URBAN HEALTH DEVELOPMENT
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Healthy Urbanization Learning Circles (HULC)
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RF_DEV_3_B_SUDHA
Healthy Urbanization Learning Circles are networks of multisectoral and interdisc
that will undertake action research projects at the city level through a guided process
introduce public health methodologies for action to improve governance, optimize the
social determinants and promote health equity in the urban settings.
Healthy Urbanization Learning Circles will undertake capacity-building activities c
9-12 month period that is organized around four modules:
• Module 1: Overview of Healthy Urbanization: Situation analysis
• Module 2: Healthy Urbanization Challenges: Strategy development and project
writing
• Module 3: Healthy Urbanization Opportunities: Social mobilization for intersect
• Module 4: Mainstreaming Healthy Urbanization: Sustaining action through adv<
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Healthy Urbanization Learning Circles will be guided by the following principles:
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• Emphasizing applied skills, not just theoretical knowledge;
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• Training in a highly interactive manner, drawing on personal experience to reinforc
learning;
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• Encouraging strategic thinking on the promotion of healthy urbanization;
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• Emphasizing the use of good governance principles in decision-making;
• Using action research projects to reinforce classroom learning, multiply training be
generate results;
• Providing opportunities for mentoring and technical support through national and ii
networking; and
• Soliciting feedback as a means of improving the learning process.
General criteria for participants in the Healthy Urbanization Learning Circles are i
preliminary guidance, but local groups are strongly encouraged to develop appropriat
meet the needs of their own site. It is proposed that participants are:
•
•
•
•
•
•
Recognized as being committed to the improvement of health in the city;
Known to value social justice and equity;
Respected as influential members of the community;
Engaged in work that promotes positive social values;
Highly motivated and will exercise leadership in their sphere of influence;
Representatives of different gender and sectors who are stakeholders in social
health.
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Developing strategies (Project Objective 1)
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Two frameworks for assessing Healthy Urbanization are presented here.
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A Framework for Assessing Healthy Urbanization - The WHO Regional Office for
has developed an urban health assessment framework to function as a practical-1
to provide reliable and comprehensive information for decision-makers, local governn
researchers, local communities, and public and private sectors to effectively and appr
address the challenges and opportunities to improve the health conditions in cities.
As urban health is a relatively new concept, there is little consensus on definitions an
Yet there is a common understanding that health and quality of life are influenced b/
conditions as well as lifestyles. Cities are facing great challenges in dealing with the u
its consequences, such as increasing health inequities and the emergence and deteric
and informal settlements; health inequities are observed within the city, from block t<
household to household. It is argued that the inequalities among individuals and citie
of local dynamics relating to economic, political, social and health conditions. The mu
act on these matters but effective intersectoral collaboration is needed.
The Healthy Urbanization Spidergram - This simple, powerful tool has been devel
WKC experience as a mean to measure social perceptions about the eight elements
urbanization. It can be appropriate for use at the municipal level to:
• understand "felt needs" of a group in relation to urbanization as a social deterr
• define a baseline on social perception within groups from the same setting and
one group feels about urbanization as a social determinant in relation to anot.i
• identify key areas for intervention based on subjective perceptions of lopsided
within an urban setting;
• provide a basis for analyzing a social gradient in perceptions about the urbaniz
• measure how group perceptions can be used as a variable that can be linked t<
outcomes;
• Serve as a starting point for complementary quantitative measurement.
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Capacity building (Project Objective 3)
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The capacity-building component, called the "Healthy Urbanization Learning Circl<
provides a structure for implementation of activities at the Healthy Urbanization Field
Participants are expected to carry out projects that will address social determinants o
health promotion approaches* and tools introduced during the didactic portion of the
programme is flexible, dynamic and can be adapted to local contexts by including aof
training and capacity-building materials, methods and approaches that are most suite
needs. It aims to enhance practical skills among teams across five categories (intra-p
qualities, interpersonal qualities, cognitive skills, communication skills and task-speci'
Opportunities for cross-regional sharing and learning are also provided.
In addition to training, activities may include action research projects, technical assis
monitoring group learning, technology transfer, field visits and international exchanqc
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*The curriculum and training materials of the Healthy Urbanization Learning Circles v\
materials that have been developed and tested through "Prolead", a health promotior
training template that was initiated at the WHO Western Pacific Regional Office in 20C
further expanded by the WHO Centre for Health Development in collaboration with th
offices of the Eastern Mediterranean Region and the Southeast Asian Region.
