Implementation of the UN’s Sustainable Development Goals (SDGs) among the Member Cities of the “Healthy Cities Network” in Israel

Abstract

The Israeli Healthy Cities Network (IHCN), as one of the accredited networks of the WHO European Healthy Cities Network in its seventh phase, started mapping the level of adoption and efforts that are being made towards achieving the 17SDGs. Data for all 55 member cities was collected from the most recent online national databases. As not all indicators are available in national data sets, an online questionnaire was distributed to all 55 cities’ health coordinators, via e-mail, to acquire the needed data; 45 of the 55 replied (81.8% response rate). All SDG measures were analyzed by socio-economic cluster (SEC) using one-way ANOVA. Implementation of some indicators was checked for association with population size of municipalities, as well as structure and process measures of the healthy cities’ operation. Cities implement between 4 and 14 SDGs, and 98% implement SDG3, while the lowest implementations are of SDG13 (44%) and SDG12 (28%). Cities in higher SECs are in a better position in relation to most SDGs. However, cities in a low SEC can achieve implementation of at least some of the goals through policy and commitment. This study provides municipalities with a baseline for tracking future progress and a tool for mapping gaps in implementation. The methodology and tools presented here could be used by any municipality, as well as by national networks and other governance bodies.

1. Introduction

Over 30 years have passed since 172 governments adopted the Rio declaration on Environment and development, Agenda 21, which offered pragmatic solutions towards sustainable development (SD) [1]. SD was initiated to meet the growing needs of the present generation without compromising the ability of future generations to fulfil their own needs [2]. Technological advances, wars, epidemics, global warming, dwindling resources, a culture of consumption, and economic growth have created larger disparities between communities, cultures, countries, and continents [2]. All these factors and more, have made SD as relevant and important as ever.

The “Millennium Summit”, which took place in September 2000 [3], set the goal of promoting principles that were founded on justice, equality, and global partnership. The summit adopted the “Millennium Declaration” of the United Nations [4]. This statement was presented as a series of time-limited goals, up to the year 2015, which were called “The Millennium Development Goals (MDGs)”. These were eight goals that constituted a plan to fight poverty in its many dimensions. According to a 2014 UN report, the joint efforts to achieve the MDGs saved the lives of many millions and improved the living conditions of many others [4].

In September 2015, the UN General Assembly adopted the “2030 Agenda for Sustainable Development”. The agenda supports a model in which economic development is measured according to its contribution to the advancement of people and society, and the sustainable management of the planet [5]. In 2015, the World Health Organization (WHO) welcomed the 2030 Agenda for Sustainable Development, and expressed its commitment to work with partners around the world to achieve the new Sustainable Development Goals (SDGs) [6].

The 17 sustainable development goals (17SDGs) [7], which were adopted by the UN in 2015, set objectives to end poverty, protect the planet, and ensure that all people enjoy prosperity and peace now and in the future [8]. They present global priorities and highlight how the challenges inter-relate. In fact, although goal 11 focuses on sustainable cities and communities, all 17SDGs impact health. As a result, cities seized the opportunity to lead public health in their city through the SDGs [9,10,11].

A total of 231 indicators have been suggested to evaluate the progress each country makes towards achieving the SDGs [12]. Most SDG indicators were suggested at the national level. Countries were encouraged to submit a Voluntary National Review (VNR), which assesses the levels of implementation, assimilation, and action taken toward achieving the SDGs at a national level [13,14]. Israel presented its VNR to the UN in 2019 [15].

Following the complexity of implementing and evaluating the SDGs at a national level, the concept of exploring the indicators at a local level evolved [11]. The diversity of evaluation methods and indicators used was noted. There were studies that just researched a specific SDG [16,17,18,19]. For example, Mudau et al. studied the significance of Indicator 11.3.1 in understanding the urbanization trends in cities of different sizes [16]. Others evaluated processes and products related to the implementation [20,21,22,23]. Several indicators were compiled to assess progress in specific, health-related SDGs [24,25], or those related to specific populations, e.g., the older population [26].

The WHO European Healthy Cities Network (HCN), which was founded in 1987–1988, has specific goals and objectives, as well as a set of values and principles [27]. The network has a unique approach to “put health high on the political and social agenda of cities.” It is based on 5-year phases, in which each phase works on different priorities, with essential values and principles remaining at the core of the movement over the phases. The first phase focused on setting up structures for the healthy city, and the second on developing healthy public policies and comprehensive city health plans. The third focused on equity and the social determinants of health [27,28]. Phase IV focused on healthy aging, healthy urban planning, health impact assessment, and active living, phase V on health and health equity in all policies, and phase VI on life course approaches in city policies and plans [28]. Phase VII, which was initiated in 2019, highlighted the priority of implementing the UN’s 2030 Agenda for Sustainable Development in the local arena. Thus, the HCN members were urged to promote this agenda through a “whole-of-government and Whole-of-society approach” [28]. An implementation framework [29] guided cities and national networks in their applications for designation and accreditation, respectively, in Phase VII. Currently, the HCN is comprised of about 100 flagship cities and 30 national networks around Europe [30]. De Leeuw and her colleagues [31] claim that there is a complete alignment between the 11 characteristics of a healthy city and the 17SDGs; thus, the SDGs should be easily implemented in healthy cities.

The Israeli Healthy City Network (IHCN) has been a member of the European HCN since 1990. It was initiated with four cities, and in 2020 it included 55 municipalities (of the total of 256 municipalities in Israel). The network is comprised of local and regional authorities, which vary in population size and socio-demographic characteristics. Through all seven phases, the IHCN has fulfilled the accreditation requirements of the WHO European HCN. The IHCN conducted a number of full-scope and smaller, more localized evaluations, to estimate the level of assimilation of the principles and strategies of the healthy cities idea [32,33].

