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/