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Policy advocacy (Project Objective 4)
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Activities will be undertaken to ensure that new knowledge and good practices are lin
integrated with national health systems development and wider social and political pr
project will create opportunities to advocate for healthy public policy and more respoi
systems, particularly in relation to:
• Effective management of intersectoral collaboration to ensure maximum impact an
judicious use of limited resources for health;
• Decision-making that harmonizes competing interests to achieve the higher goal ol
equity as a social good;
• Empowerment of communities to ensure:
Identification of real problems and needs;
Judicious use of available resources;
Ownership and sustainability;
Timely action for improvement; and
Community-based management.
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j/ PRESS RELEASE
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? Tel: 078 230 3130/3128,
URL: http://who.or.jp/
29 October 2006
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Mayors pledge action on social determinants of health
Suzhou -- Mayors from six cities around the world are gathered in Suzhou to pledge
the emerging theme of "healthy urbanization". The leaders will speak at the Symposi
Urbanization held by the WHO Centre for Health Development today under the subhe
"Optimizing the impact of social determinants of health on exposed populations in urt
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In recent decades, economic globalization has pushed rapid and often unplanned u O;
serious consequences. The mayors of Kobe, Japan, Suzhou, China, Bangalore, India,
Chile, Ariana, Tunisia and Nakuru, Kenya will address key issues that have emerged 1
research and scoping papers under the Healthy Urbanization Project. Findings include
• In Bangalore, around 25% of the population lives in slums, while some 40% of
greater Bangalore are part of info rmal settlements. One-fifth of slum dwellers
noncommunicable diseases, with 15-20% dying from injury - suicide, road acc
violence. .
• In San Joaquin, Santiago, Chile, a strong correlation between income and morf
observed, with men in San Joaquin losing 123.4 years of life between 1999 an<
compared to 45.7 years in the wealthy nearby borough of Lo Barneachea.
• In Japan, home to the WHO Centre for Health Development, despite economic
working hours are up and wages are down. Of workers visiting health cent’-es i
had hypertension, 67% had high cholesterol and 53% had diabetes.
Dr Soichiro Iwao, Director of the Centre, will speak on the theme, "From Healthy Citit
Urbanization in the 21 st Century" on Saturday, 28 October, at 2.00 pm on the emen
required for healthy urbanization in a city.
During this event, the mayors will sign a statement to pledge their commitment to su
Healthy Urbanization Project.
More on the Healthy Urbanization Project can be found at http://www.who.or.jp
For further info rmation, journalists can contact: Ms Susan Loo, Policy Advocacy, WH<
Health Development Telephone: +81-078-230-3131 (direct) E-mail: chungs@wkc.v
Mr Richard Bradford, Public Information, Telephone: +81-078- 230-3136 (direct) E-n
bradfordr@wkc.who.int.
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Priority Project B: The effect of urbanization on risk factors for noncommur
diseases
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Swelling cities
Urbanization is now a truly global phenomenon, with a stream of rural-urban migrai
in the developing world. The percentage of the world's population residing in urban
from 38% in 1975 to 47% by 2002. Over three billion people now live in towns and
notion that better opportunities for health and other lifestyle improvements can alw
in an urban setting is under challenge.
Driven by globalization, many cities are today characterized by rapid urbanization, i
expansion, increased environmental impact and deeper inequity. Cities and municip
not equipped to cope with the rate of change and its social, political and environmei
ramifications.
The role of inequitable and unsustainable urban settings in promoting stress and otl
and environmental risks for disease is not well understood. Hence, urbanization anc
human health in relation to chronic noncommunicable diseases (NCDs) needs to b^.
examined.
Chronic NCDs - global burden rising
The rising global burden of disease is mainly due to noncommunicable diseases (NC
cardiovascular diseases, cancer, chronic respiratory disease, diabetes and h
They are now responsible for 60% of deaths worldwide and 48% of the burden of d
are related to lifestyle as well as to the physical and social environment - all of whit
rapidly, especially in fast-urbanizing developing countries. In fact, the change to hie
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Research Programme 2006-2007
Priority Project A: Preparing Health Facilities for Disaster it
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Health facilities in urban areas with high population densities play a special role in r
containing emergencies and responding to disasters. On the other hand, health faci
affected or exposed to risks, emergencies and disasters and are unprepared may pc
and more serious risks to the communities they serve. The project contributes to th
and dissemination of scientific knowledge on how health facilities in cities can best I
into emergency preparedness policies and the programmes of selected health facilit
eventually throughout health systems.
