A Healthy City Project: A Case Study of Wonju City, South Korea and its Relevance to the Cities in Nepal

Abstract

p class="Pa9"> Introduction : One of the goals of sustainable development is to make cities inclusive, safe, resilient and sustainable. The healthy city approach is becoming increasingly important in addressing a large number of urban health problems and promoting healthy lifestyles in city dwellers.
Objectives: We performed a case study of the healthy city project in Wonju, South Korea to find out its characteristics and approaches, and to explore its relevance to the cities in Nepal.
Methods : We conducted a case study of the healthy city Wonju project by reviewing relevant published articles and web pages of the city (http://healthycity.wonju.go.kr), alliance for healthy cities, Korean statistical information service and World Health Organization. We also reviewed articles and documents related to healthy cities in South-East Asian countries and Nepal.
Results : The healthy city Wonju project, started in 2004, executed its five-year plan between 2006 and 2010, and is currently running with its 10 year long-term plan (2011- 2020). For its success, Wonju City has been awarded six times by WHO. Recently, Wonju city organized the seventh global conference of the AFHC in August, 2016 in Wonju with the main theme of “our cities, our health, our future”. Key features of the healthy city Wonju project included: Strong political commitment of local government, financing the healthy city initiative with tobacco consumption tax, partnerships with universities, well organized healthy city teams under city administration, coordination with national and regional healthy cities alliance, community participation, and involvement in research for evidence-based planning and evaluation. Nepal, one of the fast urbanizing countries in South-East Asia faces large number of urban health problems.
Conclusions : Though numbers of cities and city dwellers are increasing rapidly, Nepal lacks healthy city projects and networking. The approaches of healthy city Wonju might be useful for developing countries such as Nepal to initiate and develop healthy cities projects in a sustainable way.
Journal of Gandaki Medical College

Vol. 10, No. 1, 2017, page: 34-42</p

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J-GMC-N | Volume 10 | Issue 01 | January-June 2017page 34
Original Article | Journal of Gandaki Medical College-Nepal
A Healthy City Project: A Case Study of Wonju
City, South Korea and its
Relevance to the Cities in Nepal
Sharma B1,2, Nam EW1,2*
1Healthy City Research Center, Yonsei University, Wonju, South Korea,
2Department of Health Administration, Graduate School, Yonsei University, Wonju, South Korea
ABSTRACT
Introduction: One of the goals of sustainable development is to
make cities inclusive, safe, resilient and sustainable. The healthy city
approach is becoming increasingly important in addressing a large
number of urban health problems and promoting healthy lifestyles in
city dwellers.
Objectives: We performed a case study of the healthy city project in

to explore its relevance to the cities in Nepal.
Methods: We conducted a case study of the healthy city Wonju project
by reviewing relevant published articles and web pages of the city
(http://healthycity.wonju.go.kr), alliance for healthy cities, Korean
statistical information service and World Health Organization. We also
reviewed articles and documents related to healthy cities in South-East
Asian countries and Nepal.
Results: The healthy city Wonju project, started in 2004, executed its
  
its 10 year long-term plan (2011- 2020). For its success, Wonju City has
been awarded six times by WHO. Recently, Wonju city organized the
seventh global conference of the AFHC in August, 2016 in Wonju with
the main theme of “our cities, our health, our future”. Key features of
the healthy city Wonju project included: Strong political commitment
   
consumption tax, partnerships with universities, well organized healthy
city teams under city administration, coordination with national
and regional healthy cities alliance, community participation, and
involvement in research for evidence-based planning and evaluation.
Nepal, one of the fast urbanizing countries in South-East Asia faces
large number of urban health problems.
Conclusions: Though numbers of cities and city dwellers are
increasing rapidly, Nepal lacks healthy city projects and networking.
The approaches of healthy city Wonju might be useful for developing
countries such as Nepal to initiate and develop healthy cities projects
in a sustainable way.
Keywords
Case study, Developing countries,
Healthy City, Nepal, Wonju.
Corresponding author
Eun Woo Nam
Yonseidae-gil, Wonju-City, Gangwon-Do,
26493, Republic of Korea
E-mail: ewnam@yonsei.ac.kr
Ms Bimala Sharma
E-mail: bimalasharma@gmail.com

