Can municipalities be umbrella settings for health?

Health promotion is the process of enabling people to increase control over, and to improve their health, and thereby their wellbeing and quality of life. All to often, the focus within health promotion is still on trying to influence individual behaviours, despite the many obstacles many people, particularly those with fewer resources, can face when it comes to, for example, being more active, or eating in ways that support health.

A much more effective approach is to modify the environments in which people live, to make the healthy choice the easy and attractive default choice, for everyone. But how can municipalities facilitate this? Members from EuroHealthNet's Thematic Working Group on Healthy Urban Environments have been discussing this issue.

In 1986, the World Health Organization held its first international conference on health promotion. During this historic occasion, a charter outlining commitments to a healthier future for all was presented. 

The Ottawa Charter, which consists of five essential health promotion actions and prerequisites for health, became a turning point in global health. The meaning behind this momentous event was clear: " is created and lived by people within the settings of their everyday life; where they learn, work, play and love."

These 'everyday settings' (such as the provision of care, accessibility to green spaces, and organisation of welfare programmes) shape people's lives and are for the most part organised and provided for by all levels of governance. Political units, therefore, are key stakeholders in health promotion and disease prevention. 


Municipal governments have the means to make their communities 'umbrella settings for health.' Yet this is no easy feat. Much like all levels of government, the local political spectrum is a highly complex one comprising of a range of departments with differing priorities. 

The Wellbeing Economy focuses on ensuring that people do not serve the economy, but that the economy serves them, and generates health and wellbeing for people and the planet, as both a driver and an outcome of development. A number of cities are experimenting with how to achieve this, by respecting and restoring the natural environment and resources, while fostering participatory approaches, as well as investing in prevention and providing opportunities for all to further develop their skills and talents.

Public health leadership to strengthen engagement

Encouraging other sectors to recognise that they, too, contribute to health and wellbeing, requires leadership and action from the public health sector. The public health sector must strengthen engagementby raising awareness and knowledge amongst local leaders and other actors of the determinants of health, of how health is distributed, and how they can improve the situation in their communities. They must also demonstrate to other sectors, how the goal of health and wellbeing ultimately contributes to their interests too, so that it is embraced as a common, overarching priority.


Areas for action

 Although each country and each municipality in the EU has a diverse and indeed unique situation, it can be said that most governments do not focus sufficiently on the overall impact of their policies and programmes on health and wellbeing, and their distribution. Health promotion in this sense is often considered a ‘voluntary’ task, and there lack of clear mandates, and the necessary governance and administrative structures, to ensure that different actors are working together to co-produce health and wellbeing.  
Addressing this, to ‘make municipalities umbrella settings for health’ requires investment in capacities, as well as supportive governance and administrative structures. It also requires better, standardised monitoring systems, that can help to generate evidence around what works, to incentivise sustained funding. 

EU Joint Action on Health Inequalities

To advance these issues, the EU Joint Action on Health Inequalities (JAHEE, 2019-2022) included a work-strand that focused on the theme of Healthy Living Environments. Member State authorities involved, identified and shared relevant strategies, policies, and practices in their countries to strengthen the role of municipal governments to improve health and reduce inequities. Participating countries and municipalities implemented pilot initiatives to progress action in the field, with an emphasis on capacity-building, structural development, planning and networking. 

The learnings were brought together in a set of implementation and advocacy guidelinesfor practitioners, decision makers and stakeholders, for urban planning. Further descriptions and outcomes of the JAHEE work-strand on HLE are available on the JAHEE website and the Health Inequalities Portal. 

When JAHEE ended, several former partners that were also Members of EuroHealthNet established a Thematic Working Group (TWIG) on Healthy Living Environments, to build on the momentum of the work undertaken, and continue to share learning and experiences. 


Building on momentum

When JAHEE ended, several former partners that were also Members of EuroHealthNet established a Thematic Working Group (TWIG) on Healthy Living Environments, to build on the momentum of the work undertaken, and continue to share learning and experiences.



XarxaSalut's main goal is to make it easier to integrate a health perspective into all local policies in the Spanish region of Valencia, through an action framework with examples of best practices and scientific evidence. The primary objective is to increase municipalities' understanding of the factors that influence health and health inequalities. Active participation and intersectional strategies are also encouraged, to enhance community health. 

  • 267 Municipalities ( out of a total of 542, 49.2%) have joined the network, representing 75% of Valencia's population (approximately 5 million people). 
  • Each municipality must go through different stages including: creating a multisectoral municipal group, health situation analysis and mapping, and implementing and evaluating priority actions.
  • XarxaSalut has developed four methodological guides, namely one on the community action for health process, as well as a glossary, that aims to ‘build a common language’ around relevant concepts for non-health stakeholders and to support municipalities efforts to move through these stages.
  • A toolbox has also been created as a set of participatory approaches to help municipalities and community associations work together.
  • A set of evidence-based interventions is available that lie within the municipality’s areas of competency, addressing 11 different themes, including the early years, adolescence and young people, mobility and urbanism, art, culture and emotional wellbeing and food security. 

A new regional decree, adopted in the spring of 2023, mandates that municipalities that join XarxaSalut organise intersectional tables and bring together various departments to determine and implement priorities for action. All primary health centres must also  develop 'health councils'. 60% of the representatives sitting on these two bodies represent community associations, while 40% are professionals from the public or private sector.

Italy: promoting health and wellbeing

In Turin, Italy, and smaller municipalities of the surrounding area, EU Resilience and Recovery funds are being used to set up Community Houses that initiate actions to promote health and wellbeing. Local actors will come together in communities of practice, to identify, implement and evaluate actions that address different determinants of health, promote health, and reduce health inequalities. Health inequalities will be a common metric to stimulate an assess local, social innovation. 

The approach will be initiated by health authorities that will elaborate and share a review of geographic and social inequalities in the determinants of non-communicable diseases, cancer and mortality, as well as the use of, and the quality of health and social care. 

In order to determine what can be done in each setting to lower the risk of avoidable inequalities and improve access to care and its quality, each municipality will then organise various communities of practice. Members of the community of practice will receive training and participate in cycles of health equity audits to find specific health gaps, prioritise actions, carry them out, and then evaluate the results. The aim is to spread and transfer the model to other municipalities, to encourage and strengthen efforts to reduce health inequalities in local communities throughout Italy.

Find out more about Italy's use of the EU Recovery and Resilience funding for health equity in our annual analysis.


The authors would like to thank Rosana Peiro Pérez from the Valencia Region and Giuseppe Costa, from the University of Torino, Regional Health Observatory for their contribution to this article. 

Ingrid Stegeman
Program Manager at EuroHealthNet | + posts

Ingrid Stegeman is Programme Manager with almost 20 years of experience in the field of EU health and social policies, and in managing EU co-funded projects. She works across EuroHealthNet’s Policy, Practice and Research Platforms, and is responsible for overseeing and ensuring the quality of EuroHealthNet’s wide-ranging activities to reduce health inequalities through underlying determinants of health. She is currently managing EuroHealthNet’s Schools4Health project and our contributions to the FEAST research consortium, that focuses on transforming food systems, as policy lead.

Christina Platz
Advisor at Federal Center for Health Education (BZgA) | + posts

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