Achievements and future path of Tehran municipality in urban …mjiri.iums.ac.ir/files/site1/user_files_e9487e/admin-A... · 2016. 2. 14. · 2) Improving urban life conditions: settling

Original Articlehttp://mjiri.iums.ac.ir Medical Journal of the Islamic Republic of Iran (MJIRI)

Iran University of Medical Sciences

____________________________________________________________________________________________________________________1. Assistant Professor of Community Medicine, Department of Social Determinants of Health, National Institute of Health Research, TehranUniversity of Medical Sciences, Tehran, Iran. [email protected]. (Corresponding author) Community Medicine Specialist, Department of Social Determinants of Health, National Institute of Health Re-search, Tehran University of Medical Sciences, Tehran, Iran. [email protected]

Achievements and future path of Tehran municipality in urbanhealth domain: An Iranian experience

Behzad Damari1, Sahand Riazi-Isfahani*2

Received: 13 July 2015 Accepted: 31 October 2015 Published: 8 February 2016

AbstractBackground: According to national laws and world experiences; provision, maintenance, and im-

proving citizens’ health are considered to be the essential functions of municipalities as a “socialinstitute”. In order to equitably promote health conditions at urban level, particularly in marginalareas, since 2004 targeted efforts have been implemented in the municipality of Tehran metropolis.This study was intended to identify and analyze these targeted measures and tries to analyze healthinterventions in a conceptual framework and propose a future path.

Methods: This is a qualitative study with content analysis approach. Reviewing documents andstructured interviews with national health policy making and planning experts and executive manag-ers of 22-region municipalities of Tehran metropolis were used to collect data. The data were ana-lyzed on the basis of conceptual framework prepared for urban health in 4 domains including munic-ipal interventions, goal achievements, drivers and obstacles of success, and the way forward.

Results: From the viewpoint of interviewees, these new health actions of Tehran municipality aremore based on public participation and the municipality was able to prioritize health issue in the pro-grams and policies of Tehran city council. Tehran municipality has accomplished three types of in-terventions to improve health, which in orders of magnitude are: facilitative, promotional, and man-datory interventions. Development and institutionalization of public participation is the greatestachievement in health-oriented actions; and expansion of environmental and physical health-orientedfacilities and promoting a healthy lifestyle are next in ranks.

Conclusion: Since management alterations seriously challenges institutionalization of actions andinnovations especially in the developing countries, it is suggested that mayors of metropolitan citieslike Tehran document and review municipal health measures as soon as possible and while eliminat-ing overlapping of interventions with other sectors, design and approve the charter of “health pro-moting municipality”. The most important role of municipalities in this charter would be coordinat-ing health improvement of citizens. This charter, when approved as a national policy could be usedfor other cities too.

Keywords: Tehran Municipality, Urban health, Tehran metropolis, future path.

Cite this article as: Damari B, Riazi-Isfahani S. Achievements and future path of Tehran municipality in urban health domain: An Iranianexperience. Med J Islam Repub Iran 2016 (8 February). Vol. 30:323.

IntroductionAccording to World Health Organization

(WHO), the enjoyment of the highest at-tainable standard of health is one of thefundamental rights of every human being(1). It is estimated that by 2030, more thansix out of ten individuals will live in cities(2). The urbanization rate is higher in low-

and middle-income countries (3) and as thecities grow, providing jobs, health care, wa-ter, transportation, and education will bechallenging. Urban settings is a health de-terminant and according to WHO urbanhealth is threatened by three factors: 1) In-fectious diseases exacerbated by poor liv-ing conditions, 2) Non-communicable dis-

Tehran municipality achievements in urban health

2 Med J Islam Repub Iran 2016 (8 February). Vol. 30:323.http://mjiri.iums.ac.ir

eases such as heart disease, cancers and di-abetes and conditions fuelled by tobaccouse, unhealthy diets, physical inactivity,and harmful use of alcohol, and 3) Acci-dents, injuries, road accidents, violence andcrime (4).

