From public health to urban governance: How health becomes the strategic core of global cities

Urban civilization is at a turning point. With more than half of the global population living in cities, cities are no longer merely engines of economic growth; they are increasingly becoming the convergence point of inequality, environmental degradation, and health crises. Traditionally, urban health has been relegated to the responsibility of the healthcare system, and the core indicators for urban decision-making have been GDP, employment, and infrastructure development, with health viewed as a "consequence" rather than a "prerequisite." However, a series of urban health case studies recently released by the World Health Organization shows that this logic is undergoing a fundamental reversal—a group of cities and governments around the world have begun to embed health and equity at the core of urban strategy, redefining the decision-making frameworks for urban planning, transportation, housing, and community development.

Strategic Action: Urban Health Beyond "Medicalization"

The case studies released by WHO this time are not isolated project summaries but a coherent strategic narrative. They build on the Guide to the Strategic Approach to Urban Health and accompanying policy briefs, with the core message being: to make cities healthier, we cannot rely on single health interventions alone; rather, we must reshape the operating logic of urban systems through cross-sectoral, cross-scale systemic action. From the Urban Health Observatory in Belo Horizonte, Brazil, to the national health impact assessment mechanism in the United Kingdom, to community-led interventions in informal settlements in Bangladesh, the cases cover a broad spectrum from local to national, and from high-income to low-income countries.

The diversity of these cases itself conveys a key message: there is no single path to a healthy city. Some cases start from environmental and spatial planning, such as the urban planning and health network in Brittany, France; some start from transportation and mobility, such as active mobility projects in the Caribbean and the transport emission reduction plan in Warsaw; some use housing as a lever, such as cross-sectoral housing modifications to prevent falls among older adults; and others leverage major sporting events, such as Qatar using the 2022 World Cup to promote healthy lifestyles. But they all share the same strategic awareness: crossing institutional boundaries, coordinating different stakeholders, and pursuing the co-benefits of health, equity, sustainability, and resilience while identifying future risks in advance.

Health as a Governance Experiment: From Belo Horizonte to Utrecht

In Belo Horizonte, Brazil, the pioneering work of the Urban Health Observatory shows that data are not merely monitoring tools but governance infrastructure. By systematically collecting and analyzing the relationship between health and the urban environment, the Observatory helps decision-makers embed health evidence into urban planning and policy evaluation, making health no longer an abstract aspiration but a measurable and accountable goal. Similarly, in the United Kingdom, the HAUS project provides health impact evidence for national government assessment and decision-making, embedding the health dimension into macro-level decisions on infrastructure, housing, and urban development—a mark of the institutionalization of health impact assessment.In Utrecht, the Netherlands, the healthy urban planning team (GLO) integrates health considerations into daily urban planning processes, not as an add-on but as a foundational perspective. In Bangladesh, the BRAC and ARISE projects demonstrate a different logic: residents of informal settlements are not passive recipients but active knowledge producers and intervention designers. By co-producing community-led water, sanitation, and hygiene (WASH) interventions, these projects directly link participatory governance to health improvement. Together, these cases illustrate the "operationality" of urban health strategies: they require both top-down institutional design and bottom-up community agency, as well as continuous calibration of data, evidence, and cross-sectoral collaboration.

Cities as New Actors in Global Governance

WHO's urban health case studies reveal, at a deeper level, the evolution of global governance structures. For a long time, cities were viewed as subordinate units of national governments, lacking independence in global policy-making. But in recent years, from climate change to social equity, cities have increasingly emerged as global actors, taking on governance responsibilities when national action is absent or slow. These health cases show that cities not only have the capacity but also the legitimacy to formulate their own health strategies and participate in global knowledge exchange networks.

The rise of this "city diplomacy" means that the traditional state-centric governance model is being supplemented or even challenged by a new multi-level, networked governance order. Urban health as an issue is precisely the field that best embodies this shift: because health problems often manifest locally, yet their solutions require global knowledge sharing. WHO's role here is not just to issue guidelines, but to build a global urban health learning network, enabling Belo Horizonte's experience to inspire Nairobi, and Utrecht's practices to motivate Kolkata.

Long-Term Trend: Health as a New Dimension of Urban Competitiveness

From a broader long-term trend perspective, health is becoming a new dimension for measuring urban competitiveness. Extreme weather brought by climate change, public health vulnerabilities exposed by the pandemic, and the burden of chronic diseases caused by population aging all make a city's health resilience an important condition for attracting investment, talent, and innovation. Urban planning is no longer just a technical issue of land use, but a social contract concerning residents' well-being, social inclusion, and ecological sustainability.

The rise of cities in the Global South deserves particular attention. In Africa, Asia, and Latin America, rapid urbanization is often accompanied by the expansion of informal settlements and lagging infrastructure. However, WHO's cases show that these cities are not just a collection of problems; they are also laboratories of innovation and resilience. Residents of the Mathare informal settlement in Nairobi, Kenya, have implemented a physical addressing system to improve access to services; the city of Ashaiman in Ghana is exploring cross-sectoral collaboration to improve health; and Pokhara, Nepal, is strengthening non-communicable disease management by integrating public and private medical services—these practices break the stereotype that "Southern cities can only imitate Northern ones," proving that health strategies must be rooted in local contexts.## Conclusion: Urban Civilization Needs a New Strategic Compass

Looking ahead, urban civilization is undergoing a profound self-correction. Twentieth-century urbanization made economic growth the highest priority, generating wealth while also breeding health inequities and ecological overdraft. Twenty-first-century urbanization, in turn, must recalibrate its course among health, equity, and sustainability. These WHO case studies provide a valuable "knowledge map" for cities around the world—they demonstrate the feasibility of systemic action while also reminding us that urban health is not a short-lived project, but an enduring governance transformation.

For policymakers, urban planners, and global development institutions, the challenge is clear: embed health into every decision, and place equity at the heart of every strategy. This is not a technical patch, but a paradigm shift in the logic of urban governance. Cities are not merely spatial carriers of civilization; they are touchstones of humanity's shared destiny. When cities truly begin to prioritize human health and dignity in every decision concerning breath, mobility, housing, and belonging, only then can urban civilization be said to have entered a new stage.