Chamberlin to benefit local dwellers was critical to the introduction of infrastructure and universal services (Michael Marmot, personal communication), while at roughly the same time the medial sanitarian Max von Pettenkoffer was making a ‘return on investment’ argument in favour of sewers to the burghers of Munich.. It is clear that change and the improvement of population health did not come easily and involved many players. It also took considerably more time than the usual five-year project-cycles as defined by many donor agencies (Barten, 2007). Finally, while local government politics played a key role, national politics and central government provided leadership and support (Szreter 2005).
Governance, power and health equity
First, although many authors describe governance arrangements, the concept is not always referred to or explained. The review confirmed significant variation in meaning as well as in the practice of urban governance arrangements. Governance processes are embedded in context, and this has implications for analysis, but common characteristics (as well as challenges) also exist. It is important to differentiate between top-down and bottom-up governance innovations. Also, scale is a particularly important variable since there are some metropolitan regions that develop across country boundaries; and so is level, since supra-local factors and decisions taken by distant and powerful actors have a profound impact on health inequity within as well as between cities. Decentralization in practice often implied deconcentration, while the rules of the game are still defined at central level or influenced by global actors.
Second, governance is a dynamic process and it is important to acknowledge the fact that governance has been changing significantly over the past two decades (see Annex – Box 5). Many scholars worldwide, and particularly in the UK and the US, have started to examine the driving forces and the implications of this shift from government into governance, one in which government has now become one actor in the policy and decision making processes (Judge et al, 1995; Kooiman, 2003; Healey, 2006; Raco, 2009; Pierre, 2009). It is striking that few evaluations of Healthy Cities have analysed the implications of this important shift in governance for the conduct of policy, healthy urban planning and health equity (Barten et al, forthcoming).