As one of the accredited networks, the IHCN decided to start the seventh phase of its journey by assessing the status of its member municipalities in relation to the 17SDGs. This paper aims to describe the process of data collection, the tools that have been used, the current status, and the activities undertaken to achieve the SDGs in the IHCN member municipalities. It also tries to identify the determinants of implementation of the SDGs. These data will help the IHCN to identify gaps in the implementation of SDGs in its municipalities in order to direct further training investments for cities’ coordinators. It will also serve as a baseline for evaluation of progress towards achieving these SDGs in each city. These processes and tools may serve municipalities, national networks, and other governance bodies in assessing their own implementation level towards achieving the SDGs.

2. Materials and Method

This was a cross-sectional study that examined the current status of the IHCN member cities in relation to the 17SDGs, as well as their activities for the achievement of the goals. The first step was to select a list of indicators, based on the United Nations’ global indicator framework for the Sustainable Development Goals and targets [12]. We adopted the approach that was published by the Association of Flemish Cities and Municipalities (VVSG) [34]. Indicators were selected according to relevance to local public health in Israel, in domains that can be influenced by local policy, and indicators that could be easily accessed and retrieved. The second step was to operationally define each indicator, both in terms of their raw data and their conversion to ranked scores (see details in the analysis). The list of indicators and their operational definitions are specified in

Table 1. Operational definitions of the studied SDGs and their indicators.

SDGs		Indicator	Data Source	Scale
SDG1	Current Status	% receiving income supplement benefit out of receiving old age pensions.	C.B.S [35]	Metric Converted to scores (1–3)
		% of salaried employees earning less than minimum wage	C.B.S	Metric Converted to scores (1–3)
		Composite variable SDG1	Combination of the above ranked scores (α = 0.82)	Ordinal (scores 2–6)
	Activities	N/A
SDG2	Current Status	% First grade schoolchildren with BMI under third percentile for age	Ministry of Health website [36]	Metric Converted to scores (1–3)
		% Seventh grade schoolchildren with BMI under third percentile for age	Ministry of Health website	Metric Converted to scores (1–3)
	Activities	Ensure food security for the children and the elderly	An open question to the city’s health coordinator	Ordinal 0—do nothing 1—provide information 2—provide meals 3—1 + 2 4—a policy
SDG3	Current Status	Infant mortality rate per 1000 live births	C.B.S	Metric Converted to scores (1–3)
		Age-adjusted diabetes rates per 1000 residents	C.B.S	Metric Converted to scores (1–3)
		% First grade schoolchildren with BMI over 97th percentile for age	Ministry of Health website	Metric Converted to scores (1–3)
		% Seventh grade schoolchildren with BMI over 97th percentile for age	Ministry of Health website	Metric Converted to scores (1–3)
		Age-adjusted cancer rates per 100,000 residents—men	C.B.S	Metric Converted to scores (1–3)
		Age-adjusted cancer rates per 100,000 residents—women	C.B.S	Metric Converted to scores (1–3)
		Composite variable SDG3	Combination of the above ranked scores (α = 0.713)	Ordinal (scores 7–18)
	Activities	Health promoting programs: nutrition, physical activity, smoking prevention, community gardens, resilience, active aging	questionnaire	Open ended Number of themes of activities for which there are intervention programs (1–6)
SDG4	Current Status	% of 12th grade schoolchildren eligible for matriculation	C.B.S	Metric Converted to scores (1–3)
		% students in higher education out of total population	C.B.S	Metric Converted to scores (1–3)
		High education—composite variable	Combination of the above ranked scores (α = 0.667)	Ordinal (scores 2–6)
	Activities	% of health-promoting kindergartens in municipality.	questionnaire	Metric Converted to scores (1–3)
		% of health-promoting schools in municipality	questionnaire	Metric Converted to scores (1–3)
SDG5	Current Status	% of women in the local council	questionnaire	Metric Converted to scores (1–3)
		% of women in managerial positions	questionnaire	Metric Converted to scores (1–3)
	Activities	Gender equality program	questionnaire	Dichotomy, yes/no
		Program addressing distressed girls and women	questionnaire	Dichotomy, yes/no
		Sexual harassment prevention program	questionnaire	Dichotomy, yes/no
SDG6	Current Status	% Water depreciation out of total water receipts	C.B.S	Metric Convert to scores (1–3)
		Domestic water consumption—cubic meter per person	C.B.S	Metric Converted to scores (1–3)
	Activities	Saving water program	questionnaire	Dichotomy, yes/no
SDG7	Current Status	Solar panels for generating electricity for public usage	questionnaire	Ordinal 0—no, 1—some, 2—yes Collapsed to yes (1 + 2)/no (0)
	Activities		N/A
SDG8	Current Status	% change in realistic income salary of monthly employees compared to last year	C.B.S	Metric
		% change in realistic income of self-employed per month compared to last year	C.B.S	Metric
		% unemployed out of total labor force	Government employment agency [37]	Metric Converted to scores (1–3)
	Activities	N/A
SDG9	Current Status	% land usage for industry	C.B.S	Metric
	Activities	Local development of technology, research, and innovation programs	questionnaire	Dichotomy, yes/no
SDG10	Current Status	Inequality index—Gini	C.B.S	Metric Converted to scores (1–3)
	Activities	Programs aimed at reducing inequality	questionnaire	Dichotomy, yes/no
SDG11	Current Status	% land usage for public parks	C.B.S	Metric
		Accessible public building	questionnaire	Ordinal: 0. None, 1. in some, 2.in most/all
		Accessible open spaces (public parks and gardens)	questionnaire	Ordinal: 0. None, 1. in some, 2.in most/all
		Accessibility in the city	Combined the above scores (α = 0.746)	Ordinal (scores 0–4)
	Activities	Consultations of municipal representatives with citizens in the last 2 years	questionnaire	Dichotomy, yes/no
SDG12	Current Status	N/A
	Activities	Reducing food waste program	questionnaire	Dichotomy, yes/no
		% recycling of residential solid waste	C.B.S	Metric
SDG13	Current Status	N/A
	Activities	Preparedness program for climate change	questionnaire	Dichotomy, Yes/no
SDG16	Current Status	N/A
	Activities	A program to combat violence	questionnaire	Dichotomy, Yes/no
SDG17	Current Status	N/A
	Activities	Partnerships for sustainable development	questionnaire	Dichotomy, yes/no
		Inter-departmental working groups	questionnaire	Dichotomy, yes/no
		A team for promoting health and sustainability	questionnaire	Dichotomy, yes/no