J-GMC-N | Volume 10 | Issue 01 | January-June 2017 page 35
| Original Article
INTRODUCTION
Concept of healthy city
  
city as one that is continually creating and improving
physical and social environments, and expanding
community resources that enable people to mutually
support each other in performing all the functions of life
and to reach their maximum potential1. Currently, more
than 50% of the world’s population lives in urban areas,
and it is estimated that 70% of the world’s population
will be living in towns and cities by 2050; Africa and
Asia are urbanizing faster than the other regions2,3. The
healthy city approach is becoming increasingly important
in addressing a large number of urban health problems
arising due to urbanization and globalization in both
developed as well as developing countries. “Make cities
inclusive, safe, resilient and sustainable” is one of the goals
of sustainable development (SDGs)4
that cities have been prioritized on the global development
agenda. Municipal and local Governments have the ability
to act on urban health issues in a responsive manner to
5.
Health challenges particularly obvious in cities relate
to water, environment, violence and injury, non-
communicable diseases (NCDs), unhealthy diets, physical
inactivity, harmful use of alcohol, and outbreak of diseases.
Participation in physical activity is obstructed by a variety
of urban factors including overcrowding, high-volume of
       
quality, and lack of safe public spaces and sports facilities2.
On the other hand, acting on urban health inequities
requires the involvement of organized communities and
all levels of Government; local, and national6.
Healthy cities program is a long-term international
development initiative that aims to place health on the
agendas of decision makers and to promote comprehensive
local strategies for health protection and sustainable
development through community participation,
empowerment, intersectoral partnership, and equity.
       
launched in developed countries; developing countries
also started to implement around 1994. A healthy city
aims to create a health-supportive environment, to
achieve a good quality of life, to provide basic sanitation
and hygiene needs, and to supply access to health care7.
The healthy city Wonju project
In Korea, the healthy cities project was started in
Kwachon in 19988. Since then, Korea has developed a
unique program for healthy cities; it has developed a
healthy city act, a health impact assessment program,
an award system, and domestic networking system. A
bottom-up approach for the development of healthy city
policies and plans is promoted9. The healthy city Wonju
project started in 2004 joined the alliance for healthy
cities (AFHC) as a founding member in the same year,
and announced the healthy city Wonju declaration in
200510-12. In 2006, the project succeeded in launching its
  
City joined the Korea Healthy Cities Partnership (KHCP)
as a founding member in 2006. The indicators and home
page with database have been developed to monitor and
evaluate the program implementation since 2006. A 10
year long-term plan, vision 2020 (2011- 2020) is currently
being implemented, and will run until 202011,12. Recently,
Wonju City organized the seventh global conference of the
AFHC, running from 29th August to 1st September 2016,
in Wonju. About 550 participants attended the conference
from more than 50 cities over 15 countries and two
administrative regions. The main theme of the conference
was our cities, our health, our future13 .
Rationale of healthy city projects in developing
countries
While the current sustainable cities debate focuses on
the problems for the world's largest urban settlements,
the majority of all urban dwellers continue to reside in
far smaller urban settlements14. If rapid urbanization
focuses only on short-term economic development
rather than sustainability, the situation is likely to lead
down development paths that exacerbate global climate
change, with a wide range of negative implications for
global health and health equity. The decisions taken by
cities in developing countries should support a preventive
environmental health agenda and a goal of promoting
health and well-being15. There is a considerable need
of interventions such as the healthy cities project in
developing countries16.
In the South-East Asia Region, the healthy cities Initiative
was launched in 1994 with some cities of Bangladesh
(Chittagong, Cox’s Bazar, Rajshahi), Thailand (Bangkok),
Sri Lanka (Badula), Nepal (Kathmandu), India (New
Sharma B, et al. A Healthy City Project...