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Objective 1 - Conduct a situational analysis on the preparedness of selectei
facilities to withstand and respond to disasters
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Approach 1.1. Build an information base of health facilities that are structu
programmatically prepared for withstanding and responding to disasters
Product 1.1.1. Report findings of an analytical literature review on the pr'4
health facilities to withstand and respond to disasters in selected settings
Objective 2 - Characterize the features and attributes of effective health fa<
preparedness policies and programmes
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Approach 2.1. Develop, field-test and validate one or more methodologies i
the preparedness of health facilities to withstand and respond to disaster.
Product 2.1.1. A methodology for assessing health facility preparedness to
respond to disasters
Approach 2.2. Assess selected disaster preparedness policies and program!
characterize their features and attributes
Product 2.2.1. Report on assessment of selected disaster preparedness pol
programmes, and associated good practice guidelines
Product 2.2.2. An inventory of health facilities that are structurally and pro
prepared to withstand and respond to disasters
Objective 3 - Advocate effective health facility disaster preparedness polici
programmes within the context of health systems development using the d
reduction framework
Approach 3.1. Develop a database of experts and resource centres for heah
disaster preparedness and response
Product 3.1.1. A database of experts and resource centres for health faciliti
preparing for and responding to disasters
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Monitoring, assessment and evaluation in relation to the Healthy Urbanization Field R
will be approached from a co-learning perspective, mindful of the "learning-by-doing'
underpins project implementation. From this perspective, judgment is suspended as \
with our partners, how to improve health and reduce health inequity, particularly ami
populations. In this process, the timely gathering, documentation and dissemination <
critical — before, during and after the project.
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Evichnm Gathtring, Documcntatbn and bssamination Cycle
Formative
Assessment
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What is the status?
What do we want to change^
What do w e kno w?
\
What do we need to know?Jh^^k
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rnpact
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___________
Process
Who are we tryngto
/How are we doing it?
/ Who else must act?
Measuring the changes in the
short- i nte rme diata nd I ong-term
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Outcome
What are the
indicators?
1.
2.
3.
What are the changes?
• Policy
■ Legislation
■ Values (knowl edge, attrtu des
& practice)
4.
Be.
fime Frame. Before - During - After
This framework is a work in progress developed in collaboration with the 14
Office for South-East Asia.
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Demonstrating the applicability of strategies (Project Object
Strategies that are developed through the project will be applied in Healthy Urbanizal
Research Sites through several methods, all with an emphasis on action research to c
needs. Monitoring and evaluation of the strategies and methodologies will also take n
Action research - Action research consists of research methodologies which pursue
research outcomes simultaneously. Action research tends to be:
• cyclic — similar steps tend to recur, in a similar sequence;
• participative — the clients and informants are involved as partners, or at least actix
participants, in the research process;
• qualitative — it deals more often with language than with numbers; and
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• reflective -- critical reflection upon the process and outcomes are important compo
cycle.
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Monitoring and evaluation - Participatory methods will be emphasized in assessing
and evaluating the effectiveness of strategies in Healthy Urbanization Field Research
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J/-"-'7 i
. World Health Organization
CENTRE FOR HEALTH DEVELOPMENT^
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Hews >
___ __WKC
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Research Framework
In 2004-2005, the WHO Centre for Health Development undertook a process of con
partners and the scientific community to gain perspective on its future work for the
2015. A Research Advisory Group and associated Sub-Groups were convened to del
important research questions related to Ageing and Health; Urbanization and Healtt
Technological Innovation and Environmental Change and Health. The product of th.!
Proposed Research Framework for the WHO Centre for Health Development." This F
served as an important scientific reference in the development, by WHO and the Ko
ten-year (2006-2015) extension of the Memorandum of Understanding and the Cen
plans for the future.
A fundamental idea embodied in the Framework is that health is essential to develo
forces such as ageing and demographic change, urbanization, environmental char.g
technological innovation create conditions for both health improvement and impairn
development goals, health and welfare systems must respond in timely and creative
concept of "health in development" captures the notion that health is central to soci
development and vice-versa. The inter-relatedness of health and the development j
throughout the span of development; hence, "health in development" applies to bot
and developed countries.