Because of diverse urban components in-cluding housing, water, sanitation, food,transportation, noise exposure, indoor andoutdoor pollutions, climate change, socialenvironment, and social and health ser-vices, urban health should be considered bypolicy makers and planners as a necessity.While warning all countries, WHO sug-gests at least five solutions to improve ur-ban environment: 1) Promoting urban plan-ning for healthy behaviors and safety: Ur-ban designing to increase peoples’ activity;safe, acceptable, and accessible food provi-sion; supplying public health care; and in-creasing streets’ safety. 2) Improving urbanlife conditions: settling residential places insecure regions, improving residency condi-tions, controlling indoor and outdoor pollu-tion, safe drinking water, and confidenceand improved sanitation. 3) Ensure partici-patory urban governance: sharing infor-mation of urban planning for health, inspir-ing (encouraging) public negotiations, par-ticipating people in decision makings,providing cooperation opportunities. 4)Build inclusive cities that are accessibleand age-friendly: accessible and facilitatedpublic transportation for the disabled; se-cure pavements for the individuals withspecial movement needs; constructing pub-lic places and buildings with easy access,and promoting active urban life and sportsfor all individuals. 5) Increasing resistanceof urban regions to disasters and emergen-cies: settling health care facilities in secureregions and making them resistible, rein-forcing community preparation and capaci-ty of accountability, improving disease care(4).

During the past three decades, Iran HealthSystem had great achievements such as im-proving maternal and child health popula-tion control, reducing vaccine-preventableinfectious diseases, and access to safe

(clean) water, thus improving health out-comes in rural areas equitably and efficient-ly in the light of developing and imple-menting the Primary Health Care (PHC)network (5).

However, increased urbanization and mi-gration from rural areas which led to popu-lation growth in urban and marginal areas(6) as well as epidemiological transitionand increasing burden of non-communicable diseases (7) has confrontedurban health management with great chal-lenges.

Although, the PHC network was devel-oped in the cities too, the accelerated paceof migration to urban areas surpassed thecapabilities of health care network in thecities and the passive and fragile PHC net-works in the cities became gradually weakto respond to the needs of population andthe success in rural areas was not repeated(8). Consequently the role of private sectorand non-governmental health services incities was dominated.

Main reasons for PHC network ineffi-ciency in the cities include: A) to ease pub-lic access, urban health centers should beestablished in designated and appropriateplaces. Proper financial and administrativeresources was required for finding real es-tate and constructing it or renting a suitableplace which was difficult because of hard-ships during the war, B) rural health carecenters were the only health care serviceproviders in rural areas, but in the cities theprivate sector had considerable power andpotentials. Due to lack of appropriate rulesfor cooperation between state and privatesectors, the health system was not benefitedfrom private sector that had a major contri-bution. Therefore, private sector acted as anopponent to the state health system (9,10).

Tehran metropolis with approximately730 square kilometers area and populationof more than 8.2 million is the largest cityand the capital of Iran, and it is the world's25th most populous city. Tehran suburbanmargins are expanded three times the citysize (11). Tehran Mayer is appointed by theCity Council and is responsible for provid-

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3Med J Islam Repub Iran 2016 (8 February). Vol. 30:323. http://mjiri.iums.ac.ir

ing urban services. In order to deal with theinequity, Tehran Municipality has attempt-ed to develop a health services network es-pecially in city margins during the past tenyears (12).

This article presents results of the studyaccomplished to identify and analyzeachievements of Tehran Municipality forcitizens’ health hoping that other countriescould benefit from these experiences.

MethodsThis is a qualitative study with content

analysis approach.Due to the lack of the original data col-

lected before implementing of the interven-tions in 2004, the qualitative method wasused in order to evaluate the municipalityactions. Reviewing documents, structuredinterviews with 22 executive managers ofregion municipalities of Tehran metropolisand 9 national level health policy makingand planning experts were used to obtain avalid and generalizable sample.

With a directed approach content analysis(13), the data was collected based on con-ceptual model in four main domains includ-ing municipal interventions, goal achieve-ments, drivers and obstacles of success, andthe way forward (Box 1).

We conducted an in-depth examination oftwo groups of documents: 1) Upper handdocuments including: the Iranian Constitu-tion (14), Municipalities forming law ofIran, laws for the third, fourth, and fifth de-velopment plan of the Islamic Republic ofIran (15), and citizenship rights from the

viewpoint of Iranian leaders; 2) All docu-ments and evidence related to health-oriented actions of Tehran Municipality.The analyzed results of the first groupshowed the main emphases of the upperhand documents on duties of municipalitiesfor health, and the second group revealedTehran municipality health-oriented facili-tative, promotional, and mandatory inter-ventions effecting proximal (behavioral)and distal (social and environmental) fac-tors.

Structured interviews were conductedwith two groups of individuals (as follows)to get their opinions on achievements, driv-er factors, obstacles of success, and the wayforward:

1) Executive managers of all 22 TehranMunicipality regions.

2) Selected experts with health-relatedplanning and policymaking experience atnational level, public health related educa-tions, and familiar with the Municipalhealth actions. They were selected fromboth advocates and critics of Municipalhealth actions. Tehran Municipality’s Gen-eral Department of Health had little role inchoosing these people, and the researchersselected the interviewees based on their ex-periences. Also in each interview thesnowball sampling method was applied inorder to find other informants. All the eli-gible experts were enrolled in the study.Altogether 9 experts were interviewed thatincludes a nearly equal distribution of ad-vocates (supporters) and critics.

