Cardiovascular disease (CVD) is the leading global cause of mortality, causing 17.9 m deaths in 2019 and 38% of premature deaths from noncommunicable diseases.1 Urbanisation is known to be associated with an increase in risk factors for CVD, including unhealthy diet, inactivity, smoking and alcohol use.2 With over 55% of people living in cities as of 2022, global CVD prevention will require strategies tailored for urban settings, involving the promotion of healthy behaviours and tackling social determinants of health, such as poverty and level of education.3 One example, the Health in All Policies (HiAP) approach championed by the World Health Organisation (WHO), encourages integrating health considerations into all policy sectors, such as transport, housing and urban planning.
The City Heartbeat Index evaluates 50 cities across five domains with 44 indicators and sub-indicators, primarily serving as a benchmarking tool for assessing the drivers and barriers to cardiovascular health at the city level. In addition, it aims to raise awareness of the importance of a city-level focus on cardiovascular health, facilitate policy development, spark stakeholder discussions, promote collaboration across sectors, and spur consideration of greater investment in health initiatives.
In our City Heartbeat Index 2024 the top 10 cities are: Hong Kong, London, Madrid, New York City, Berlin, Toronto, Singapore, Tokyo, Melbourne, and Seoul. Key findings of the Index across its five domains—Social Determinants, Physical Environment, Health Risks, Health Services and Governance—are as follows:
High-income cities demonstrate superior performance in social determinants, and action is needed in cities in low- and lower-middle-income countries. The Index’s Social Determinants domain highlights factors such as income, level of education, and access to healthcare as key contributors to CVD risk. High-income cities generally perform better in these areas, with Toronto (Canada) and Berlin, the German capital, leaders in this domain. However, there are some success stories among middle-income cities, with São Paulo in Brazil and Bogotá in Colombia performing well in access to healthcare and Yangon (Myanmar) having relatively low inequality. Nevertheless, the findings underscore the urgent need for action in low- and lower-middle-income cities to address infrastructure gaps and implement policies for improved cardiovascular health.
Physical Environment is the weakest performing of all Index domains, with wealthy cities showing advantages in areas such as open and green spaces and active transport. Emerging economies face challenges related to air pollution, with particulate matter being a major contributor to cardiovascular health risks. However, innovative solutions are emerging, such as smog vacuum cleaners in Beijing (China) and pollution-absorbing substances used on the exterior of buildings in Mexico City. Open and green spaces, vital for cardiovascular health, are abundant in high-income cities like Hong Kong and Auckland. Cities in emerging economies face complex food security challenges—a result of issues with governance, infrastructure and climate change—that impact access to healthy diets.
City-level data availability highlights prioritisation of certain health risks including obesity, diabetes and hypertension over others. The Health Risks domain of the City Heartbeat Index evaluates critical factors such as tobacco use, poor diet, physical inactivity, hypertension, diabetes, obesity, and high cholesterol levels, all of which significantly impact cardiovascular health in urban settings. Greater availability of city-level data on some health risks including obesity, diabetes, and hypertension suggests that these areas are being prioritised, while other risk factors such as vegetable consumption, high cholesterol, and trans fat intake are receiving less attention. Although cities with higher data availability and lower national prevalence of key health risks are predominantly in high-income countries, middle-income Jakarta (Indonesia) stands out with comprehensive city-level data across these measures. Prioritising data collection at the city level is essential as it serves as the foundational step in informing the development of tailored urban health policies.
Low- and lower-middle-income cities have the poorest health services, pointing to limited funding, infrastructure, workforce and education. The Health Services domain evaluates metrics such as access to essential CVD medications, hypertension diagnosis coverage, undiagnosed diabetes rates, and patient-centred care. Although high-income cities typically perform better, São Paulo stands out as a middle-income city with strong health service accessibility, while Colombo (Sri Lanka) demonstrates efforts to enhance access to essential medicines and provide patient-centred care. Even high-income cities such as Dubai face hypertension diagnosis challenges, prompting national plans for improvement.
Effective governance is vital for urban cardiovascular health, requiring city autonomy, rigorous planning and consistent political support. While London and Hong Kong excel in developing autonomy in health matters, providing political support and careful planning of health strategies, Jakarta, Ho Chi Minh City (Vietnam), Mumbai (India) and Nairobi (Kenya) offer valuable insights for middle-income settings. The Index further evaluates city-level policies addressing health promotion, and specific health risks such as unhealthy diets, tobacco and air pollution, with London emerging as the most active city in this regard, implementing policies in areas such as healthy diets and air pollution, notably expanding its Ultra Low Emission Zone in 2023 to cover the entire urban area, making it reportedly the largest clean air zone in the world.4
For more insights download our findings report, or interactive data dashboard.
References
1. WHO. Cardiovascular diseases (CVDs): key facts [Internet]. Available from: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds).
2. World Heart Federation. Urbanisation and cardiovascular disease. Raising heart-healthy children in today’s cities. Available from: https://world-heart-federation.org/wp-content/uploads/2017/05/FINAL_Urbanization_Report_EXECUTIVE_SUMMARY_HiRes.pdf.
3. WHO. WHO Urban Health Repository [Internet]. Available from: https://www.knowledge-action-portal.com/en/content/who-urbanhealth-Repository.
4. Greater London Authority. The Ultra Low Emission Zone (ULEZ) for London. Available from: https://www.london.gov.uk/programmes-strategies/environment-and-climate-change/pollution-and-airquality/ultra-low-emission-zone-ulez-london.