From this perspective, the complex interdependency of increasing pressures on hea
systems and the effects of specific driving forces shape the research framework of t
Centre. The search for appropriate and practicable solutions to related priority publi
problems provides the focus for the Centre's work. With this in mind, the Research
proposed the following vision statement for the Centre:
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"Healthier People in Healthier Environments'’
The Centre adopted this vision statement with a view of health as a resource for livi
context of sustainable development. The Centre is positioned to undertake multidisc
research to optimize the determinants of health by generating, analyzing and com nr
evidence base that drives health-related policy and programme development and in
From this perspective, the complex interdependency of increasing pressures on hea
systems and the effects of specific driving forces shape the research framework of t
Centre.
Figure 1: The intersection of driving forces for health in
development
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Interaction of Driving Forces for
Health in Development
E nvironmental Change
logical
ration
Urbaniziftion
Ageing and
Demographic Change
The priority areas of research identified by the Research Advisory Group and the as
Groups cluster in five critical research arenas:
• Characterizing the determinants of health and health infrastructure;
• Assessing the existing situation;
• Projecting into the future;
• Providing solutions; and,
• Evaluating outcomes, programmes, models, needs and capacities, and measurinc
These five critical research arenas comprise the sequential steps of an integrated, it
that is necessary to generate the evidence base for driving health-related policy an<
development and implementation in relation to the challenges associated with the d
While this dynamic process can be entered at any of the steps, successfully meetinc
posed by a particular driving force requires strategic cycling through the complete p
ensure that the outcomes of research initiatives lead to viable and sustainable solut
problems.
Figure 2: Elements of a research framework
W Elements of a Research
Framework
Action and Interactive Research
Driving Forces
People interacting
vith Uieir
environment
Outcomes
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7The Healthy Urbanization Project
“ j
proposes eight elements of healthy urbanize
guide local, municipal and global action on social determinants of health in th
setting.
The eight elements represent key action areas for multisectoral stakeholders.
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Engages alt sectors
Energy eOctency
><
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Eiirmation of exreme
utUan poverty
-F-H-t—.. 1...t...
4—1- enforcements
and secur
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Squrty-based
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Empowerment Indi
and commune
systems
Expression of ctiinoi diversity
and spiritual vafees
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The Healthy Urbanization Spidergram is being field-tested as a tool for assessing social pe
urbanization and health in the Healthy Urbanization Field Research Sites.
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nutrient fast food diets and sedentary lifestyles is happening much more quickly in f
than was the case in the developed countries, bringing a double burden of commun
and NCDs.
The extent to which these risk factors are linked to urban living and the urban envir
to be better understood.
%
75
♦
Causes of death in WHO Regions
Source: WHO, World Health Report 2001
hronic NCD
Injuries
50
25
AIR
EMR
SEAR
WPR
AMR
EUR
Background in Depth
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The Urban Health Assessment Framework
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The ultimate purpose of the Urban Health Assessment Framework (UHF) is to provide
comprehensive information for decision and policy-makers, local governments and at
researchers, local communities, and public and private sectors. Functioning as a strat
the UHF aims to effectively and appropriately identify and address strength, weaknes
and opportunities to improve urban health conditions.
The UHF is considered a work in progress. It consists of conditioning phases such as
external forces, local forces, pressure, alert, action/vulnerability, impact and
conditioning phase is represented by macro determinants of urban health such as oer
economic, governance, social and physical environments as well as health. Each dete
denoted by major factors according to its respective conditioning phase.
The framework starts with external forces represented by the effects of globalization
policies that affect local decision-making and ultimately the health of people in the cit
external forces impact on local forces, represented by the economic and governance
turn exert pressure on the demographic pattern in the city, provoking an alert situau<
the various macro determinants. The outcomes of urbanization depend on the level o
the actions taken. Yet if these actions are deficient or absent, the city might face vulr
represented by the risk factors. This will eventually impact on the physical, social anc
environments of the city and its population.
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loosing and monii
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of the Americas
Pressure
'5
th the citees
*
Alert
/
1g
1
J
I
15
52
Action
-
Impact
*
I I
V
Favwafc!*
PAHO/WHO Urban Health Assessment Framework
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.,
?
