The 1992 constitution of Ghana structures the local government into three assemblies: the Metropolitan, Municipal, and District Assemblies (MMDAs). Resnick ^[1][29] indicated that a population density of 250,000 or more persons forms the metropolitan assembly, municipal assemblies constitute between 95,000–250,000 community members while the district assemblies account for 75,000–95,000 of the population. Ghana’s decentralized system of government relies largely on District Assemblies, which offer a forum for citizen participation in decision-making, and a vehicle for local development ^[1][29]. Since the inception of the three-tier local government system in 1988, the District Assemblies have been responsible for planning, implementing, and overseeing development projects in their respective jurisdictions ^[2][30]. Currently numbering 261 district assemblies, they are ranked as the lowest tier in the local government structure ^[3][31]. According to Fuseini ^[4][32], 70% of the members of MMDAs are elected by universal adult suffrage while the President of the Republic appoints the remaining 30%. At the district level, the District Chief Executive (DCE) heads the assembly upon the President’s appointment and subsequent approval by two-thirds of the assembly members ^[3][31]. The assembly members in this structured system comprise elected representatives from the various electoral areas (i.e., towns) within the district ^[5][33]. Furthermore, there exists a non-partisan interest within the local government structure due to the pros of creating an autonomous decision-making body with the sole aim of growing the local economy ^[5][33].

The District Assemblies in Ghana play a key fundamental role at the local level affecting the day-to-day livelihoods of the people. They are responsible for providing basic human needs such as quality education, adequate water supply, efficient health care delivery, proper sanitation, effective security measures, and infrastructure, among others ^[3][31]. In addition, they coordinate and promote the development of the economy, social welfare, and cultural values at the district level ^[6][34]. In terms of financing, the Local Government Act 1993 allows the District Assembly (DA) to levy taxes and rates, collect revenues and fee charges in the form of market tolls, issuance of permits or licenses, and property rates, among others which form part of their internally generated funds (IGF) ^[7][35]. Moreover, the central government also supports the DA with funding known as the District Assembly Common Fund (DACF) for the execution of developmental projects and initiatives ^[8][36]. For instance, Wang ^[3][31] recorded about 241 road and transportation projects in 2015 within the Accra Metropolitan Assembly (AMA) with most of the funding traceable to the DACF and donor grants. The Tolon District Assembly ^[9][37] also indicated in their 2020 annual progress report that out of 92 projects planned for the 2020 developmental year, about 73% of the projects were completed reaching an overall of 91.4% of their 2020 annual action plan.

Despite the achievements of the district assemblies, their system of operation is tainted with some constraints. Togba ^[10][38] argued that low resources, insufficient procedures of accountability and responsibility, and restricted access to vital information are a few of the significant obstacles crippling project initiatives at the local level. Hackman et al. ^[11][39] also added that the effects of weak institutional capacity identified as one of the peculiar problems inhibiting the effective implementation of developmental and sustainable projects at the MMDA level. Due to some of these challenges, Abdul-Rahaman and Adusah-Karikari ^[12][40] revealed that out of 36 planned projects within the East Gonja district in the Northern region of Ghana, only 8 representing 19.05% of the total projects for the 2010–2013 District Assembly Medium Term Development Plan (DMTDP) were implemented. To address these challenges, stakeholders and researchers in local governance have advocated for reforms that ensure the sustainability of the socioeconomic well-being of the people ^[13][41].