J-GMC-N | Volume 10 | Issue 01 | January-June 2017page 36
Original Article | Journal of Gandaki Medical College-Nepal
Delhi); a comprehensive review of the program was
carried out in 1998, and a healthy cities framework for
action was developed for the region in 199917,18. Review
studies show that the slow progress in developing
healthy cities was due to unclear concepts among local
authorities, lack of coordinated urban infrastructure
and lack of community participation, preventive services
being a low Government priority, and poor empowerment
of local Government17,19.
Nepal is a developing country situated in South-East Asia
with a human development index of 0.548, and a life
expectancy of 69.6 years20. Nepal has a total population
of 28 million, with an average annual population growth
rate of 1.35%. Estimated per capita GDP is 762$, with a
GDP growth rate of 3.04 for the year of 2014/201521,22.
Nepal currently has 217 municipalities and 3157
village development committees. An increasing number
of municipalities indicates the rapid urbanization in
Nepal; there were 58 municipalities until 2014, 133 new
municipalities were established in 2014, and 26 were
added in 2015. About 30% of the total population has
been living in municipalities21,47.
The objective of the current study is to review initiation,
implementation, approaches, and achievements of the
healthy city Wonju project as a case; and discuss the
relevance of healthy city projects in cities in Nepal.
METHODS
Primarily, the study is a review-based case study of the
healthy city project executed in Wonju city, Gangwon
Province, Korea. We extensively reviewed the literature
and web pages relating to the healthy city Wonju project.
Most of the information we obtained from relevant
published articles and homepage of healthy city Wonju,
and the proceedings of the seventh global conference of
the AFHC. We also searched online website for appropriate
information from Korean Statistical Information Service
(KOSIS), AFHC, and WHO publication. In addition, we
reviewed published articles and documents related
to healthy city projects in developing countries. For
additional relevant information, we searched the website
of the Central Bureau of Statistics (CBS) of Nepal, project
report of Asian Development Bank (ADB) and National
Nepalese News papers.
RESULTS
Wonju city profile
Korea is located on the East Asia, Southern Korean
peninsula. The total population of Korea is 51,649,552 as
of August 2016, with an annual fertility rate of 1.24, and
a life expectancy of 82 years23,24. Wonju City, located in
central Korea, in the South West of the Gangwon province
is approximately 140 kilometers East of Seoul, and has a
total area of 867.76 per square km25. It is the biggest city
in Gangwon-do; it has a total population of 330,134, with
164,246 males, and 165,888 females, and has a fertility
rate of 0.8% (Table 1)26.
Table 1: 
Indicators Magnitude
Size 867.76 km2
Total population 330,134
Males 164, 246
Females 165,888
Population over 65 years 39862
Population growth rate 0.8%
Population density 380.4 persons/km2
Total area 867.97 km2
The healthy city Wonju: History of development
Korea has national guidelines, local Government acts
and the Korea healthy city partnership (KHCP) for the
implementation of healthy city projects. The Korean
health promotion healthy city act plays a key role in
healthy city project implementation9,27.
The healthy city Wonju project was initiated in 2004
by establishing a healthy city team and a healthy city
advisory committee. It joined the AFHC as a founding
member in the same year. The AFHC is an international
network aiming at protecting and enhancing the health of
city dwellers. The Alliance is a group of cities and other
organizations that try to achieve the goal through an
approach called “Healthy cities” in the close collaboration
with the WHO10. In 2005, Wonju city announced the
‘healthy city Wonju declaration’ to give municipal
commitment to make each citizen lead healthy and active
life through healthy city Wonju. As founding member, it
joined KHCP, national network of Korean healthy cities in
 
with the main objective of setting out systematic policies

J-GMC-N | Volume 10 | Issue 01 | January-June 2017 page 37
| Original Article
for healthy city projects through the effective investment
of tobacco consumption tax. The plan generally
      
and rehabilitation, and setting healthy industry,
infrastructure and environment11,12
healthy city was evaluated through a community survey
and key informants’ interviews. Both processes as well
as output indicators were used. The SPRIT checklist
was used for the process evaluation28. Vision 2020, a
10-year plan (2011 - 2020), includes two approaches:
An individual approach and a socio-environmental
approach. The individual approach includes life style