Updated hv 7’/ April 2006
1
THE CORE PROJECT
PLAN OF WORK
WHO Centre for Health Development
Kobe, Japan
■ ■
b;
'
■
■
■
Updated by Tl April 2006
1.0
2
Introduction
1.1
Background
In 2004-2005, the Centre undertook a process of consultation with its partners
and the scientific community to gain perspective on its future work for the period
2006 2015. An Ad hoc Research Advisory Group (RAG) and associated Sub-groups
were convened to delineate the most important research questions related to Ageing
and Health, Urbanization and Health, and Technological Innovation and
Environmental Change and Health. The product of this process was “A Proposed
Research Framework for the WHO Centre for Health Development.”1 This
Framework served as an important scientific reference in the development, by WHO
and the Kobe Group, of the ten-year extension of the Memorandum of Understanding
to 201 5 and the Centre’s research plans for the future that are reflected in the Plan of
Work for 2006-2007.
The Ad hoc Research Advisory Group process highlighted the growing
importance of urbanization as a cross-cutting driving force and the central role that
cities and urban municipalities are beginning to play as key drivers of
modernization and social change. There was consensus on the need for inter
disciplinary, applied research into priority public health issues affecting urban
settings, particularly in relation to exposed populations. It was recognized that the
character of these settings in the 21st century is changing rapidly, and that the
increasing complexity of the factors affecting change and their impact on health and
well-being is not well understood.
Emphasis was also placed on the need to focus on the health and well-being of
exposed populations including the poor, the elderly, women and children. In the
context of urbanization and globalization, the problem of health inequity, particularly
in relation to exposed populations, was noted in all of the discussions. For example,
of the three billion people who live in urban areas today, one billion live in slums. As
the number of people born in cities increases and as people continue to be displaced
from rural areas, the urban slum population is expected to grow to approximately two
billion by 2030. resulting in a continuing and rapid urbanization of poverty and ill
health whose greatest impact will be felt in the developing world.
A significant amount of discussion in the Ad hoc Research Advisory Group
process in general, and in the Urbanization and Health Sub-group in particular,
revolved around the importance ot the social determinants of health in relation to
health inequity and the role of health governance as a critical pathway by which
social conditions translate into health impacts.
Based on deliberations during the Ad hoc Research Advisor}7 Group process,
related discussions with members of the Kobe Group2 and others, and the selection of
the Wl IO Kobe Centre as the Hub for the Commission on Social Determinants of
The World Health Organization Centre for Health Development. Health in Development - Healthier People in
Healthier Environments. A Proposed Research Framework for the WHO Centre for Health Development.
Kobe, Japan, August 2004.
' Comprising: Hyogo Prefecture, Kobe City, Kobe Chamber of Commerce and Industry, and Kobe Steel, Ltd.
Updated by ’U. April 2006
Health s Knowledge Network on Urban Settings, the future work of the Centre will
have the following strategic foci:
□ Monitoring and responding to “felt needs” - aiming to complement the
findings of epidemiological and public health research with information about the
needs felt by exposed populations.
□ Packaging knowledge from a health equity perspective to inform policy and
practice - Aiming to reduce health inequity by improving health governance.
□ Developing new knowledge to address existing and emerging areas of
vulnerability — Aiming to identify and advocate effective responses and
interventions in relation to driving forces.
The work will be carried out with a major emphasis on urban settings,
mindful of the “globalization-urbanization interface” that exists in these settings, with
the overall aim of reducing health inequity by optimizing the impact of social
determinants of health on exposed populations.
1.2
The presentation
The Core Project is organized around four areas of emphasis:
I • Developing strategies: Building an evidence base, generating policy ideas,
evaluating current experiences and interventions, developing public health
methodologies for health inequity assessment and evaluation and deriving new
knowledge on social determinants and health inequity.
-
Demonstrating the applicability7 of strategies: Demonstrating how 'generic”
municipal strategies can be applied and combined with tactical and context
specific interventions to reduce health inequity.
3. C apacitv building: Building capacity at the level of the individual, the
organization and the system through leadership training and applied projects.
4. Policy advocacy: Developing and applying principles of strategic communication
and advocacy to influence health governance at all levels and enhance
understanding of how the impact of social determinants can be optimized to
reduce health inequity.