We adhered to principles of interview in-

Box 1. Conceptual Model for Urban HealthFunctions(stewardship,resources, andservices)

Promoting urban healthy lifestyleProviding health-oriented environmental and physical facilities (direct and indirect)

Building support and leadership for improving major factors affecting citizens’ healthImplementing health-oriented urban policies, programs, and projects

Developing and institutionalizing public contributionsManaging information, research, and evaluating urban health

Goals

Distal factors Proximal factors Final effectsHealth influencing social

factors, controllable inurban limits

Reduction of risk factors, diseases,injuries, and death; and rise of protect-

ing factors (life style improvement)

Promoting Indices:Quality of life, happiness, ahealthy life expectancy, and

equity in healthHealth influencing socialfactors, impressive on

extra-urban levels



cluding written correspondence and send-ing questionnaires, interview guide, using afamiliar interviewer, and confidentiality.The interview questions are shown in Box2.

All interviews were recorded and tran-scribed. Following the conceptual model athematic analysis was conducted in order toidentify key issues and actions. Then allanswers were classified in 4 main areas andafter reviewing speeches in each area, do-mains were specified.

In order to organize “the way forward”,two matters were considered:

1) How should an achievement (whetheras a strength point oran improvement op-portunity) be stabilized and institutionalize?

2) How should strength points be general-ized?

Scientific rigor was confirmed accordingto Guba and Lincoln, using credibility, de-pendability, confirmability and transferabil-ity (16). Credibility was assessed by re-checking the results with each of the inter-viewees. Dependability, confirmability andtransferability was confirmed in a groupdiscussion session with all expert inter-

viewees and the research team.

ResultsHealth-oriented ActionsReviewing upper hand documents in Iran

shows that municipal health-oriented inter-ventions for citizens, environmental health,citizen rights, and citizen empowerment,are emphasized in existing laws; moreover,cooperation with the Ministry of Health forhealth care provision is posed in forth de-velopment plan of the Islamic Republic ofIran. Table 1 shows health-oriented actionsof Tehran Municipality classified as facili-tative, promotional, and mandatory inter-ventions influencing proximal and distalfactors.

AchievementsFrom the view of interviewees, Tehran

Municipal achievements were numerous,including encouraging public participationwhich is carried out through formation of10 societies and NGOs in different do-mains, setting up health houses (centers), atleast one for each urban region to supplydirect health care services, neighborhood

Box 2. Questions of the interview1. How and when did you get familiar with Municipal actions?2. From your point of view, what are the achievements of Tehran Municipality in health promotion? How many goals are

achieved?(at least three important achievements)3. What are the main and auxiliary factors influencing those achievements?4. What obstacles and reasons hindered more achievements?5. In your opinion, what can be expected from of the next Mayor on health-oriented actions? (What are other necessary or

complementary actions could the potential Mayer could do?)6. What are your suggestions for stabilizing and institutionalizing the Municipal achievements in citizen’s health promo-

tion? What about other cities?In your opinion, hass satisfaction of citizens with Municipal health-oriented affairs compared to the past periods become

more or less? Why?

Table 1. Health-oriented Actions of Tehran MunicipalityIntervention Effective on the proximal factor Effective on the distal factorsCompulsory Enactments of Tehran Islamic Council including the

decree “Tehran, No Tobacco City" The Decree “Municipal obligation to change the

pattern and reduce consumption of plastic bags,dishes, and disposable products”

Municipal strategic management (five-year plan ofTehran Municipality, decentralization, neighbor-

hood orientation)Financial management of Municipality and city

economic condition developmentUrban-planning and legality (developing structuralstrategic comprehensive plan of Tehran, preparingdetailed plan of Tehran urban regions, constructioncontrol and supervision, standardization of urban

planning guidelines)Implementing Urban Health Equity Assessment

and Response Tool (Urban HEART)