The socio-environmental approach comprises: Setting,
infrastructure, environment, and health industries.
Here, settings include healthy schools, healthy work
places, healthy hospitals, healthy communities, healthy
markets and food safety, and healthy farming villages.
Infrastructure includes transportation, culture and
welfare, and safety and social marketing. Environmental
planning and environmental education are included
under environment. Advanced health technology, smart
healthy city, and health tourism are included in health
industries11,12. These priorities were decided after
collecting and analyzing the responses from healthy city
   29. The chronological
development events are shown in Table 2.
Table 2: Historical development of healthy city Wonju
Contents Year
Starting of healthy city Wonju project 2004
Joining the AFHC 2004
Announcement of “Declaration of healthy
city Wonju”
2005
Joining KHCP 2006
Enactment of healthy city advisory
committee
2005

2010)
2006
Development of 10-year plan, “Vision 2020” 2010
Organization of “the seventh global
conference of the AFHC”
2016
Examples of healthy city projects of Wonju city
Several setting oriented healthy city projects were
conducted by citizens between 2011 and 2016; 25 were
supported by the city. Most of the activities were focused
on health promotion, such as establishing physical
activity clubs, gardening, and food education12. Table 3
shows some examples of healthy city projects of Wonju
city.
Table 3: Healthy city projects of Wonju city
Name of the projects Interventions
1.
Sport and medicine
center: Evidence-
based
Physical checkup, exercise
prescription, health education
2.
Environment-
friendly streamside
park

dam, and providing various
themed spaces
3.
Culture street project Cultural space for citizens and
pedestrians with amenities:
Installation of fountains, land
purchased for performance
spaces, and building purchased
for exhibitions
4.
Climate change
response education
and research center
Education and research center
Renewable energy exhibition
facility
5.
Walkable city Safe road for both drivers and

with three lanes, underground
distribution line and pedestrian
path extension
Monitoring and evaluation
The Project has developed its own indicators, database,
and monitoring system. The database includes
information regarding demographic, health status,
life style, physical and social infrastructure, and socio-
economic status11. The database was developed in 2006
and updated in 2009. The evaluation of web database
quality was performed; some indicators were added and
some were deleted from web database for the better
 
study30. A comparative study of healthy cities, Liverpool
         
      
used quantitative analysis with some qualitative analysis
for the evaluation and vice versa in Liverpool28.
Awards for good practice
The WHO and the AFHC recognize and award outstanding
        
Sharma B, et al. A Healthy City Project...

J-GMC-N | Volume 10 | Issue 01 | January-June 2017page 38
Original Article | Journal of Gandaki Medical College-Nepal
       
promoting and protecting the health of urban populations.
Based on the good practice, Wonju city has been awarded
for the following works (Table 4)10,12.
Table 4: Awards for good practice
Year Awards Organizations
2008 Good practice award :
Comprehensive no-smoking
program
WHO
2008 Best proposal award : Climate
change and response
WHO
2010 Good practice award: Physical
activities
WHO
2010 Creative development award:
Evaluation of Healthy City
AFHC
2008 Good Dynamic Award AFHC
2012 Good Practice Award: Safe city WHO
2014 Good Practice Award: Woman
friendly city
WHO
2016 Good Practice Award: Out of
school youth
WHO
Investing tobacco tax for healthy city
        
to fund the healthy city project through collection of the
local tobacco consumption tax. For effective collection
and allocation of the tobacco consumption tax, strong
leadership from local authorities, particularly from the
Mayor, was found to be the most important element
in securing tobacco consumption tax revenues to fund
the healthy cities Initiative9,31. The healthy city Wonju
       
local tobacco consumption tax, which has legal approval
from the city council9. At present (2015), 34% of the total
budget for the healthy city Wonju project comes from
tobacco consumption tax, whereas it was 59% in 2010.
Its discrepancy is due to the total budget for the project
being doubled by city administration in 201512.
Strong political commitment
In Korea, healthy city projects have been voluntarily
initiated by local Governments. Support from the central
Government and funding from the health promotion fund
is supposed to boost the projects. One study conducted
         