Staff will work in and across these areas of emphasis in a multi-disciplinary
lashion to develop specific products. In addition, to provide effective liaison with
other WHO programmes and offices, as well as with other organizations, they will
serve as designated Focal Points for the following Areas of Work:
■
'
■
Surveillance, prevention and management of chronic, noncommunicable
diseases
Health promotion
Tobacco
3
'fi^-.^^^.ii^i't': ''T’rfJ.: ' ivliz''
Updated by 'l l. April 2006
■
■
■
■
■
■
■
■
■
2.0
4
Health and environment
Gender, women and health
Policy-making for health in development
Health system policies and service delivery
Human resources for health
Health information, evidence and research policy
Emergency preparedness and response
Mental health and substance abuse
Ageing and life course
Plan of Work Details
2.7
The Core Project - Optimizing the Impact of Social
Determinants of Health on Exposed Populations in
Urban Settings
2.1.1 Objectives
Within the overall purpose of the project - to reduce health inequity in urban
settings - the specific objectives for 2006-2007 are to:
1. Develop strategies to reduce health inequity in urban settings;
2. Demonstrate the applicability of strategies for reducing health inequity
among exposed populations in urban settings;
3. Build capacity for reducing health inequity in urban settings;
4. Advocate the reduction of health inequity in urban settings.
The model of the “Evidence-Informed Policy and Practice Pathway”3 (Brown
and Zwi, 2005) provides the basis for the research design of the Core Project.
According to this model, policy ideas, evidence, use of evidence and capacity to
implement evidence-based policies are interlocked in a series of decision-making
steps that are characteristic of how events unfold in practice. Policy ideas provide the
starting point for the sourcing of evidence. Sources of evidence are multiple and
varied. Using the evidence includes interpreting and applying knowledge in specific
contexts. Capacity to implement is considered from the perspective of the individual,
the organization and the system.
' From the PowerPoint presentation of the Knowledge Network on Measurements, given at the Meeting of the
Knowledge Networks, 10-12 September 2005, Ahmedabad, India.
Policy
idea
Sourcing the
EVIDENCE
•Knowledge
•Research
•Ideas/lnterests
•Poliltes
•Economics
USING the
EVIDENCE
Introducing. Interpreting,
applying
•Knowledge utilisation
CONSIDERING
CAPACITY
TO
IMPLEMENT
•Individual
•Organisational
•System/Pollcy
DOI: 10.1371/}ournal.prned.0020166.g001
2.1.2 Present plans, 2006-2007
Objective 1 - Develop strategies to reduce health inequity7 in urban settings
Approaches and products
Building the evidence base
Closer examination of existing evidence will be a key component for
developing strategies to reduce health inequity in urban settings. Knowledge will be
collated, analyzed, synthesized and organized to enable researchers, implementers and
decision-makers to gain easy access to information on the associations and pathways
betw een social determinants and health inequity in urban settings, in particular, the
evidence base will try to capture the policy ideas emanating from attempts to bridge
equity gaps through municipal health governance. Materials to be included in the
evidence-base will come from published and grey literature and from the worldwide
experience of Healthy Cities, Local Agenda 21 cities. Sustainable Cities, Cities
without Slums, the Urban Governance Initiative and other initiatives where the
city/municipality is both the entry point and setting for achieving sustainable change
and improvement in health.
From the evidence base, research teams will systematically review evidence
and select good examples of strategies and interventions that are promising or proven
to be effective in reducing health inequities in urban settings. A glossary of terms and
concepts will be developed to promote wider discourse on the subject in the scientific
community, as well as to supplement advocacy efforts in the political domain.
Updated by 77 April 2006
6
Ensuring local participation and ownership of research
Research activities will emphasize principles of community and stakeholder
participation and ownership. People’s participation in planning, implementation and
evaluation of research activities will be ensured. Thus, at the early stages of the
project, participatory and consultative processes will guide the identification of
exposed populations, prioritization of issues and concerns and the pursuit of
opportunities and imperatives for influencing health governance at the local level.
Multiple pathways of causality and associations may necessitate a wide range of
interventions for enhancing health governance. The emphasis in Objective 1 however,
will be on creating enabling environments for municipal-level action.