N/A—Not applicable.

.

Some municipal indicators, as well as information on the socio-economic cluster (SEC), population size of municipalities, municipality type, and main population group, are available on official national websites and online databases for every municipality in Israel. The data were collected from the most recent files for all 55 member municipalities. These are type I indicators, according to the definition of Jossin and Peters [38]. Most type I indicators were retrieved from the Central Bureau of Statistic (C.B.S) website [35]. Cluster 1 is the lowest SEC and cluster 10 is the highest (the IHCN does not have any city member in cluster 10). Population size data were collapsed into less than 100,000 and 100,000+ (range 9663 to 966,210). For the type II indicators, an online Google Forms questionnaire consisting of both open- and closed-ended items was distributed to all 55 cities’ health coordinators, via e-mail, at the end of 2020. The coordinators were asked to gather information with the help of other city officials and departments in the municipality. These questions comprised those related to the current status and activities towards achieving the SDGs. In addition, a direct question was asked (adopted from the WHO questionnaire): “Has your city made an explicit commitment to implementing the 2030 UN Agenda at the local level”, with four possible answers on an ordinal scale (Yes, there is a complete commitment; yes, partial; yes, low commitment; no commitment). This scale was then collapsed to complete, partial, and no (+low) commitment. For further analysis, the complete and partial categories were collapsed. Questions related to the structure and processes of the healthy cities’ operation were also included: health coordinators’ time investment in healthy city activities (less than 25/25+ h/week); political commitment for health and sustainability (coordinators were asked to select a score between 0 and 10, collapsed to high (8–10)/medium and low (0–7)); the existence of a sustainability coordinator in the city (yes/no); a common team for sustainability and health (yes/no); existence of a special budget for health promotion or “healthy city” (yes/no); and whether citizens partake in municipal committees (yes/no). Existence of a common team for sustainability and health indicator is also mentioned as one of the SDG17 indicators.

Responses to the questionnaire (type II indicators) were obtained from 45 coordinators (81.8% response rate); in some cases coordinators did not answer the full questionnaire. Municipalities who replied to the questionnaire have similar characteristics to those who did not reply regarding the following characteristics: distribution by socio-economic cluster (SEC), 12th grade schoolchildren eligible for matriculation, water depreciation, domestic water consumption, and recycling.

3. Analysis

In the first step in ranking cities’ status and activities towards achieving each SDG, a cumulative distribution of all those for whom data was available was derived [39]. In the second step, metric indicators were converted into ordinal scores by dividing the cumulative distribution data into three equal-sized categories, similarly to the method described by Sebestyén and Abonyi as their second step [39], although they divided data into quartiles. For each indicator, a score of 3 was given to the values reflecting approaching the Sustainable Development Goal, while a score of 1 reflects the opposite pole. This methodology enables a presentation of scores as traffic light colors for each of the participating municipalities, where 1 is colored red, 2 is yellow, and 3 is green, similarly to the presentation of Lafortune et al. [40]. Some SDG indicators (part of 8, current status of 9, part of 11 status, part of 12), as well as the ordinal scale of SDG2 activities, were left as their raw data as these values reflect the direction to achieve the goals. Dichotomized indicators are presented as proportions (SDGs 5, 6, 9, 10, 11, part of 12, 13, and 17 activities, current status of 7). For the presentation as a traffic light color, the cumulative distributions of the summed scores were divided into three equal groups. For the dichotomized indicators, “no” was marked red and “yes” was marked green (see Supplementary Materials).

Scores for SDGs that had at least two indicators were assembled and tested for internal reliability, and collapsed to a composite indicator if the α Cronbach was above 0.65 (SDGs 1, current status of 3 and 4, and part of current status of 11). In these indicators, the sum of scores presents its ranked scale. Higher values indicate approaching the goals. For the presentation as a traffic light color, the summed scores were divided into three equal groups according to their cumulative distribution.

All the SDG indicators were analyzed according to the SEC of the municipality. Some indicators were analyzed according to other relevant independent variables. In addition, activities towards achieving the goals were summed to a total score indicating how many SDGs are being implemented in the municipality. For further analysis, the number of SDGs that were targeted by cities’ activities were divided into two categories, based on the cumulative distribution: up to the median (4–11) and above the median (12–14). Six themes of health-promoting activities (SDG3) were gathered from the open-ended question (specified in Table 1). The number of themes of activities for which the municipality has an intervention program were summed. Analysis included descriptive statistics. Mean values were compared using one-way ANOVA and association of categorical variables was tested via the chi-square test.

4. Results

4.1. Characteristics of the Study Participants

The survey included all 55 IHCN municipalities, which represent all types of local government and populations—cities, local councils, and regional councils—and Jewish, Arab, mixed Jewish and Arab, and Ultra-Orthodox Jew (UOJ) populations. Their distribution by SEC (

Table 2. Distribution (%) of local governments by type and size, in each socio-economic cluster group.

