Cities are important drivers of productivity, innovation, and economic growth. To achieve their full economic potential, cities must deliver high-quality public services to their residents and businesses. This is very important for Latin American cities given rapid urbanization and the deepening of decentralization reforms in many countries. The extent to which they can carry out all of these responsibilities depends at least partially on their fiscal health, ability to meet their service, infrastructure, and financial obligations with the revenue available to them. This study assesses the fiscal health of 80 main cities in Brazil, Colombia, Mexico, and Peru, from 2010 to 2017, and explores the factors that drive it. A primary purpose is to provide a methodology for cities to assess their own fiscal health, given available data. As such, it helps to determine whether fiscal distress is building up in selected large cities across the region and to understand whether and how financial solvency, public service delivery, and the maintenance and expansion of urban infrastructure may be compromised.