B. Damari, et al.


health councils, recruitment of Sala-matyaran (community health workers), ed-

ucating and empowering the communityabout prevention particularly by establish-

Table 1. CntdPromotionaland SupportBuilding

Providing health educationEducating high risk behavior prevention and empowering citizensRelief and first aid trainingLife skills trainingPreparing and distributing educational materialsImplementing special programsOrganizing health care tours (visit of Malaysian delegation, deputyof WHO General Director, advisor and representative of WHO inthe field of aging, Lebanese delegation, foreign guests participatedin International Conference on Crisis Management, social andcultural experts from Mashhad Municipality, some faculties ofTehran universities, Advisor to the Minister of Health and head ofthe health care supporting donors association).Organizing health exhibitions (“Iran Health”Exhibition, DigitalMedia Fair, Festival of best things for buds of our city, strategicmeeting on cultural and social development of cities in Iran,neighborhood management exhibition held in Milad Tower, “Sev-en Apples Fair”)Participating in the World Conference of Urbanization and HealthReinforcing family structureNo smoking city planHealth taxi plan

Cultural and Social ManagementSoftware Activities (expansion and development of reli-gious identity; production and dissemination of culturalproducts; promoting the culture of enjoining the lawful andforbidding the sinful acts; fostering prayer; promotion andconsolidation of jihad, sacrifice, and martyrdom; publiciz-ing the culture of reading)Improving scientific insight in urban administration andholding scientific conferencesPerforming various educational programs (rights and dutiesof citizenship, training headlines for the Department ofTransportation and Traffic, educating through media, train-ing headlines for Legal Departments of the Council, theParliament, and City Council, training headlines for tech-nical and developmental deputy, instructing topics for ur-ban-planning and architecture deputy, training headlines forthe deputy of urban services)Citizenship trainings and social participations

Facilitative

Formation and Development of Health social networksDistrict health councilTehran’s Salamatyaran networkHealth strategic council of TehranStrategic council of Tehran Municipality for the disabled22-district health care board of directorsHealth-oriented social institutes (elderly, physicians, mothers andchildren, mosques health servants, voluntary blood donators, thedisabled, the youth, diabetes prevention, tobacco prevention, andobesity prevention)Providing consulting servicesImplementing occasional programsHealth week, world day and national week of No Smoking, greatfestival of Shabanie, national day for blood donation, worldbreastfeeding week, the blessed month of Ramadan, national doc-tor’s day, world day and cultural week of the elderly, world dayand national week of vision, world day and national week of dia-betes, AIDs prevention week, International day of the disabled,Besij week, Nutrition training and improving food consumptionpattern, clean air week, and Men’s health week)Developing physical spacesEstablishing the community-based innovation centerConstruction and setting up health Pardisconstruction and management of neighborhood health houses /toyshouses/children social skills training houses(Faramouz)/obesityclubs/relaxation housesConstruction and setting up urban health management centerImplementing special programs:Neighborhood blood donationExpanding public sport (holding annual fair for citizen sport, de-veloping health stations, setting up and expanding family walkingprograms, biking, mountain climbing, and group running, settingup men and women sport competitions, and the elderly sport ser-vices)Prevention and control of social damages (shelters, mobile patrolunits in order to collect, settle, and refer working and street chil-dren, and runaway girls and women, high-risk addicts, beggers,the homeless, and down-and-outs (vagrants), counseling and socialwork services, implementing urban social worker plan, empower-ing socially vulnerable women)

Construction and maintenance of urban physical infra-structures and capacitiesconstruction and maintenance of highways and urban pas-sagesConstruction of bridges and Street Interchanges.construction and maintenance of tunnels and underpassesConstruction of urban parking, terminals, and park-and-ridesConstruction of surface water managing networkConstruction and inauguration of multipurpose Milad Tow-erManagement of public transportations and traffic im-provementsconstruction and maintenance of rail transportconstruction and maintenance of public transport bus ser-vicesManaging and improving taxi servicesManagement and development of combined systems and(Bus Rapid Transit) BRTs.Traffic monitoring, controlling and Management system.Urban management services and environmental issues:Waste managementconstruction and maintenance of urban green spacesDealing with environmental pollutionsGoods and services supplying systemsCivic beautification and visual improvement of urban sightsTehran disaster relief, and rescue managementComprehensive disaster management in TehranManaging and developing capacities and infrastructures forrelief, rescue, and firefightingRenovating and strengthening Urban decaySocial and cultural ManagementDeveloping religious spaces and infrastructuresDeveloping social and cultural spaces (a collection of ritualtheaters, audio studio of music museum, Neynava culturalfacility, the city’s professional theater center, turning Ghasrprison into a recreational center, BanooyeAftab cultural-recreational complex, Raga cinema complex, Mellat Park,Iran Faranama, Pardis-e-shargh cultural and recreationalcomplex, Tehran book garden, Bagh-e-Ferdous Cinema,Aban 13th Library