Type of Local Government	Cluster 1–3 N (%)	Cluster 4–6 N (%)	Cluster 7–9 N (%)	Total
Total	13 (100)	20 (100)	22 (100)	55 (100)
Ultra-Orthodox Jews	2 (15.4)	0 (0.0)	0 (0.0)	2 (3.6)
Arab city	8 (61.5)	0 (0.0)	0 (0.0)	8 (14.5)
Mixed Arab-Jewish	1 (7.7)	4 (20.0)	2 (9.1)	7 (12.7)
Other Jewish cities	2 (15.4)	12 (60.0)	16 (72.7)	30 (54.5)
Regional council	0 (0.0)	4 (20.0)	4 (18.2)	8 (14.5)
Population size:
Less than 100,000	10 (76.9)	15 (75.0)	15 (68.2)	40 (72.7)
100,000+	3 (23.1)	5 (25.0)	7 (31.8)	15 (27.3)

) emphasizes the fact that all Arab and UOJ cities are in the 1–3 clusters. No regional council is presented in these low clusters. There is no association between cities’ population size and their SEC. Some structure and process characteristics of the healthy cities who replied to the survey are presented in

Table 3. Selected characteristics of the municipalities in each SEC group and population size.

Characteristic	Total		Cluster 1–3		Cluster 4–6		Cluster 7–9		Cities with <100,000		Cities with 100,000+
	N	%	N	%	N	%	N	%	N	%	N	%
High political commitment for health and sustainability	43	76.7 **	10	40.0	15	86.7	18	88.9	30	76.7	13	76.9
There is a special budget item for health promotion or healthy city	44	79.5	11	72.7	15	80.0	18	83.3	31	74.2	13	92.3
The health coordinator invests at least 25 h weekly in healthy city	44	52.3	10	50.0	15	53.3	19	52.6	31	51.6	13	53.8
There is a sustainability coordinator	45	71.1	11	36.4	15	66.7	19	73.7	32	46.9 ***	13	100.0
Sustainability and health team	45	71.1	11	63.6	13	73.3	19	73.7	32	65.6	13	84.6
Citizens partake in municipal committees	45	82.2	11	81.8	15	80.0	19	84.2	32	81.3	13	84.6

** p < 0.01 *** p < 0.001 (Fisher exact test).

, by SEC and population size of cities.

High political commitment is prevalent in most municipalities of SEC 4+, and only in 40% of those in clusters 1–3 (p = 0.007). Political commitment is not associated with population size. There is a special budget item for health promotion or a healthy city in 80% of the municipalities, with a higher proportion in large cities (100,000+ population). The health coordinator invests over 25 h per week on topics related to a healthy city in half of the municipalities, with no difference between clusters or population size. A sustainability coordinator is employed in all large cities and in most municipalities of clusters 4+, but only in 36% of those in cluster 1–3. A common team for health and sustainability operates in most municipalities. They exist in 82% of municipalities with a sustainability coordinator, but also in 53% of municipalities that do not have one, although they are statistically different (p = 0.036). Citizens take part in municipality committees in 82% of the municipalities. All the indicators presenting partnerships in the municipalities are defined as SDG17.

4.2. Current Status and Activities toward Achieving the SDGs

A complete commitment to the implementation of the 2030 UN Agenda exists in only 7 (out of 44) municipalities, and in another 12 there was a partial strategy. All of those seven cities have a common team for sustainability and health, and five of them have a sustainability coordinator, and they represent all SECs. A 2030 strategy (complete or partial) was more prevalent in large cities, municipalities with a political commitment, municipalities with a sustainability coordinator, municipalities where the health coordinator invests at least 25 h a week, and municipalities where citizens partake in municipal committees, although this was not statistically significant (

Table 4. Prevalence of Agenda 2030 strategy and activities towards SDGs by selected characteristics.

Characteristics		Agenda 2030 Strategy (Complete or Partial)		Activities towards 12+ SDGs
		N	%	N	%
Cluster	1–3	10	30.0	11	27.3
	4–6	15	53.3	15	46.7
	7–9	19	42.1	19	52.6
Population size	<100,000	31	35.5	32	34.4
	100,000+	13	61.5	13	69.2 *
Political commitment	Medium and low	10	30.0	10	30.0
	High	33	48.5	33	51.5
Special budget	No	8	50.0	9	55.6
	Yes	35	42.9	35	42.9
Health coordinator time investment	Less than 25 h/w	21	33.3	21	47.6
	25+ h/w	23	52.2	23	43.5
Sustainability coordinator	No	16	25.0	17	29.4
	Yes	28	53.6	28	53.6
A team for sustainability and health	No	12	16.7 *	13	30.8
	Yes	32	53.1	32	50.0
Citizens partake in municipal committees	No	8	25.0	8	37.5
	Yes	36	47.2	37	45.9

* p < 0.05 (Fisher exact test).

). Having a common team for sustainability and health is significantly associated with having a 2030 strategy (p = 0.042). However, activities toward addressing SDGs could be found in most municipalities. The mean number of SDGs that are addressed is 11 (s.d 2), ranging between 4 and 14. A total of 98 percent of the municipalities act towards SDG3, 93% toward SDG16, 87% toward SDG2, 82% toward SDG9 and SDG11, 81% toward SDG17, 75% toward SDG5, 73% toward SDG10, 69% toward SDG7, and only 44% toward SDG13 and 28% toward SDG12.

When comparing the characteristics of municipalities according to the number of activities towards achieving the SDGs (Table 4), we found that 12+ SDGs are addressed in twice the proportion of large cities compared to smaller ones (p = 0.033). All the other characteristics that are specified in Table 4, except for the budget item, are associated with having 12+ activities, although not statistically significantly. In cities where there is an Agenda 2030 strategy, 63% have 12+ SDGs activities, compared to 32% of cities without a strategy (p = 0.04).

