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: – 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 time s Ottawa Charter, 1986 Healthy Cities In Europe 1980s Ottawa Charter, 1986 Healthy Cities In Europe 2000s Report of WHO Commission on Social Determinants of Health, 2008; Bangkok Charter on Health Promotion in a Globalized World, 2005; WPRO Alliance for Healthy Cities 2000s Report of WHO Commission on Social Determinants of Health, 2008; Bangkok Charter on Health Promotion in a Globalized World, 2005; WPRO Alliance for Healthy Cities 1990s Agenda 21 WHO Commission on Health and Environment 1995: Healthy Islands 1990s Agenda 21 WHO Commission on Health and Environment 1995: Healthy Islands 2009 Resolution WHA 62.14: Reducing health inequities through action on the social determinants of health 2009 Resolution WHA 62.14: Reducing health inequities through action on the social determinants of health 2011: Rio Political Declaration on Social Determinants of Health; 9 th PIHMM 2011: Rio Political Declaration on Social Determinants of Health; 9 th PIHMM 2012: WHA Outcome of the World Conference on Social Determinants of Health 2012: WHA Outcome of the World Conference on Social Determinants of Health 2015: Sustainable Development Goals 2015: Sustainable Development Goals 1946 WHO definition of health 1946 WHO definition of health 1960’s Studies on Environmental health 1960’s Studies on Environmental health 1970s Primary health Care, health for all, urban primary health care 1970s Primary 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 Urbanization, including slum formation and suburbanization Economic environment Social environment Natural environment Built environment Other factors Globalization 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 Matrix POLICY DOMAIN INDICATORSNEIGHBOURHOODS #1#2#3#4#5#6 PHYSICAL ENVIRONMENT & INFRASTRUCTURE Access to safe water Access to improved sanitation SOCIAL & HUMAN DEVELOPMENT 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 Steps 1.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 cities NCDs 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