ing Faramouz (learner) centers to teach lifeskills to children and adolescents and pre-vent high risk behaviors, assessment andannouncement of health and equity condi-tions of residents throughout regions ofTehran city and identifying problems ofeach region in 2010 Urban HEART pro-jects (17,18), Intersectoral cooperation par-ticularly through Neighborhood HealthCouncils with participation of the repre-sentatives of the Ministry of Education, Po-lice Force (Disciplinary Force), and theNGOs. Neighborhood-oriented approachbrings about bordering neighborhoods andhighlighting local identity for individuals.Identifying neighborhood potential capaci-ties such as the benevolent and localizingservice provision in social health domainincreases the community’s social capital.Raising the subject of health impact as-sessments of municipal macro projects andacquaintance of municipal with this con-cept is another level of prosperity. Greenspace development, promoting publicsports, improvement of urban sidewalks,and development of public transport led toincrease physical activities of citizens.

Changing municipality as a merely ser-vice providing organization into a socialand dynamic entity, and entering urban so-cial health issues and accepting health as apriority by municipal and other organiza-tions involved in health of urban societyauthorities are other important results ofefforts in this period.

Expanding coverage of health-orientedservices to target groups such as mothers,children, disabled, and elderly and payingattention to physical and mental health ofpeople in the society are among otherachievements.

Intra-organizational contribution with So-cial Deputy of the Municipality and devis-ing managerial structure of Urban Health isresulted from municipal health-orientedactions. The interviewees emphasized onthe necessity of making a precise and quan-titative evaluation of each achievement.

Different answers were given to the ques-tion: “In your opinion, how is satisfaction

of citizens with Municipal health-orientedaffairs compared to the past periods?Why?” Five experts believed that fieldstudies are required to determine theamount of citizens’ satisfaction changes; afew believed that it would be recognizedover time. Two of 9 interviewees thoughtthat satisfaction has raised and most execu-tive managers assumed that public satisfac-tion is increased with the municipal healthinterventions; others believe that satisfac-tion rate and cooperation were reduced af-ter the implementation of NeighborhoodManagement Plan (receiving tariffs) as im-plementing some unsystematic and merelypropaganda programs are also caused thedecline of satisfaction. From the viewpointof executive managers of Tehran municipalregions, vastness of provided services andculture building activities at Health Cen-ters, community empowerment and increas-ing their demands, high public participa-tion, people’s feedback through 1888 hot-line and other communication ways, de-signing programs according to people’sneeds and demands, support and contribu-tion of neighborhood trustees and participa-tion of secretaries for neighborhood coun-cils in monthly and annual sessions inhealth domain of municipal regions, anddecrease in destruction of public propertydue to increased public awareness and peo-ple trust are signs for their improved satis-faction.

DriversDriver factors in previously mentioned

achievements from the interviewees’ viewsconsist of participatory and health-orientedapproach of municipal authorities, presenceof the experts in policy making and imple-mentation (municipal health steering coun-cil), using existed capacities of citizens inevery locality as physicians or specialistsand drawing their contribution and partici-pation, cooperative approach rather thanindividualism, involvement and participa-tion of urban council with comprehensivecomposition and diversity of expertise andalso Neighborhoods’ Shorayariha (Coun-

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cils), increasing available financial re-sources and infrastructures, simplificationand offering a new definition of health (so-cial determinants of health approach) fo-cusing on “health for all” through “all forhealth”, legislating new laws (%3 of totalmunicipal revenues should be spent onhealth costs and %10 on social expenditureand poverty reduction), presence of Teh-ran’s Strategic Document prior to for-mation of General Department of Healthand Annual planning, support of WHO,subject-oriented programs (Commemoratethe occasions), trust of organizations suchas Welfare Organization and also staff con-tribution. Embracing new ideas, recruitinga great number of educated staff in Tehranmunicipality, a proper and specific defini-tion of “urban health” and its constituentelements, trying to make a socially ratherthan medically healthy citizen, identifyingurban dangers affecting social and mentalhealth of citizens, planning according toneeds of citizens, and free service to citi-zens, are the other components contributingto success.

ObstaclesAccording to respondents, obstacles and

impediments that hindered the achieve-ments, can be summarized into five catego-ries: 1) poor inter-sectoral and intra-sectoral collaborations: A lasting under-standing and consensus was not formed be-tween the municipality and other govern-ment departments particularly the Ministryof Health in order to deliver integratedhealth services in the city; the policies andpriorities of Family Physician national planwhich was initiated in mid-2005, had a sig-nificant effect in this conflict; absence of amemorandum of cooperation between gov-ernmental, non-governmental, and privateorganizations in Tehran and the Munici-pality is another obstacle; the lack ofteamwork within the municipality that hasled to collateral activities by municipal de-partments is another affecting factor;meanwhile, we should point to the non-health-oriented budgeting of the Municipal-