All SDG status and current activities are presented by the municipalities’ SEC in

Table 5. Mean score of SDGs or prevalence (%) by socio-economic cluster.

SDG	Indicator		Mean Score (s.d) by Cluster
			N	1–3	4–6	7–9
SDG1	Current Status	SDG1	55	2.4 *** (0.51)	3.4 (1.10)	5.4 (0.67)
	Activities	N/A
SDG2	Current Status	First grade children with BMI < 3%—score	55	2.4 (0.77)	1.6 (0.74)	2.0 (0.78)
		Seventh grade children with BMI < 3%—score	55	2.1 (1.04)	1.8 (0.88)	1.9 (0.84)
	Activities	Ensure food security for children and the elderly	45	2.1 (0.94)	1.7 (0.82)	2.0 (1.33)
SDG3	Current Status	SDG3	35	11.6 *** (2.50)	9.8 (2.39)	14.4 (2.38)
	activities	Health-promoting activities	45	2.8 (1.33)	2.7 (1.11)	2.5 (1.17)
SDG4	Current Status	High education	55	2.8 *** (0.80)	3.9 (1.33)	5.0 (1.09)
	Activities	Health-promoting kindergartens	36	2.1 (0.60)	1.8 (0.93)	2.1 (0.86)
		Health-promoting schools	33	2.0 (0.92)	2.1 (0.79)	1.9 (0.86)
SDG5	Current Status	Women in the local council	41	1.3 *** (0.47)	2.1 (0.74)	2.5 (0.74)
		Women in managerial positions	41	1.6 (0.84)	2.2 (0.77)	2.3 (0.80)
	Activities	Gender equality program	42	50.0%	64.3%	72.7%
		Program addressing girls and women in trouble	44	100%	100%	98.9%
		Sexual harassment prevention program in the municipality	43	30.0% *	73.3%	83.3%
SDG6	Current Status	Water depreciation out of total water receipts	47	1.5 (0.78)	2.2 (0.75)	2.1 (0.83)
		Domestic water consumption	47	2.8 *** (0.55)	1.6 (0.73)	1.7 (0.57)
	Activities	Water conservation program	42	50.0%	85.7%	72.2%
SDG7	Current Status	Presence of solar panels for generating electricity	42	20.0% *	53.3%	58.8%
	Activities	N/A
SDG8	Current Status	% change in realistic income of salaried employee monthly	55	2.0 * (1.14)	2.9 (0.84)	2.3 (1.08)
		% change in monthly realistic income of self-employed	55	−1.9 (2.77)	−0.05 (3.03)	3.2 (14.4)
		unemployed out of total labor force	55	1.4 *** (0.65)	1.7 (0.73)	2.6 (0.49)
	Activities	N/A
SDG9	Current Status	% land usage for industry	55	1.6 (1.51)	3.7 (3.40)	2.4 (2.47)
	Activities	Local development of technology, research, and innovation programs	42	90.0%	92.9%	83.3%
SDG10	Current Status	Inequality index of salaried employees—Gini	55	2.46 *** (0.78)	2.35 (0.67)	1.38 (0.59)
	Activities	Reducing inequality program	43	70.0%	86.7%	72.2%
SDG11	Current Status	% land usage for public parks	55	0.5 * (0.65)	1.2 (1.12)	1.8 (1.72)
		Accessibility in the city	43	3.0 (1.61)	3.6 (0.63)	3.3 (0.84)
	Activities	Consultations with citizens	44	72.7%	80.0%	94.4%
SDG12	Activities	% recycling of residential solid waste	55	17.6 * (15.19)	18.4 (10.65)	27.7 (13.05)
		Reducing food waste program	43	18.2%	42.9%	22.2%
SDG13	Current Status	N/A
	Activities	Preparedness program for climate change	43	18.2% *	46.7%	64.7%
SDG17	Current Status	N/A
	Activities	Partnerships for sustainable development	41	90.0%	100%	93.8%
		Inter-departmental working groups	45	90.9%	86.7%	89.5%
		A team for promoting health and sustainability	45	63.6%	73.3%	73.7%

* p < 0.05, *** p < 0.001. N/A—Not applicable.

.

SDG1—End poverty—was measured by two indicators; 17.7% (s.d 12.32) of the residents receiving old age pensions, receive an income supplement benefit, and 39.4% (s.d 8.73) of salaried employees earn less than minimum wage. Cities in a higher SEC are closer to achieving the goal of ending poverty.

SDG2—End hunger, achieve food security, and improved nutrition—1.9% (s.d 0.78) and 3.5% (s.d 1.30) of first and seventh grade schoolchildren have BMI for age less than percentile 3. These indicators are not associated with socio-economic cluster. A definite policy in relation to food security exists only in 3 cities (out of 45 who replied); 12.7% only provide information, 36.4% provide meals to elderly clubs or schoolchildren, 16.4% provide both information and meals, and 10.9% provide nothing.

SDG3—Ensure healthy lives and promote well-being for all at all ages—Only one city received the highest score (18) and one received 17; both are at 7–9 SEC. Almost all municipalities implement health-promotion activities, which include promoting healthy and sustainable nutrition (39 out of 45), physical activity (36), special programs for senior citizens (13), prevention of smoking (11), community gardens (10), and resilience (9). On average, each municipality provides programs in 2.6 (s.d. 1.17) themes. There is no difference between SECs.

SDG4—Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all. The combined score of high education increases in accordance with SEC (Table 5). Investing in health promoting kindergartens and schools (mainly elementary schools) is not related to SEC.