stated three main challenges that the head of the city
should commit to healthy city projects to succeed:
investing more funds and human resources in projects,
local government should provide administrative support
to implement multi-sectoral collaborative projects, and
central Government should encourage and support local
Government’s healthy city projects. The healthy city
Wonju project is under the stewardship of Wonju city
hall12,32.
Collaboration with Universities
Since 2004, the project has been working in collaboration
with the Yonsei healthy city research center for evidence
based planning and execution12. The healthy city Wonju
      
national and international journals collaborating with
the healthy city research center. It helps the project in
Wonju, as well as those in other cities, with evidence
based planning, implementation and, evaluation of
projects9,28,30-32.
Innovative and enterprise city
Wonju city has stated new concept as innovative and
enterprise city since 2010, based on the concept of
the healthy city. The innovative city zone comprised of
headquarters of the national health insurance service,
health insurance review and assessment service, Red
Cross society, and the national forensic service in Wonju
city. Enterprise city has built medical device complex in
Wonju12.
Healthy city program in Nepal: Situation and
possibilities
The Bangkok declaration held in 2010 on ‘Urbanization
and health’ recommended member states of South-East
Asian region to tackle urbanization and health using
healthy city approaches, which focuses intersectoral
collaboration and an increased role of municipalities in
ensuring infrastructures for health and development33.
Some cities such as Delhi (India), Bangkok metropolitan
administration and Phanat Nikhom town municipality
(Thailand), Jakarta (Indonesia) have already implemented
healthy city approach to address the urban health
problems and inequality in health34.
Nepal is experiencing 3.18% rate of urbanization (2010
- 2015) annually. The population density of Nepal
is estimated to be 180 persons per km2 with urban
population density of 693 persons per km2. However,
some municipalities have high population densities; the
  

J-GMC-N | Volume 10 | Issue 01 | January-June 2017 page 39
| Original Article
than 6000 persons/km2 including 19726 persons/km2
in Kathmandu metropolitan area21. Most of the cities
in Nepal are facing challenges of safe drinking water,
sanitation facilities and waste management, limited
access to quality health services; slum and squatters
settlements34. According to the global burden of disease
study 2015, Nepal is at 158th rank of 188 countries.
Health-related SDGs indicators such as hygiene, water,
disaster, occupational risk burden, mean PM 2.5, malaria,
air pollution mortality, road injuries, household air
pollution, and sanitation shows very low status in Nepal.
For achievement of health-related SDGs, Nepal needs to
invest to improve basic living condition of the citizens35.
The Ministry of urban development created in 2012
is responsible for urban planning; developing and
managing basic urban infrastructure and services such
as water supply, sanitation, solid waste management; and
housing36. Recently, national urban health policy 2015,
 
and the development of urban health strategy is on the
process37. ADB have supported some municipalities to
implement urban development program, for example,
“Nepal Cities: Clean and healthy urban development”,
a project implemented with ADB support in Bharatpur
municipality, one of the fastest growing municipalities.
The project established in 2005 promoted sustainable
urban development through better municipal planning
and upgrading of infrastructure for clean water supply,
drainage, and sanitation38.
In spite of such efforts, cities in Nepal has not initiated
and developed healthy city projects, have not created
any national networking system or joined international
networks of healthy cities as per the concept, except few
initial programs that were implemented in the Kathmandu
valley10,17,39.
DISCUSSION
In the era of sustainable development, “if cities do not
act, the SDGs will not be achieved”. The WHO Regional
        
city must do to be a healthy city: It need to focus on
the poorest and most vulnerable, address water and
sanitation, manage municipal waste; create resilient
health facilities; preserve green spaces and heritage sites,
plan for clean air; encourage physical activities and other
healthy behaviors40.
        