ity, and maybe the main reason for this islack of clear guidelines and regulations forintra-sectoral coordination or clarify health-oriented duties for each municipal units (of-fices). 2) The different attitudes of munici-pal managers to the health issue: Tehranregional mayors are not convinced equallyabout the health issue, the centralized verti-cal management instead of a horizontalmanagement and lack of existing an ‘urbanunited management’ is a result of manag-ers’ perspectives. The policy making is atop-down process and planning is not car-ried out based on the feedbacks from citi-zens and the scientific need assessment. Inother words, municipal health-oriented in-terventions are sometimes merely based onpersonal preferences. Unfamiliarity of othermanagers with objectives and missions ofthe newly-established social deputy andunderestimating social domain and its goalsis another reason; without a defined rule,statute, and guideline for the Department ofHealth approved by the City Council itsactivities is not enforced. 3) Poor planning,resource provision and evaluation system:health dimensions and multiplicity health-related programs, in some cases have led todeviation from the original programs andpurposes. There is no long-term systematicprograming, thus planning is mainly fo-cused on one-year programs. Same plan-ning for all regions without considering so-cial and economic circumstances of each,and the differences in regional indicesmakes it difficult to implement the pro-grams; budget shortage and low proportionof the allocated budget considering the ex-tent of services, unsuitable physical spaceof Health Houses and absence of adequatefacilities and equipment in Health Houseswhich is inappropriate to the physical andpsychological conditions of target popula-tion (the elderly and disabled) are other ob-stacles.Poor attention to human workforcesin health houses and lack of reimburse-ment, bonuses, insurance, and job securityfor them and inattention to their motiva-tions are some other challenges in munici-pal health-oriented programs. The lack of



attention to effectiveness of plans and theheld courses; paying attention to the quanti-ty of programs rather than the quality ofperformed activities and failure to intro-duce scientific indices for evaluatinghealth-oriented programs are also amongproblems and obstacles. 4) Operationalproblems: difficulty in coordinating HealthHouses in different neighborhoods; lack ofconsistent social marketing about health-oriented actions and achievements to in-crease public awareness and participation;self-governing of Health Houses in neigh-borhoods without proper preparationswhich has led to receiving tariffs for con-sulting and training services in HealthHouses. The administrative bureaucracy, asa result of region-oriented, district- orientedand locality-oriented managements, is an-other operational barrier. Refusing to trans-fer new ideas and health-oriented achieve-ments from one region to the others pre-vents the spread of achievements. Emer-gency implementation of some non-scientific policies and programspreventsdevelopment of original programs and du-ties. Numerous ongoing projects and theirconcurrencies, restraining rules and con-straints in the implementation of programsby regional health managers will cause adelay in the implementation of programs ornot implementing them at all. 5) Problemsregarding working with the people: Theunilateral expectations of people from theMunicipality for service delivery as theyonly prefer receiving services and not real-izing the importance of contributing andparticipation, and inequalities in the levelsof literacy and culture in different regionscaused some regions to achieve municipalhealth–oriented goals with delay. Lowpower of local councils and shortage of thequalified local managers familiar to admin-istrative affairs; unclear duties and jurisdic-tions of the local directors leading to aneconomical-look to health issue; the effectof other municipal sectors on public confi-dence and contribution should not be un-derestimated and must be considered as achallenge.

The way forwardThe way forward for Tehran Municipality

in health domain from the viewpoint of re-spondents are as follows: 1) efficient anduseful actions of the Municipality in thehealth domain should be institutionalized:application of urban health equity assess-ment and response tool (Urban HEART) inTehran; organizing health tours for Parlia-ment Members and then ratifying bills forchild and elderly’s friendly city, transform-ing Tehran to a No Smoking City, strength-ening Tehran Islamic Council HealthCommission; supporting the spreading ofachievements to other cities through theAssembly of Metropolitans of Iran, for-mation of urban health committee in met-ropolitans; revision, approval, and en-forcement of Tehran Municipality structureaccording to the diversity of activities;training and empowering municipal staff;putting health-oriented actions in urbanprograms; division of work and signingagreements with the Ministry of Healthwith support of Ministry of Interior, Par-liament and legislation structures in orderto ensure institutionalization and durabilityof programs. Documenting experiences,organizing health exhibitions and expand-ing health-oriented social marketing pro-grams in a way that health would changedinto a well-known 'brand' to citizens, areamong proposed measures for institutional-ization. 2) Generalizing experiences ofTehran Municipality to other cities: therewere different ideas in this regard whichwere mostly posed by executive regions’mangers including: the pattern implement-ed in Tehran can carried out in other citiesas a country model. This is possible regard-ing the maturity (completion) of the im-plemented plan in Tehran and eliminatingits weaknesses; health be considered as anintegral (inseparable) part of the Municipal-ities, and related laws and legislations be-come a binding law by the Supreme IslamicCouncil of Provinces and be promulgatedto other cities; the pattern should beadapted for other cities on the basis of as-sessment and be specially tailored accord-