The development of healthy cities is becoming a global strategic initiative that seeks to address the myriad issues caused by urbanization ^[14][28]. A healthy city is described by Ashton and Thurston ^[15][42] as a place where people aid each other in carrying out life’s duties and reaching their full potential by continuously enhancing its physical and social settings and its range of available resources ^[15][42]. In supplementing this definition, WHO ^[16][13] defines healthy cities as a process rather than an outcome that consists of 6Ps that is People, Place, Peace, Participation, Prosperity, and Planet. According to Barton and Tsourou ^[17][43], Healthy City Planning also known as Healthy Urban Planning (HUP) prioritizes the well-being of its residents, recognizing that a city encompasses more than just its physical infrastructure such as buildings, streets, and public areas. Rather, it views a city as a dynamic entity, deeply interconnected with the health of its inhabitants ^[17][43]. Historically, it has been recognized that urban conditions, often exacerbated by urban planning decisions, can negatively impact public health ^[17][43]. Healthy urban planning shifts the focus toward the constructive influence that urban planning can exert on human health, overall well-being, and quality of life. This approach aligns with the World Health Organization’s comprehensive definition of health ^[17][18][19][43,44,45].

The concept of healthy urban planning has been developed within the framework of the WHO Healthy Cities project, a long-established initiative that addresses various aspects of health within urban settings ^[17][18][43,44]. Urban planning practices, like the cities they shape, wield significant influence over the well-being of individual residents, with both positive and negative impacts ^[19][45]. These connections are intricate and multifaceted, spanning social, environmental, and economic dimensions. Healthy urban planning concentrates on the constructive aspects of these connections. Its primary goal is to realign the priorities of urban planners by emphasizing the repercussions of their decisions on human health and overall quality of life ^[17][20][43,46]. This approach positions people at the core of urban planning discussions, recognizing health as a fundamental component of sustainable development. Healthy urban planning seeks to enhance both the quality of the physical urban environment and the well-being of individuals and communities within cities, contributing to the cultivation of a healthy economy, a sustainable environment, and a thriving society ^[17][20][43,46].

The Sustainable Development Goals (SDGs) offer a genuine chance to instigate transformation and, notably, to address objectives that are common to all global inhabitants ^[21][47]. While it is undeniable that the outstanding tasks of the Millennium Development Goals must be wrapped up, it is equally evident that the world faces considerable jeopardy as numerous swiftly industrializing economies take a toll on the environment ^[21][47]. If these trends persist unchecked, they could lead to severe consequences. The SDGs and the New Urban Agenda (NUA) are intricately connected and reinforce each other, with health serving as a fundamental pillar in both ^[22][48].

The UN Global Sample of Cities, an initiative led by the United Nations, was the first scientific analysis of world urbanization based on satellite images in 2010. This examination was based on satellite imagery and focused on a representative selection of 200 cities out of the 4231 cities worldwide ^[21][22][47,48]. The findings from this analysis highlighted a concerning trend: current urban practices, despite being the primary driver of economic progress, are unsustainable ^[21][22][47,48].

Cities are becoming increasingly less organized and structured, leading to spontaneous urban growth and a subsequent increase in urban poverty. This, in turn, negatively impacts the quality of life for millions of people. Additionally, the population density in cities has experienced a significant decline, with a reduction of 52.5% in developed countries and 37.5% in developing countries ^[23][49]. This shift towards urban sprawl and reduced population density can be attributed to changing lifestyles and has significant implications for urban health ^[24][50]. It contributes to issues such as the spread of diseases and unhealthy living conditions ^{[21][22][23][24]}[47,48,49,50].

The development of healthy cities is gaining global recognition because of its alignment with SDG 11. To assess the level of healthy city construction in China, a model was developed by Wang et al. ^[25][27] and it was found that although over the years, there has been an increase in the implementation of healthy city construction, the performance level is very low ^[25][27]. From the recent voluntary national review submitted by the UN Ghana, it was worthy to note that implementation of the SDG goals was still underway, and the progress made is mixed. In order to attain SDG 11, the government made four key interventions of which two have been completely successful ^[26][51].

The concept of sustainable development dates back to 1987 when the Brundtland Report of the World Commission on Environment and Development ^[27][52] described sustainable development as an advancement or growth curve that satisfies current demands without compromising the ability of future generations to fulfill their own needs. Sustainability has since become a global issue of interest that seeks to be achieved by world economies and institutions. Samara et al. ^[28][53] averred that without sustainable development, the guarantee of the existence of limited and non-renewable resources for subsequent generations will be jeopardized. Owing to the credible and proficient approach sustainability offers in combating socioeconomic and environmental problems on a global scale such as climate change, inequity, low quality of life, increased carbon emissions, and environmental degradation, among others ^[29][54], it has been a major concern to international organizations. Particular among these organizations is the United Nations (UN).

