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Healthy Settings Healthy Settings –– to address to address Social Determinants of HealthSocial Determinants of Health

By AbdulBy Abdul--Sattar Yoosuf, Sattar Yoosuf, SDE/WHOSDE/WHO--SEAROSEARO

Presentation to thePresentation to theSEA Regional Consultation on SEA Regional Consultation on Social Determinants of HealthSocial Determinants of HealthSEARO, New Delhi, INDIA,SEARO, New Delhi, INDIA,1414--16 September, 200516 September, 2005

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Objectives of the presentationObjectives of the presentation1.1. To highlight principles underlying the To highlight principles underlying the

idea of Healthy Settingsidea of Healthy Settings2.2. To describe the ongoing action on To describe the ongoing action on

Healthy Settings in SEAR and present Healthy Settings in SEAR and present some findings on performancesome findings on performance

3.3. To delineate relevance of the HS To delineate relevance of the HS process for informing and effecting process for informing and effecting change in SDHchange in SDH

4.4. How WHO can help the process How WHO can help the process

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1. Contextual and Elemental 1. Contextual and Elemental SettingsSettings

Contextual settingElemental

Setting

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Types of settingsTypes of settings

MunicipalityMunicipalityTownshipTownshipIslandIslandSchoolsSchoolsWardWardVillageVillageWorkplace Workplace HospitalHospitalBuildingBuildingGreenspaceGreenspace / park/ parkRestaurantRestaurantMarketplaceMarketplace

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Characterizing a Healthy City type of activity

Written POA

Managerial Mechanisms

Community involvement

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Dynamic of Healthy Settings - an Evolving process

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2. SEARO action2. SEARO actionSupport planning / Support planning / conceiving /advocatingconceiving /advocatingTraining / EvaluatingTraining / EvaluatingInformation sharingInformation sharingInterInter--departmental team departmental team building building –– Healthy Healthy Districts idea Districts idea Generating regional Generating regional policypolicy

ESCAP resolutionESCAP resolutionRC54 resolution RC54 resolution ––Healthy settingsHealthy settings

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Healthy Cities in SEAR Healthy Cities in SEAR –– some some examplesexamples

Bangladesh Bangladesh –– ChittagongChittagong, Cox, Cox’’s Bazaar, s Bazaar, RajshahiRajshahi, , SylhetSylhet

BhutanBhutan –– ThimpuThimpu, , GelephuGelephu, , PhoenshoelingPhoenshoeling

IndiaIndia –– Delhi, Delhi, MirzapurMirzapur, , Bangalore Bangalore KottayamKottayam

MyanmarMyanmar –– MadalayMadalay, Yangon, YangonMaldivesMaldives –– Male island, Male island,

GA GA VillingiliVillingili islandislandNepal Nepal –– LalitpurLalitpur, , TansenTansen, ,

BanepaBanepa, , DhulikelDhulikelSri LankaSri Lanka –– MataleMatale, , BadullaBadulla, , AmpareAmpare, ,

ElluvapitiyaElluvapitiya village, village, ColomboColombo

ThailandThailand -- YalaYala, Bangkok, , Bangkok, NakornNakorn--ratchasimaratchasima, , PhayaoPhayao and and PanutnikomPanutnikom

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Community Action in SEAR Community Action in SEAR (NGO/(NGO/GovtGovt/development agency promoted)/development agency promoted)

Metropolitan Metropolitan EnvEnv. Improvement . Improvement programsprogramsSaravodayaSaravodayaJanasaviya/Suvasaviya/SamurdiJanasaviya/Suvasaviya/SamurdiAdipuraAdipura/Clean Friday/Clean FridayModel villageModel villageBasic minimum needs actionBasic minimum needs actionCooperative group housingCooperative group housingGrameenGrameen Bank and other microBank and other micro--creditcreditBRAC/BRAC/GonashasthyaGonashasthya KendraKendraSulabhSulabh /Religious Missions/Religious MissionsSEWASEWA

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Types of issues addressedTypes of issues addressedPublic health awareness Public health awareness raising raising Water quality, sanitation, Water quality, sanitation, vector control, air qualityvector control, air qualityImmunizationImmunizationHealth servicesHealth servicesHealth information generationHealth information generationMother and Child healthMother and Child healthIncome generationIncome generationFood safety and hygieneFood safety and hygieneCommunicable diseases Communicable diseases (HIV/AIDS, Malaria, TB)(HIV/AIDS, Malaria, TB)NCD risk factors (tobacco, NCD risk factors (tobacco, physical inactivity, diet), injury physical inactivity, diet), injury prevention, substance abuseprevention, substance abuse

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Evaluation parametersEvaluation parametersfor Healthy Citiesfor Healthy Cities

Achievement of Achievement of objectivesobjectivesDegree of involvement Degree of involvement of stakeholdersof stakeholdersMunicipal process Municipal process changechangePartnership and Partnership and collaborationcollaborationSustainabilitySustainability

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Findings Findings –– Strengths/opportunitiesStrengths/opportunities