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ing to requirements and circumstances ofeach city; introduction of health-orientedactions of Tehran Municipality through: 1)holding health exhibitions in other cities tobe visited by their authorities and holdingeducational workshops, 2) piloting HealthDepartment plans (e.g. Health Houses) inother cities; the task of empowering otherprovinces can be assigned to senior manag-ers of provinces and cities or each healthmanager of Tehran regions be delegated asa health ambassador to another city andshare the experiences with other urbanmanagers. 3) Continuity of Support of thenext Mayor and his colleagues: That willappear in promoting interactions with otherstate sectors particularly the Ministry ofHealth and agreement for joint actions suchas designing long-term plans and creating asingle annual program, intra-organizationalcoordination and synergy for health-oriented actions including formation ofhealth organization, development of com-munity-level action, institutionalizing ofneighborhood-oriented programs, increas-ing jurisdictions of the regional healthmanagers, operating in legal frameworkand accepting stewardship of the Ministryof Health in health-oriented actions andmaking interventions merely as selling ser-vices to the stewards e.g. public education,initiating and implementing of programs ina measurable and agreed order, accepting acertain volume of responsibility and remov-ing duty of the other organizations, collect-ing and monitoring indices and setting up acomprehensive system of health infor-mation, institutionalizing Tehran healthmap, presenting an administrative plan tofulfill “integrative and coordinated man-agement of urban services”, strengtheningand inspiring scientific-based potential ofregional municipals, putting urban healthconcept prior to security and environmentaldomain, dealing with social, economic, andcultural factors, and using NGOs and mediacapacity. During the following periods, it isnecessary to pay special attention to work-forces employed in Health Houses regard-ing job security, wages, bonuses, and insur-

ance systems, attendance of district mayorsin locality council sessions, creating organ-izational position of “Health Manager” inthe Municipality chart, reducing manage-ment changes, receiving and regulating newideas and more serious attention to envi-ronmental health.

DiscussionThis study revealed that Tehran Munici-

pality has obtained numerous achievementsin health domain. According to conceptualframework of urban health result chain,these achievements mostly have focused onenvironmental changes as encouraging (in-centive) facilities to change health behavior(proximal factors). Comparing health-oriented actions of Tehran Municipalitywith five strategies recommended by WHOshows that the Tehran Municipality hastried to improve urban planning for soundand safe behaviors; urban designing to in-crease people’s physical activity, setting upfairs in order to promote safe and healthyfoods, establishing Health Houses, socialhealth-oriented messages through environ-mental advertisements, resolutions for fi-nancing health programs in the City Coun-cil, application of Urban HEART in Teh-ran, traffic engineering and improvingstreet security. The municipality has triedto advance urban collaborative governanceas one of the most pivotal recommenda-tions; creating neighborhood council in dif-ferent specialized workgroups, ten healthcenters, neighborhood meeting places (Pa-togh) and public announcement of UrbanHEART study results are evidences thatshows managers’ decision to share infor-mation on urban planning with people, en-couraging public participations, gettingthem involved in decision making and pre-paring opportunities to collaborate.

Development of urban green spaces,providing sports facilities in parks andspaces of collective games, safe playingareas for children, facilitating the elderlyand the disabled movements and expanding(developing) sidewalks are objective exam-ples of establishing the strategy of elderly



and child friendly cities. Reinforcing com-munity preparation and accountability po-tential are actions to raise resistance of ur-ban regions to disasters and emergencies.

In the conceptual model used in the study,six main functions of municipalities in citi-zens’ health were as follows:

1. Promoting urban healthy lifestyle2. Providing health-oriented environmen-

tal and physical facilities (direct and indi-rect)