WHO in Europe in 1986, the healthy cities movement has
spread across the six WHO regions, thousands of cities
worldwide are part of the healthy cities network and exist
in all WHO regions7. WHO has developed guidelines for
establishing healthy city projects in low income countries
in 1995, and it aims to develop role of local government
in public health and encourage them to implement health
for all policy at city level39. However, the effectiveness of

countries41.
A key political challenge to urban health development is
the general weakness of municipal structures in South-
East Asian Region19,42. A study evaluating healthy city
projects in developing countries shows that there was
limited political commitment to the projects, perhaps
due to the fact that most of the municipalities had not
requested the projects43. In contrast to this, the healthy
city Wonju project is under the stewardship of the
Wonju city administration. An evaluation study states
that Wonju city was equipped with the resources, plans,
infrastructure, cooperative organizations, and the healthy
city networks, enabling the consistent implementation of
the project based on strong political commitment44. The
lesson from this case of Wonju, is that the involvement
and leadership of municipality in collaboration with
cooperative organization and comprehensive planning
may improve urban health and living environments.
There is a need to generate political commitment and
community participation in preparing and implementing
a municipal health plan; to increase awareness of health
issues in urban development efforts by municipal and
national authorities; and to create a network of cities that
promotes information exchange and technology transfer.
An evaluation study of healthy cities projects conducted
in 2002 in cities in India, Nepal, Sri Lanka, and Thailand
indicated that the exposure and commitment of decision-
makers, particularly local politicians; clarity of vision
and mission, with a strong planning and management
team; sense of ownership of policies; high degree of stake
holder involvement; and institutionalization of healthy
cities programs, are the factors contributing to successful
implementation18.
Community participation is an essential part of the
process of good local governance, and empowerment
remains at the heart of effective health promotions. These
processes must be seen as fundamental values of healthy
Sharma B, et al. A Healthy City Project...

J-GMC-N | Volume 10 | Issue 01 | January-June 2017page 40
Original Article | Journal of Gandaki Medical College-Nepal
cities and so must be developed as an integral part of
long-term development42. Even though health is the
entry point of the healthy cities approach, its underlying
rationale has always been based on a model of good
urban governance, which includes political commitment,
intersectoral planning, city wide partnerships, community
participation, and monitoring and evaluation41. The
healthy city Wonju is not limited to the public health
         
planning of urban developments. The ‘Vision 2020’ plan
for Wonju has established multiple programs, including
infrastructure development; health promotion, disease
prevention, and rehabilitation, welfare; and improvement
of the physical environment and health industries9,11,12.
Tobacco consumption tax has a dual advantage: Tobacco
controlling strategy and a sustainable funding source
for healthy city projects31,45. As the healthy city Wonju
        
the revenues collected from tobacco consumption tax,
cities in Nepal could adopt this strategy to reduce the
prevalence of tobacco consumption and fund healthy city
initiatives31,46. Healthy cities principles are drawn on the
social determinants of health, such as improvements in
living and working conditions, public education, medical
science, democratic governance, public health practices,
and human rights41. The socio-demographic, economic,
political and cultural backgrounds of countries vary
      
healthy city projects. However, the approaches used by
the healthy city Wonju, such as securing the leadership
      
resources; participation of cooperating community
organizations; multi-sectoral approaches may be effective
strategies for many developing countries hoping to move
forward with healthy city initiatives. Thus, the healthy city
movement can contribute toward promoting health as
well as urban development through healthy city networks
between cities and countries.
CONCLUSIONS
The healthy city Wonju project has been continuing since
2004 under the leadership of the Wonju city administration
in collaboration with the healthy city advisory committee,
and Yonsei healthy city research center. The project
carries out a variety of activities promoting the health of
citizens and sustainable city development, based on both
individual and socio-environmental approaches. In the
last 10 years, Wonju city has been awarded for its good
practice on different areas by the WHO and the AFHC. The
approaches of the healthy city Wonju project included:
The strong political commitment of local Government,
funding from tobacco consumption tax, partnerships with
Universities, a well-organized healthy city team under
city administration, community participation through
cooperative organizations, comprehensive multisectoral
planning, coordination with the AFHC and KHCP and
involvement in research activities for evidence based
planning. Such strategies maybe useful and crucial for
developing countries like Nepal to tackle the existing
urban health and development problems by initiating and
developing healthy city initiatives.
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