The Millennium Summit held in 2001 by the UN introduced eight initiatives known as the Millennium Development Goals (MDGs) which aimed at tackling and solving issues concerning hunger, poverty, health, education, gender equality, and the environment by 2015 ^[30][55]. In 2012, the United Nations Conference on Sustainable Development (UNCSD) also known as Rio +20 represented a paradigm shift in the area of development that sought to nurture the growth of global cooperation in implementing sustainable measures that make the world a better living hub ^[31][56]. However, due to the emergence of novel and intricate challenges in diverse aspects of the global framework, the U.N., in 2015, initiated the Sustainable Development Goals (SDGs) as an extension of the MDGs to achieve its targets by 2030 ^[32][57].

The SDGs comprise 17 different but interdependent goals with 169 targets which represent parameters that seek to measure the progress of achieving global sustainability ^[33][58]. Referenced from the UN’s SDG report ^[34][59], SDG 1 focuses on eradicating all forms of poverty worldwide; SDG 2 targets a zero-hunger society where people achieve food security and adequate nutrition through sustainable agricultural practices; SDG 3 strives to maintain a healthy living standard across the globe as well as promote the well-being of people at all ages; SDG 4 emphasizes on the provision of equitable quality education for all and SDG 5 advocates for gender equality and women empowerment. In addition, SDG 6 concentrates on improving sustainable water and sanitation management worldwide; SDG 7 aims to ensure that the global populace gains access to sustainable and modern energy; SDG 8 targets the promotion of sustainable economic growth and decent work for all persons; SDG 9 focuses on promoting sustainable industrialization and nurturing innovation and the reduction of income inequality globally is identified with SDG 10.

Goal 11 ensures inclusivity, safety, and sustainability within cities and human settlements across the globe; SDG 12 highlights the pathway to achieve sustainable consumption and production patterns; SDG 13 addresses expediency in combating climate change and its adverse impacts; Issues concerning the conservation of marine species and resources for sustainable development is associated with Goal 14 and SDG 15 seeks the protection, restoration and sustainable use of the natural ecosystem. Subsequently, SDG 16 advocates for international peace, the rule of law, and inclusive institutions at all levels and SDG 17 focuses on fostering global partnerships among the countries to achieve all the established goals.

However, the focus of this study resonates with goal 11 which exclusively addresses sustainability within cities and communities. SDG 11 operates through 10 different targets under which there are 15 indicators with each tackling either the social, economic, and environmental issues within the community ^[35][60]. In the same report, Target 11.1 addresses a policy on access to affordable housing and basic services; Target 11.2 focuses on access to a safe, resilient and affordable transportation system inter and intra-city; Target 11.3 also highlights inclusive and sustainable urban planning for all; Target 11.4 subsequently ensures the protection and preservation of societal cultures and natural heritage and Target 11.5 emphasizes on sustainable disaster management as a solution to reduce casualties and direct economic losses relative to gross domestic product (GDP). Additionally, Target 11.6 aims at reducing the adverse environmental impacts within cities; the provision of green buildings and spaces within communities identifies with Target 11.7; Target 11.a focuses on regional and national development planning to enhance urban, peri-urban and rural communities; Target 11.b aims at achieving an integrated sustainability policy implementation within cities, especially in terms of disaster risk reduction and the last target (i.e., Target 11.c) concentrates on the provision of technical and financial support to developing countries in constructing sustainable buildings using local resources.

Osman et al. ^[36][61] asserted that advances in the inclusivity, safety, resilience, and sustainability of cities will pave the way for accomplishing the goals of the other SDGs, such as eradicating poverty, promoting equality, fostering economic growth, and ensuring that residents live healthy lives. In the future, urban, peri-urban and rural communities should be sustainable and efficient, thus addressing the existing disparities between them ^[37][62].