SDG5—Achieve gender equality and empower all women and girls. There is no gender equality in relation to seats held by women in the local council of low-SEC municipalities. Women do not partake in the local council of the UOJ cities and in four out of six Arab cities. Similarly, women in managerial positions are less prevalent in 1–3 SEC municipalities. In the two UOJ cities, there are no gender equality or sexual harassment prevention programs. These programs exist in 67% and 17% of Arab cities, respectively. Programs addressing distressed girls and women are present almost in all cities.

SDG6—We referred mainly to sustainable management of water. In 68% of the municipalities, there is less than 8% water depreciation out of total water receipts (there are no data on regional councils). As for domestic water consumption, the mean cubic meter per person is 83.4 (s.d. 26.3), with a wide distribution through the municipalities. Lower consumption is present in low-SEC municipalities, presenting a better score regarding achieving the goal. Water conservation programs are present in 71.4% of all municipalities, but in only 50% of those in 1–3 SEC municipalities.

SDG7—Ensure access to affordable, reliable, sustainable, and modern energy for all. In 47% of the municipalities there are solar panels for public use. Their presence is higher in higher SEC municipalities (p = 0.033). There are no solar panels in Arab cities. Solar panels are present in 88.5% of municipalities that employ a sustainability coordinator, compared to 50% of municipalities that do not employ a sustainability coordinator (p = 0.009).

SDG8—Promote sustained, inclusive, and sustainable economic growth, full and productive employment. The total mean percent change (in 2019) for salaried employees was 2.4%, and that for self-employed was 0.8%. The change in self-employed income was positive only in clusters 7–9. The mean rate of unemployment was 3.5% (s.d 1.82), with a range of 1.6 to 8.8%. This indicator is significantly associated with the SEC of the municipality. The score increases as the municipality cluster increases.

SDG9—Build resilient infrastructure, promote inclusive and sustainable industrialization, and foster innovation. The mean percent land usage for industry is 2.7% (s.d 2.76), the lowest percentages are in 1–3 clusters. A total of 88% of the municipalities have local programs for development of technology, research, and innovation, with no differences between clusters.

SDG10—Reduce inequality. The mean Gini score for the study population is 0.414 (s.d. 0.038). The higher Gini scores were found in the upper socio-economic clusters. The low-SEC municipalities are closer to achieving the goal than the 7–9 municipalities. A total of 76.7% of the municipalities who replied to the survey have a program for reducing inequality. There are no differences between clusters. However, there is an association (although not significant) between the Gini index and the existence of a program for reducing inequalities. The program exists in 61.5%, 81.3%, and 84.6% of municipalities with a Gini of 0.4264 and over, 0.3899–0.4240, and 0.3894 and less, respectively.

SDG11—Make cities and human settlements inclusive, safe, resilient, and sustainable. Mean land usage for gardens and parks is 1.3% (s.d 1.39), with a range of 0 to 7.6%. Municipalities in higher clusters have a higher percentage of this indicator (p = 0.026). In 77% of municipalities, most or all public buildings are accessible to people with special needs, and in 70% of cities, most or all open spaces and parks are accessible. There is no significant difference between the clusters.

In the last 2 years, 84% of the municipalities held consultations between municipal representatives and citizens on health, welfare, and the environment. This activity is more prevalent in higher SEC municipalities (although not significantly so).

SDG12—Ensure sustainable consumption. Total residential solid waste is recycled in 22% of the 55 municipalities, although there is a wide variability between municipalities (1.3% to 56.3%). In the 7–9 clusters, the mean is 27.7% (p = 0.029).

Food waste reduction programs exist in 28% of the municipalities that replied. These programs are more prevalent in the 4–6 clusters, and exist in 38.5% of municipalities where a sustainability coordinator is employed, compared to 11.8% where one is not employed (p = 0.056). Similarly, they exist in 33.3% of municipalities that have a common team for sustainability and health, compared to only 15.4% who do not. Where such a program exists, there is 27.5% recycling compared to 19.8% where it does not exist.

SDG13—Take urgent action to combat climate change and its impacts. Climate change preparedness programs exist in 42.5% of the municipalities who replied to the survey. The prevalence of such a program increased significantly with the increase in the SEC (p = 0.046). They exist in 61.5% of municipalities where a sustainability coordinator is employed, compared to 23.5% where one is not employed (p = 0.016).

SDG16—Promote peaceful and inclusive societies. A program to combat violence exists in 42 out of 43 municipalities. The one municipality that does not operate this program is a regional council in cluster 7.

SDG17—Strengthen the means of implementation and revitalize the Global Partnership for Sustainable Development. Partnerships for sustainable development exist in 39 out of 41 municipalities who replied. Inter-departmental task groups exist in 89% (40 out of 45), and joint teams for promoting health and sustainability exist in 71% (32 out of 45) of municipalities. In addition, 15 municipalities mentioned partnerships with different services within the city. All these indicators were not associated with socio-economic cluster.

In summary, more affluent cities (higher SEC) are in a better position regarding achieving most of the SDGs. Low-SEC municipalities are in a better position only in relation to SDG6 and SDG10. However, in most activities related to achieving the goals, the political commitment is most influential, and not the SEC. The existence of a sustainability coordinator mainly promotes the most direct environmental activities, such as solar panels, reducing food waste programs, and climate change preparedness programs. Specific details on each municipality, using the traffic light colors, are presented in the Supplementary Materials (Table S1).

