addressing the social determinants of health in cities through health in all policies (hiap)...
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Addressing the social determinants of health in cities through Health in All Policies (HiAP)
approaches
Anjana Bhushan Coordinator (Equity and Social Determinants), Division of Health Systems,
WHO Regional Office for the Western Pacific
Health in megacities
•People in new urban settings may be the most vulnerable
•Their health needs may be invisible
•Their living and working conditions may pose serious health risks and threats
TB prevalence among poor and non-poor, Philippines
Source: Philippines NTP, 2000
Urbanization as a social determinant
Urban determinants of health
Structural determinants• Poverty• Gender• Ethnicity• Education and health literacy
Intermediate determinants• Living and working conditions• Social and political exclusion• Social capital• Access to quality health care• Violence and crime: gender-based violence• Transportation• The environment
• 24% of urban dwellers live in slums
• Since 200, 55 million new slum dwellers added
• 120,000 people added daily to Asian cities, requiring at least 20,000 new dwellings and supporting infrastructure
• By 2030, about 3 billion people will need proper housing
Living conditions
Characteristics of slums
• Lack of basic services• Substandard, inadequate
building structures• Overcrowding, high density• Unhealthy, hazardous
locations• Insecure tenure, irregular
or informal settlements• Poverty, social exclusion
Urban health hazards
• Estimated annual impact of urban air pollution in developing countries:– 130 000 premature deaths– 50–70 million incidents of respiratory illness
• Traffic: among worst health hazards for urban poor– despite terrible congestion, motor vehicle use is soaring– by 2020, about ½ of the world’s 1.3 billion motor vehicles
will run in cities in poorer countries– road accidents will be 3rd leading cause of death
A look back over time1940 1960 1970 1980 1990 20001950 2010
1980sOttawa
Charter, 1986Healthy Cities
In Europe
2000sReport of WHO Commission
on Social Determinantsof Health, 2008; Bangkok
Charter on Health Promotion in a Globalized
World, 2005; WPRO Alliance for Healthy Cities
1990sAgenda 21
WHO Commissionon Health and Environment
1995: Healthy Islands
2009Resolution WHA 62.14:
Reducing health inequities through action on
the social determinants of health
2011: Rio Political
Declarationon Social
Determinantsof Health;9th PIHMM
2012: WHA 62.14Outcome of the
World Conference on Social
Determinants of Health
2015: Sustainable
Development Goals
1946WHO definition
of health1960’s
Studies on Environmental
health
1970sPrimary health
Care, health for all, urban
primary health care
2015
Horizontal health governance: evolving concepts
First wave: intersectoral action—Alma Ata and PHC• Health sector collaborates with other sectors to improve health
outcomes• Rational approach
Second wave: healthy public policy—Ottawa & beyond• Explicit concern for health and equity in all areas of policy and
accountability for health impact• Incremental approach
Third wave: Health in all Policies—acting on SDH• Horizontal, complementary policy-related strategy with high
potential to strengthen population health. Examines determinants of health, which can be influenced to improve health but are mainly controlled by policies of other sectors
• Network approach, suited to addressing “wicked problems”
The social determinants of health: The conditions in which we are born, grow, live, work, age & die
Overarching recommendations of the Commission
1. Improve daily living conditions
2. Tackle the inequitable distribution of power, money, and resources
3. Measure and understand the problem and assess the impact of action
Rio Political Declaration
(a) Better governance at the national level for health and development
(b) Participation in policy-making and implementation(c) Reorienting the health sector towards reducing
health inequities(d) Srengthening global governance and collaboration(e) Reinforcing accountability and monitoring of
progress
What can cities do?
Healthy urban governance
Industrialization Population growth,demographic change
Rural-urban migration
Marginalization and poverty
Urbanization,including slum formation
and suburbanization
Economicenvironment
Socialenvironment
Naturalenvironment
Built environment
Other factorsGlobalization
Health, wellbeing and human development
Health and its
determinants are
inequitably distributed within and between
urban settings
Healthy urban governance:
Manages these forces
Seeks balanced development
Creates conditions for health for all
Reduces inequity in health
and its determinants
• Geographical barriers: target/prioritize underserved areas
• Economic barriers: reduce out-of-pocket expenditure, consider targeted subsidies to underserved groups
• Low knowledge/awareness: language, gender, ethnicity barriers
• Stigma, fear of social isolation
• Lack of health system responsiveness: improve quality, reduce provider bias, contracting service delivery
Tackle barriers to access
Improve health system responsiveness
In monitoring and evaluation:• Disaggregate information by income, sex,
ethnicity, rural-urban residence, employment status, etc.
• Conduct operational research to: – Analyze incidence of benefits: do the poor
benefit at least proportionately?
Why or why not?
– Identify and evaluate options
Foster Health in All Policies
• Role of health sector: advocacy, evidence building, strengthening its capacity to convene stakeholders
• Multisectoral mechanisms and processes needed
• Tools: Urban HEART; health (equity) impact assessment; health lens analysis
Urban HEART
• Guides local policymakers, communities on appropriate actions to tackle health inequities
• Follows a standardized procedure of gathering relevant evidence and planning efficiently
• Core elements:– Sound evidence: disaggregation– Intersectoral action for health– Community participation
Urban Health Equity MatrixPOLICY DOMAIN INDICATORS NEIGHBOURHOODS
#1 #2 #3 #4 #5 #6
PHYSICALENVIRONMENT &INFRASTRUCTURE
Access to safe water
Access to improved sanitation
SOCIAL & HUMANDEVELOPMENT
Prevalence of tobacco smoking
Completion of primary education
Skilled birth attendance
ECONOMICS Poverty
Unemployment
GOVERNANCE Government spending on health
Voter participation
Urban HEART: Response
5 Strategy Packages of Interventions• Strategy A: Incorporate health in urban planning &
development• Strategy B: Emphasize and strengthen role of urban
primary health care• Strategy C: Strengthen the health equity focus in urban
settings• Strategy D: Put the health equity higher on the agenda of
local governments• Strategy E: Pursue a national agenda
ISA: 2 approaches, 10 Steps1. Health in All Policies: systematically consider health in all other sectors’
policies; identify approaches, opportunities for better quality of life
2. Issue-centred strategy: integrate a specific health concern into other relevant sectors’ policies, programmes and activities, e.g., FCTC adoption
10 steps (relevant to both approaches):1. Self-assessment
2. Assessment and engagement of other sectors
3. Analyse the area of concern
4. Select an engagement approach: issue, sector, opportunistic
5. Develop an engagement strategy and policy
6. Use a framework to foster common understanding between sectors
7. Strengthen governance structures, political will and accountability mechanisms
8. Enhance community participation
9. Choose other good practices to foster intersectoral action
10. Monitor and evaluate
Acting on SDH in citiesNCDs as programmatic entry point: •Build on ongoing development of multisectoral action plans for NCDs•Expand mechanisms for multisectoral action on NCDs to address broader SDH and health inequities, beyond NCDs•Value added of SDH approach: elevates attention beyond health sector, to higher (whole-of-government) level (e.g., Cabinet)•Role of health sector:
– Networking, partnerships, convening
– Advocacy
– Evidence-building
Supporting a HiAP approach• Policy development:
– Regional action agenda on UHC– SDH Sectoral briefing series
• Measurement, evidence: – Regional report on SDH– Regional report, case studies on HiAP– Urban HEART: China, Philippines,
Mongolia, Viet Nam, Fiji• Capacity building: HiAP training
manuals• Partnerships: UN platform on SDH
Thank you
http://www.wpro.who.int/topics/social_determinants_health/en/