Political will mobilized Political will mobilized –– even though more at the even though more at the initiation stageinitiation stageThe idea/concept of Healthy Settings as The idea/concept of Healthy Settings as potential for interpotential for inter--sectoralsectoral action is catching on action is catching on ––evidenced by the increased numbers of such evidenced by the increased numbers of such settings and WHO and ESCAP resolutionssettings and WHO and ESCAP resolutionsThere is increasing inquiry by levels of policy There is increasing inquiry by levels of policy and academiaand academiaManagerial capacity of coordinators and settings Managerial capacity of coordinators and settings managers have improvedmanagers have improved

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Findings Findings –– Strengths/opportunitiesStrengths/opportunities

Committed mayors (ownership) have Committed mayors (ownership) have made intermade inter--sectoralsectoral collaboration possiblecollaboration possibleNGO involvement in capacity building and NGO involvement in capacity building and service delivery seenservice delivery seenIncorporation of HC as a operational Incorporation of HC as a operational mechanism for urban development into mechanism for urban development into national plan in one country including national plan in one country including budget (Thailand 9budget (Thailand 9thth National National Development Plan 02Development Plan 02--06)06)

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Findings Findings –– weaknessesweaknesses

Involvement of the poor and women were limited Involvement of the poor and women were limited (why?? (why?? –– not focused on them?)not focused on them?)Predominantly male leadership in Predominantly male leadership in HCPsHCPs. Why?. Why?Decentralization remained poor in larger Decentralization remained poor in larger programs (city and even municipality level) programs (city and even municipality level) Why??? Parochial/patronage culture??Why??? Parochial/patronage culture??Very limited change in written policies and Very limited change in written policies and processes of the local government because of processes of the local government because of HC (HC (BanepaBanepa, , YalaYala, , MataleMatale, are exceptions). , are exceptions). Why?Why?

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Findings Findings –– weaknessesweaknesses

Deeper roots of healthy cities seen where Deeper roots of healthy cities seen where cooperatively written plans and separate HC cooperatively written plans and separate HC management structures exist.management structures exist.Political leadership takes too much of the Political leadership takes too much of the ownership leaving others players reactive (public ownership leaving others players reactive (public sector driven)sector driven)Networking among cities minimal Networking among cities minimal Too much banking on image, power and charisma Too much banking on image, power and charisma of the leaderof the leaderAlthough new resources are being mobilized, Although new resources are being mobilized, scanty evidence of rescanty evidence of re--programmed local resourcesprogrammed local resources

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LessonsLessonsParticipation was greater when the community Participation was greater when the community was well aware of the programwas well aware of the programDegree of involvement of stakeholder was Degree of involvement of stakeholder was influenced by the economic status of individual influenced by the economic status of individual and by type of activity. and by type of activity. Output was better in smaller settings (school, Output was better in smaller settings (school, ward, township, island, building, etc) than in city ward, township, island, building, etc) than in city wide actionwide actionWell prepared plans and management Well prepared plans and management processes are needed for success processes are needed for success –– inclusive inclusive community involvement for sustainability community involvement for sustainability

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Examples of Healthy Settings Examples of Healthy Settings EffectivenessEffectiveness

Healthy cities initiatives in Thailand in 1996 have Healthy cities initiatives in Thailand in 1996 have led to the inclusion in the 8led to the inclusion in the 8thth and 9and 9thth National National Economic and Social Development Plan (1997 Economic and Social Development Plan (1997 ––2006), as main approach for urban development2006), as main approach for urban developmentHealth promoting schools and hospitals (in some Health promoting schools and hospitals (in some countries) demonstrated the benefit to children, countries) demonstrated the benefit to children, families, schools, hospitals and communities, in families, schools, hospitals and communities, in terms of health gains and increasing productivityterms of health gains and increasing productivityHealthy Healthy VillingiliVillingili Island demonstrated the Island demonstrated the resilience of community energy in a total selfresilience of community energy in a total self--help strategy help strategy –– fully community resourced.fully community resourced.

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3. SDH3. SDH--Healthy Setting linkageHealthy Setting linkage

Going beyond the proximate determinants Going beyond the proximate determinants (cause behind the cause) (cause behind the cause) Interventions to move from being merely Interventions to move from being merely technical to political applicationstechnical to political applicationsGovernance structure and mechanisms need Governance structure and mechanisms need attentionattentionSustainability focus through attending to Sustainability focus through attending to behaviorbehaviorTeam building nurtured through local valuesTeam building nurtured through local values

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How can WHO be more How can WHO be more involved?involved?

Have an inHave an in--house participative house participative demonstration project in the Regiondemonstration project in the RegionHave an MCA area of work on H/SettingHave an MCA area of work on H/SettingCollectively embark on implementing the Collectively embark on implementing the RC54 Resolution on Healthy Settings RC54 Resolution on Healthy Settings Transform existing other Transform existing other TUsTUs’’ community community based interventions into Healthy Settingsbased interventions into Healthy SettingsMore focused operational policy on teamMore focused operational policy on team--work (in planning, monitoring, evaluating)work (in planning, monitoring, evaluating)

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InterInter--program concept for the cooperative program concept for the cooperative effort.effort.

Health PpromotingSchools

Distric Health Systems

Healthy Cities

Healthy Settings program

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How to Do????How to Do????How can we make this happen?How can we make this happen?What would be the in house mechanisms?What would be the in house mechanisms?How should programs structures be How should programs structures be changed?changed?How should budget allocation processes How should budget allocation processes be be changed?changed?What should be new managerial structures What should be new managerial structures and mechanisms?and mechanisms?

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