Our cities, our health, our future: Acting on social determinants for health equity in urban settings Report to the WHO Commission on Social Determinants of Health from the Knowledge Network on Urban Settings Hub: WHO Kobe Centre, Kobe, Japan July 2007 Presented by: Mohamad Ranjbar PhD student in health policy Tehran university of medical sciences 1

1.Introduction The purpose of this report is to synthesize what is known about social determinants of health in urban settings and provide guidance and examples of interventions that have been shown to be effective in achieving health equity. Health equity, as defined by WHO, is “the absence of unfair and avoidable or remediable difference in health among populations groups defined socially, economically, demographically and geographically” 2

The Commission’s conceptual framework (WHO, 2005d) identified two major groups of social determinants of health: 1.“Structural determinants are those that generate social stratification. These include income, education, gender, age, ethnicity and sexuality. 2.Intermediate determinants emerge from underlying social stratification and determine differences in exposure and vulnerability to health-compromising conditions (e.g. living and working conditions, housing, access to health care and education). 3

Figure 1. Percentage of urban population living in “slums” in different countries 4 A strategic focus on slums and informal settlements in the urban setting

5 Table 1. Infant and under-five mortality rates in Nairobi, Kenya, Sweden and Japan (Source: APHRC, 2002; IMR = deaths per 1000 new born; U5M = deaths per 1000 children) Unmasking health inequity in urban settings

Optimizing the urban setting for health Urbanization can be beneficial for health. Urban areas can provide a healthy living environment; indeed, they can improve health via their various material, service-provision, cultural and aesthetic attributes The improvements over the last 50 years in mortality and morbidity in highly urbanized countries like Japan, Sweden, the Netherlands and Singapore are testimony to the potentially health promoting features of modern cities. Health hazards remain and new health challenges have developed but creating healthy urban living conditions is possible. 6

2. Urbanization and the urban setting as health determinants 2.1 Urbanization in a global context - The world is becoming urban Slide 8Slide Slum formation with rapid urbanization - Poverty leads to slum formation and ill-health 2.3 A conceptual framework for urban health figure 1figure The economics of urban health development - Investments in urban health can create major returns for the economy - Improvements in incomes in the urban setting contribute to better health - Economic growth and better income is not enough 7

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2.3 A conceptual framework for urban health 9

2. Urbanization and the urban setting as health determinants 2.5. Poverty, deprived urban living conditions and health vulnerability - Urban poverty and unhealthy living conditions are associated health determinants 2.6. Healthy urban governance - Governance is not just about government - The emerging pathway for change: Healthy urban governance 10

Figure 5. Developing interventions for health equity in urban settings (simplified approach prepared for KNUS) 11

3. The urban health situation 1.Urban poverty is a cause of much of the global burden of disease 2.Communicable diseases: remaining and emerging concerns 3.Social determinants of great importance for the spread of the HIV/AIDS pandemic 4.Road traffic injuries: a growing urban health threat in developing countries 5.Urban violence and crime affect the poor in countries at all development levels 6.The stresses of poverty are a factor in poor mental health 7.Substance abuse and illicit drug use linked to social conditions 12

4. Key issues and challenges in achieving health equity 4.1. Environmental health threats in the home and neighbourhood - Lack of water and sanitation remains a major health threat for the urban poor Table 2Table 2 - The poor need cleaner household fuels figure3figure3 - Housing and shelter quality: strong health determinants 13

Table 2. Estimates for the proportion of people without adequate provision for water and sanitation in urban areas,

Proportion of urban poor and rich using solid fuels in the household 15

4.2. Environmental health threats in the wider urban area - Urban air pollution, traffic safety and emerging infections of concern 4.3. Health threats at work - Uncontrolled workplace health hazards common in low income settings 4.4. Urban health impacts of global resource depletion and environmental change - Policies for sustainable development need to integrate aim of health equity - Global climate change, a major threat to health of the poor in rural and urban areas 16

4.5. Health care systems and emergency services - Access to affordable health care in urban settings is a key health equity issue - Ill-health can be a cause of poverty and inequality 4.6. Gender and women’s health equity issues - Women have particular health needs and vulnerabilities 4.7. Other vulnerable groups - Demographic change and ageing: growing health equity challenges 17

5. A broad spectrum of interventions 5.1 Building trust, social capital and social cohesion Social cohesion, a firm base for urban health equity interventions 5.2 A range of specific interventions Improving the living environment is essential 5.3 Interventions via primary health care A health system that is equitable Communicable disease control a priority Primary health care services for all 5.5. Healthy settings and healthy cities approaches to interventions The healthy cities movement has created a vehicle for health equity interventions 18

5.6 Urban development planning and investment to avoid new slum formation Proactive urban planning with genuine engagement of the urban poor supported by sufficient investment 5.7. Good governance bringing together all interventions Combined impact of many interventions maximized by good governance 19

6. Approaches and policies to make interventions happen 6.1 Toward an integrated approach to reducing health inequity in the urban setting An integrated approach with meaningful community participation brings lasting solutions 6.2 Health, a rallying point for achieving improved life quality Healthy public policy brings different sectors together for urban health equity 20

6.3. Microfinance and local investment The local community can make step-wise health improvements even with limited funds 6.4. The global investments required for health equity At global level, approximately $200 billion per year of funding transfer from high income countries is needed to support health equity programs in low income countries 6.5 A fairer distribution of resources for health The funding transfer requirement is only 20% of the increased economic output of the high income countries 21