5. Discussion

The results of this study provide the IHCN information on the current status and activities that are being carried out in its member municipalities in relation to achieving the SDGs. It serves the three purposes that we set out to accomplish. The first is identifying gaps and weaknesses to direct capacity building and supporting programs of the member municipalities. The second is a baseline for evaluating the municipalities’ progress over time. This also identified some structure and process determinants, which may direct further interventions. Municipalities differ in their SEC, population size, and type. All these variations have an impact on their status and activities relating to achieving the SDGs. However, as all the municipalities in this study are members of the IHCN, most of them have a political commitment to health and sustainability, a health coordinator, and partners in the municipality and in the city. These characteristics are mandatory in all member cities [41]. The similarities made the comparison between municipalities challenging.

Evaluation of processes in municipalities and comparisons between municipalities, even within the same country, is a complex mission [42]. The uniqueness of each municipality relates to many variations, i.e., geographical, socio-economic, cultural, and religious. These variations are more pronounced in immigration countries, such as Israel [43,44,45]. Regarding the assessment of the SDGs, this mission becomes even more complex. A total of 231 indicators are available to assess achieving the 17SDGs [12]; however, not all are relevant to every country or local municipality. Our study corroborates previous recommendations that each country and municipality should focus on SDG indicators that are relevant to them [1,34]. A smaller set of indicators that are relevant and easily accessed should be used. As we followed this recommendation, a short list of indicators was chosen, leaving out SDG14 and 15, as their indicators are not relevant to our municipalities. Regarding comparisons between municipalities, we adopted the idea of referring municipalities to the cumulative distribution of all those who participated in the study [39]. We simplified the comparative analysis of Lafortune et al., who succeeded in presenting European cities’ achievements on a scale of 0 to 100 [40].

The SDGs are a combination of three dimensions—economic, social, and environmental—and are closely linked to health promotion [46,47]. Morton et al. [8] claim that there is an agreement that “addressing all three dimensions collaboratively will yield the greatest benefits”. It seems that municipalities, especially the lower SEC municipalities, need national support to achieve some goals. On an individual basis, Israel provides support to alleviate poverty through special programs of several Ministries and national agencies [15]. This support system is reflected in the indicator of SDG1. At the municipal level, the Ministry of the Interior provides Balancing Grants to low-SEC municipalities, which are supposed to financially support them.

Our underlying assumption was that affluent municipalities have the resources to invest in climate-change-related and other long-term strategies and developments related to the SDGs, compared to destitute municipalities who need to allocate their resources for mundane, basic day-to-day services for their residents. However, commitment to the implementation of the 2030 UN Agenda is not associated with SEC. It probably reflects higher awareness of sustainable development, which is represented by having a common team for sustainability and health.

Ultra-orthodox Jews (UOJ) and Muslim Arabs are both insular, traditional, and religious populations with a unique culture [48,49,50]. These populations have similarities between them and yet have significant differences. A few common denominators between them are low socio-economic status (SES), modesty between genders, patriarchal societies, the importance of religious studies, and religious leadership [51,52,53]. All UOJ and Arab municipalities of the IHCN are in the lowest SEC. The unique cultural and religious characteristics must be considered when assessing these communities, as well as when monitoring their progress over time.

Another assumption was that the coordinators who replied to the questionnaire are more active in the IHCN and have more activities related to achieving the SDGs than those who did not. The only available data for checking this compared the participation in the IHCN activities in the last three years (2018–2020). These data are recorded routinely. A share of 38% of the coordinators who replied participated in more than 50% of the activities; this is compared to only 20% of those who did not reply.

This study noted that although only a few municipalities have a defined policy for the 2030 agenda, most municipalities provide activities toward achieving the SDGs. The proportion of cities that are active in achieving the goals presents a similar trend to what is presented in the 2019 SDG index and Dashboards report of 45 capital cities in Europe [40]. Most IHCN cities are active towards SDG3 and SDG2, and in much lower proportion regarding SDG13 and SDG12. This is similar to the performances of the European cities. Municipalities in the higher SEC received a higher score in most SDGs. However, the data demonstrated that the higher SEC municipalities have a lower score in the inequality indicator and water conservation. The higher class in these municipalities is mostly due to those who own larger houses with gardens that consume substantial amounts of water. This is consistent with Wackernagel, who claims that an increase in income influences the ecological footprint [54]. A larger ecological footprint is counter-productive to achieving many of the SDGs.

Poverty is prevalent in the lower SEC municipalities, as was also demonstrated in the national report to the UN [15]. However, these municipalities are active in supporting their residents. Our results show that the lower SEC municipalities have a higher score for programs to ensure food security for children and the elderly. There is a national project for nutrition security, by which needy families receive support for purchasing certain food products [15]. This project operates in 36 Israeli municipalities [15]. These municipalities also have fewer programs for reducing inequalities, as there is less inequality in these municipalities, compared to the higher SEC municipalities where the inequality is more pronounced. The big question is how to close the gap between municipalities and within affluent ones. Health equity indicators that focus on the social determinants of health should be used. These indicators should be context-specific and meet local needs [42,55,56]. Giles-Corti et al. [11] refers to these indicators as “up-stream” indicators. We used indicators that reflect the structure and processes of the healthy cities’ operation as “up-stream” indicators.

Higher SEC municipalities have food security programs for children and elders even though the percentage of the needy population is much lower than in lower municipalities. Food waste reduction programs are more prevalent in higher SEC municipalities. This might reflect the excessive amount of food that goes to waste in the higher SES population, as was demonstrated by Gupta et al. [57]. This would necessitate programs to abolish this phenomenon or, at the very least, salvage food for the needy.

Education is a pathway to reduce inequalities in income and life expectancy [58,59]. Our results highlight that the lower SEC municipalities have a lower score relating to higher education. Acquaintance with the study population is fundamental as it must be considered that the UOJ population in Israel has its own education system. This system is primarily focused on religious studies, especially for men. The UOJ population does not undertake the matriculation exams [60]. This inhibits the possibility of higher education for this population unless they learn in specific segregated schools.