Cities and their developmental components have garnered more attention in recent years, in part due to worries about climate change and in part due to the social and organizational challenges posed by massive rural-urban migration ^[38][63]. In a positive light, the healthy and sustainable cities movement has also gained consideration from researchers and urban policy stakeholders since the World Health Organization identified it as an ‘effective marker’ for a safe, resilient, sustainable city ^[39][64]. This is because a healthy city is viewed as addressing the consequence of several inputs from various sectors, including the economy, education, the environment, culture, social welfare, infrastructure, and public service institutions ^[40][65]. For instance, Sodiq et al. ^[41][66] posited that elements such as green buildings, energy efficiency, sustainable transportation and circular economy practice not only classify a city to be deemed sustainable or healthy but also deal with daily city challenges. Besides, international policy drivers such as the UN SDGs also support healthy city development through its 17 goals that need to be achieved by 2030, especially Goal 11 which targets the sustainability of cities and communities.

In supporting the cause for sustainable cities, countries such as Brazil have enrolled major initiatives such as the Healthy Municipalities, Cities and Communities (HMC) initiative, the MDGs, Local Agenda 21 (LA21), and Master Plans (MPs) to ensure that all urban stakeholders collaborate to transform their societal and environmental conditions ^[42][67]. Meanwhile, they are also developing action plans to integrate these initiatives to facilitate the delivery of SDG 11 at the local level. Similarly, Koch and Krellenberg ^[43][68] investigated the contextualization of SDG 11 indicators within the German context by examining three major initiatives rolled out by the German government, an academic institution on urban affairs, and a German non-governmental organization (NGO) to ascertain whether the initiatives explicitly addressed SDG at the local level. Subsequently, in India, the national government also registered clear missions such as the Jawaharlal National Urban Renewal Mission, Atal Mission for Rejuvenation and Urban Transformation, and Smart Cities mission, among others, to promote sustainability within the urban local bodies ^[44][69]. Nevertheless, the African continent has also organized efforts to contribute to achieving healthy cities through the implementation of the SDGs. Cartwright et al. ^[45][70] stated that about 18 countries within Africa have been instrumental in making headway toward achieving Agenda 2030. Lesotho, Kenya, Senegal and South Africa have witnessed a reduction in slum dwellings while Cape Verde, Mauritius, Comoros and Seychelles seem to be on track to achieving access to sanitation and waste reduction ^[46][71].

Despite the ambitious implementation plans launched by several governments and NGOs of developed and developing countries concerning healthy city development, concerns have been raised regarding the realization of these plans ^[43][47][68,72]. This can be somewhat attributed to challenges urban stakeholders encounter during the implementation process. Elias and de Albuquerque ^[48][73] argued that the lack of required resources on the part of local authorities in managing large city centers has been one of the most significant obstacles to the implementation of sustainable city policies, the foremost of these resources relating to financing. Bandauko et al. ^[49][74] confirmed this assertion stating that the national urban policies on the sustainability of some countries fail to allocate national and municipal budgets to these initiatives, resulting in poor implementation action. However, according to an International Monetary Fund (IMF) publication, this accounts for a USD 2.6 trillion average funding gap per annum developing countries face in sustainable development investment ^[50][75]. Furthermore, another obstacle discussed within current literature relates to the incompetency of agents tasked to implement sustainable developmental policies, exercised through poor monitoring of the implementation process. This is evident in Croese et al. ^[51][76], suggesting that action on the implementation process has been slow in part due to the optimistic nature of the SDG regarding urbanization, meanwhile, not enough data are available to translate it into action at the national and local levels. Additionally, due to technical capacity constraints and incompetency, the impacts of sustainable cities are seldom experienced ^[52][77]. Few studies have also stated that changes in government hinder the implementation of a resilient long-term plan that addresses and marks the progress of the healthy city curve ^[53][78].