and sharing their expertise with a
range of national governments and international
agencies.
FUNDING
This article is based on an evaluation commis-
sioned by the WHO Regional Office for Europe.
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