The project will develop generic municipal-level strategies for reducing health
inequity but will also construct a framework for tactical actions that facilitate
achieving rapid results in relation to the specific and unique contexts of urban settings
through collaborative research and other means. For this reason, selected urban areas
are initially proposed as field research sites for 2006-2007, where these will be
applied in: China, Chile, Japan and India. Sites in African and the Eastern
Mediterranean regions will follow. Project steering committees will be organized for
each urban health field research site and will include representatives from regional
and country offices of WHO, national and local representatives and stakeholders as
well as key partner research institutions from the local community. Other sites will be
involved in subsequent biennia.
Strengthening public health at the local level
The role of the public health sector at the city and municipal level in
enhancing health governance will be highlighted in the project. As both social and
environmental determinants of health necessitate action and responsibility from many
actors (e.g. transportation, housing, education, welfare, finance, police and law
enforcement), public health officers may need to play a more important role as
catalysts for change than as implementors in the locality and will need to steer highly
complex political processes toward healthy public policy. While the research
objective is focused on reduction of health inequity, the key products of the project
will be public health methodologies that enhance the performance of local health
officials in the new role they must play in the face of rapid urbanization.
In particular, tools will be developed to derive the “felt needs’’ of exposed
populations who may otherwise be excluded from regular census activities or routine
public health reporting systems. Felt needs can then be used as a reference point for
assessing the responsiveness of public health policies, programmes and practices in
contexts where health inequity is manifest.
In conjunction with public health methodologies for deriving felt needs,
checklists to ensure that health equity principles are embedded in public policies,
programmes and practices will be developed, field-tested and pilot-tested in the field
research sites. Ihese checklists will demonstrate how municipal development
decisions may affect human, social, economic and ecological capital (together
Updated by 7'1. April 2006
7
referred to as “community capital”4) and what possible impacts these would have on
exposed populations such as disaster survivors, women and children exposed to
abuse, violence and HIV-AIDS, workers suffering from depression or individuals
predisposed to suicide.
Highlighting the interaction between local and national determinants
The project will also develop tools to assist municipal planners in assessing
long-term development decisions. In particular, work will be initiated to develop
models that render visible the impact of broad determinants on the health of exposed
populations in future scenarios, using projections and trends of urbanization in the
first instance, and demographic and environmental change as well. An example of this
might be the effect of heat waves on exposed populations in urban settings.
Work will also be initiated for the development of a core set of indicators that
countries, cities and municipalities can use to assess how socioeconomic factors and
rapid urbanization are interacting to produce changes in health and quality of life in
their cities through the development of a Poverty-Health-New Urban Settings Index.?
Contributing to global action on social determinants of health
As WHO Kobe Centre is the hub of the Knowledge Network on Urban
Settings (KNUS) of the Commission on Social Determinants of Health, the Project
and the KNUS will work in tandem to develop new knowledge on slum dwellers as a
priority exposed urban population. The Project will collaborate with the KNUS to
produce new knowledge on interventions to address the health conditions of people
who live in slums and informal settlements. The KNUS will convene meetings to
draw on the knowledge of international experts on this subject. Some of the activities
of the network will include the writing of historical and analytic narratives on
countries that have demonstrated success and the scaling up and documentation of
interventions in one field project sites. The KNUS will also forward policy
recommendations to the Commission.
Approach
Product
Build an evidence base of experiences and
current interventions
An evidence base on how health
inequity is reduced through municipal
level interventions that address social
determinants of health
Evaluate selected experiences and current
interventions against existing theoretical
frameworks and conceptual models that
describe the relationship between social
A review of grey and published
literature on promising and successful
interventions
A glossary of terms and key concepts
' Hancock T. People, partnerships and human progress: building community capital. Health Promotion
International, September 2001, 16,3.
The notion o! "New Urban Settings” (NUS) was introduced by the Sub-group on Urbanization of the Ad hoc
Research Advisory Group. It refers to urban sellings that are characterized by a radical process of change with
positive and negative effects, increased inequities, greater environmental impacts, expanding metropolitan areas
and fast-growing slums.
■
.