3. Building support and leadership forimproving major factors affecting citizens’health

4. Implementing health-oriented urbanpolicies, programs, and projects

5. Developing and institutionalizing pub-lic contributions

6. Managing information, research, andevaluating urban health.

The most important achievement of Teh-ran Municipality during the past decade isto have a more social look to the municipalsystem of service; but it has to be noted thatpeople’s participation is one of the twoarms of health equity improvement and in-tra-sectoral cooperation is the other armwhich has to be improved. In another word,public participation arm is more powerfulthan intra-sectoral cooperation and TehranMunicipality is far from achieving inter-sectoral collaboration and playing a coordi-nating role. However, it should be empha-sized that since people are able to have aneffect in all community domains by acquir-ing experience and knowledge, in scientificliterature people’s contribution is consid-ered as an end not a means. Municipalityhas developed a pattern for promoting pub-lic participation in all three steps of the par-ticipation ladder. The disseminating healthinformation to people (as the first step), re-ceiving neighborhood consultations andcooperation in order to solve the problems(as the second step), and creating surveil-lance systems by city council and shoraya-riha(as the third step) are some examples.Developing health-oriented environmentaland physical facilities and promotinghealthy life style are respectively next in

ranks in Tehran Municipality achieve-ments. According to the views of expertsand executive managers of this study com-pared to previous years, the health actionsof Tehran Municipality are now more fun-damental and are based on people’s realcontributions, and despite huge political,economical, social, and international trans-formations during past eight years, the Mu-nicipality has been able to draw satisfac-tions of citizens to a great extent. But thisclaim needs to be examined and studiedmore and it is therefore suggested that thefuture urban managers initially adopt spe-cific measures for citizens’ satisfaction andevaluate them at the beginning and at theend of their management period.

As suggested by WHO, most municipalhealth-oriented actions should focus on en-suring the existence and adequacy of facili-tative, promotional, and compulsory inter-ventions affecting healthy behaviors andproviding an encouraging and protectiveenvironment for citizens’ health improve-ment and does not have a clear recommen-dation for delivering health care services.So, some of Tehran Municipal programssuch as examining and population screen-ing and patients’ treatment required to bereviewed and overlapping programs shouldbe discarded. Continuing those programswill certainly lead to a waste of resources.

Also, according to the respondents, inter-sectoral coordination is weak and incentivetechniques such as ranking and consultingare recommended for health-orienting othermunicipal sectors as principal duties ofgeneral department of health in TehranMunicipality.

Implementing health impact assessmentin large-scale municipal projects and as-sessing compliance with health standards inthese programs and projects are furthersteps in the completion of municipal health-oriented actions.

Despite the approval of legal guaranteesfor the allocation of municipal revenues onpublic health improvement, does the viewsof respondents regarding budget deficitshould be considered as an obstacle? It

B. Damari, et al.


looks like that the main problem is weakprioritization of resources and then if notenough, more attempts should be made toattract further resources.

Evaluation is recommended as a tool toall planners. Spending a part of the budgetof each program on periodic evaluationmay help the managers to identify effec-tiveness of spent resources. In this context,evaluating the establishment of healthhouses is suggested.

In this study, views of experts and execu-tive managers were examined and it is nec-essary to measure all mentioned issuesthrough quantitative research. The rate ofchanges in the level of people’s satisfactionwith municipal health-oriented affairs,changing behavior and life style of peopleliving in Tehran, quantitative process ofvarious health-oriented facilities in Tehran,changes in the rate of diseases, mortalityand morbidity of citizens in different re-gions are some examples.

Management changes almost always chal-lenges institutionalization of former inno-vations and actions, particularly in develop-ing countries. Thus, in order to draw politi-cal support and commitment, the im-portance of explaining the health-orientedactions to the next mayor and his team iscrucial. Also it is recommended thatmayors of megacities like Tehran documentand review their actions with the assistanceof national experts as soon as possible, aim-ing the stability and durability of theirhealth-oriented experiences, and while re-moving overlaps with other sectors expressand approve “Health promoting Munici-pality” workbook. The key role of munici-palities in this workbook would be coordi-nating citizens’ health promotion in metro-politans, which could be establishedthrough health management of urban re-gions and coordination with national healthcare system. This workbook when changedinto a national policy can be applied forother cities as well.

The factors that hindered furtherachievements are rooted in the cultural con-text, as lack of a teamwork spirit, "Plural-

istic" attitude, and a "systemic" thinking.These hindering factors may be different inother societies.

LimitationsThis study has the inherent limitations of

the qualitative method.. Research quality isheavily dependent on the researchers’ skillsand could be influenced by the researchers’own mental background. Moreover the un-avoidable presence of the researcher in theinterviews might affect the subjects' re-sponses (19).

AcknowledgmentsHereby, we would like to appreciate all

who helped with this study. This study wascommissioned by General Department ofHealth with financial contribution of SocialDeputy of Tehran Municipality.

Conflict of interestResearchers state that although the project

was ordered (commissioned) by TehranMunicipality, but in the process of collect-ing and analyzing the data and making re-ports, they have tried to stay away from anypossible bias and have no conflict of inter-ests.

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