Almost all municipalities have health-promotion programs, which align with SDG3. This was expected, as each of the municipalities in the IHCN has a health coordinator as a prerequisite for participating in the network [27,61]. Municipalities who employ a health coordinator are entitled to apply for a grant from the Ministry of Health (MOH) through an initiative called “EfshariBari in the City” [62]. The grant funds are specific to implementing health-promotion programs in the municipality in a variety of topics. Most municipalities in the IHCN, of all SECs, were entitled to the grant money and have a special budget item for health promotion or a healthy city, either from the MOH or a combination of a budget allocated from the municipality and the MOH. As these funds are primarily targeted for health-promotion activities (SDG3), they do not always coincide with other SDGs. This may explain the lack of association between having a special budget item for health and the performance in terms of achieving most of the goals. Cities may have other budget items, from other departments, that cover environmental and sustainability issues.

Another fundamental role of the health coordinators is to work in partnerships, both with representatives from departments within the municipality, and local and professional representatives from outside the municipality. They are also encouraged to conduct consultations with citizens. A common team for sustainability and health that operates even without a sustainability coordinator is a good example of partnership within the municipality. This common team is found to be one of the building blocks for having a 2030 agenda. This is correlated with SDG11 and SDG17.

A positive predictor for success in several SDGs (7, 12, 13) is the presence of a sustainability coordinator within the municipality. Having a sustainability coordinator suggests the commitment of the mayor towards environmental issues. Political commitment is reflected by three characteristics: adequate funding, a comprehensive program together with a strategic plan towards implementation of sustainability, and a coordinator to lead the program/plan [63].

As discussed previously, most of the lower SEC municipalities are Arab or UOJ municipalities. We see that the lower cluster of municipalities has lower rates of gender equality programs, although these are mandatory in Israel [15]. They also have lower rates of sexual harassment prevention programs, as these topics are considered “impure” by religious leaders [64,65]. Women are not encouraged in both communities to pursue managerial careers or high position professions; this is reflected by the low score these municipalities achieved in SDG5. The program addressing girls and women in trouble, as a national program, is provided by almost all municipalities, as it does not contradict any values or traditions.

Our results showed significantly lower scores for recycling (SDG12) and solar panels (SDG7) in low-SEC municipalities. Solar energy is the primary renewable energy in Israel [15]; however, it requires a significant municipal investment. These lower SEC municipalities probably allocate more funds to tackle hunger and poverty (SDG1 and SDG2) than environmental issues. These SDGs are probably high on the mayor’s agenda. He has a better chance of being reelected if he supplies the basic amenities and services for his residents. Progress towards achieving those goals should be evaluated.

Asadikia et al. [66] identified the top co-beneficial SDGs that determine having a higher SDG index. In European and central Asias countries, SDG10, SDG9, and SDG8 are the most influential. In our study population, low-SEC municipalities have a low score for SDG9, which was measured as percent land usage for industry. This situation impacts the municipality’s income from property taxes, which, in turn, impacts the ability to invest in activities. This goes hand-in-hand with the negative change in the realistic monthly income of self-employed, which is higher in the low-SEC municipalities.

Although this research was aimed at municipalities, it is necessary to understand the implication of the inter-relationship between the local and national commitment to achieve the SDGs. On issues where the national government has embedded laws and policies and allocated funds, activities towards achieving those SDGs will be implemented in almost all municipalities. An example is the national program to abolish violence (SDG16) and the law that enforces accessibility in public places (SDG11). All municipalities are required to deal with these topics. However, more national support is needed for the low-SEC municipalities. On the other hand, as was suggested by Jossin and Peters [38], each municipality is advised to relate to its own needs and may add indicators reflecting them. An alignment of local goals and needs assessment, together with national funding and program guidance, may be the winning card for achieving the SDGs.

6. Limitations

The main limitation is the fact that most of the data that might indicate achieving the SDGs are not available in the monitoring systems. We had to compile data by asking the city coordinators to provide it. As only 45 replied (out of 55), although there were similarities between the respondents and the nonresponses in relation to some available variables, the respondents may differ in their activities as they are less active in the IHCN. The impression that we have regarding progress of active municipalities in achieving the goals might be biased. However, we should track those who replied and monitor their progress over time. Another limitation is the small number of participants in the study, and the fact that most independent variables are prevalent in most municipalities; therefore, it was impossible to undertake a multivariate analysis. We could not indicate the independent contribution of several variables that were interconnected, such as political commitment, investment of the health coordinator, and existence of a sustainable development coordinator. However, we may assume that political commitment is a prerequisite to having all other amenities. As we referred only to member cities of the IHCN, we may not assume that they represent other cities in Israel.

7. Conclusions

The present study provides the IHCN with a valuable database, both for planning capacity building processes and for monitoring and evaluating progress over time. It also raises the issue of the role of the IHCN in advocating for national equity policies and raising awareness of municipal leaders. An explicit commitment to implementing the 2030 UN Agenda at the local level is more prevalent in municipalities that have a sustainability coordinator or at least a common team for health and sustainability. We urge and advise municipalities to nominate the coordinator and assemble the team.

The variabilities between municipalities should direct the monitoring and evaluation system to be specific for each municipality. At the very least, changes should be tracked over time in similar municipalities according to their SEC, population size, or demographic characteristics. Each municipality is advised to track its own progress over time. The type I indicators can be accessed by anyone as they are available on national websites. For the type II indicators, our tool may guide municipalities in assessing their own activities. It is also clear that municipalities are not completely independent. They benefit from national support whether by appropriate laws, policies, or funds. We could verify this notion with the wide implementation across different SECs of indicators that reflect national policies or programs. The simple methodology and tools presented here can be used by any municipality for its own monitoring and evaluation, as well as by national networks and other governance bodies.