8
Updated by 77 April 2006
determinants of health and health inequity | Strategies to enable municipal level
in urban settings
action to reduce health inequity in
urban settings
Develop methodologies to determine
health needs of exposed populations in
urban settings
Checklists for assessing and
evaluating health equity in urban
settings using “felt needs’* of exposed
populations as reference
Develop methodologies for projecting
future scenarios in relation to
determinants of health and their impact on
exposed populations in urban settings
Models for forecasting and scenario
building on the future of cities and
municipalities based on demographic
and environmental change,
urbanization and health with reference .
to “felt needs”
Develop methodologies for evaluating
health inequity at the city or municipal
level
Core set of indicators to evaluate
health inequity in cities and
municipalities (Poverty-Health-New
Urban Settings Index)
Develop new knowledge on reducing
health inequity in urban settings
Syntheses of evidence on effective
interventions for reducing health
inequity in urban settings
Ob jective 2 - Demonstrate the applicability of strategies for reducing health
inequity among exposed populations in urban settings
Approaches and products
Urban Health Field Research Sites will be established in selected urban
settings6 to create learning environments for local decision-makers to apply generic
municipal- level strategies and further evolve localized and context-specific and
tactical interventions to reduce health inequity. Local project steering committees
will be organized and workshops will be conducted. Social, community and political
mobilization will be done to ensure multi-sector stakeholder participation in the
app 1 ical ion of strategies.
Research units will be set up in offices of WHO Representatives with full-time
staff under special services agreements. The research units will coordinate research
activities but will also play a coordinating role in the implementation of local projects
to reduce health inequity. Technic al advice and support will be provided for local
projects.
6 China. Chile, Japan and India.
.'if ft n
Approach
Product
Establish Urban Health Field Research
Sites that will serve as learning
environments for local decision-makers
and communities for the application of
strategies for reducing health inequity
Three Urban Health Field Research
Sites where the strategies for reducing
health inequity will be applied
Apply the strategies for reducing health
inequity
Application of the strategies in three
Urban Health Field Research Sites
Three research units based in WR
offices with capacity to coordinate
stakeholder activities and oversee
implementation of the strategies at the
local level
Objective 3 - Build capacity for reducing health inequity in urban settings
Approaches and products
Capacity building,7 or the ‘'development of sustainable skills, organizational
structures, resources and commitment to health improvement in health and other
sectors, to prolong and multiply health gains many times over”, will be a critical part
of the project. Teams of leaders who are key players in health governance at the local
level will be organized and engaged in a health promotion leadership training
programme using the WHO Prolead model.8 Each team will design and implement a
specific project to optimize the impact of social determinants and reduce health
inequity in urban settings. Projects will also emphasize strengthening infrastructure
and financing for the promotion of health in the city/municipality in order to ensure
the sustainability of interventions to reduce health inequity. The course is conducted
over a nine-month period with 160 hours of group learning sessions. The learning
sessions are organized into three modules featuring didactics, workshops and field
visits. Topics covered by the training will include leadership principles,
communication and social mobilization skills, health sector reform, total quality
management, governance, social determinants and health inequity, management of
change and organizational development, among others.
Prolead III aims to enhance me practical skills of teams across/ive categories
that may be needed to improve go\ crnance for the promotion ot health: intra
personal qualities; inter-personaj q. .Jitics, cognitive skills; communication skills;
and. task-specific skills.
' Hawe P, King L, Noort M, Jordens C & Lloyd 13. f.idicators io help with capacity building in health
promotion. NSW Health: 1999
8 Prolead 111: Health Governance Initiative builds on a leadership development model that started in 2003 in
the WHO Western Pacific Region as a collaborative effort between the WHO Western Pacific Regional Office,
the Southeast Asian Ministers of Education Organization Tropical Medicine Network (SEAMEO-TROPMED
Network), the School of Public Health at La Trobe > niversity (Australia), and the Field Epidemiology Training
Program Alumni Foundation, Inc., with the support if the Japan Voluntary' Fund.
-
•
10
Upcfate.dby TL April 2006
Prolead III guiding principles include:
■
■
■
■
■
■
■
Emphasizing applied skiiis, not just theoretical knowledge;
Training in a high!) interactive manner, drawing on personal experience to
reinforce team learning;
Encouraging strategic thinking in the promotion of health;
Emphasizing the use of good governance principles in decision-making;
Using applied field projects to reinforce classroom learning, multiply
training benefits, and generate results;
Providing opportunities for mentoring and technical support;
Soliciting feedback as a means of improving the learning process.
Approach
Conduct leadership development,
mentoring and training on using the
strategies to reduce health inequity in
urban settings
Product
Trained teams of leaders who are
undertaking projects to reduce health
inequity in the three urban health field
research sites
Objective 4 - Advocate the reduction of health inequity in urban settings
Approaches and products
A strategic communication and advocacy plan will be developed to ensure that
different audiences and stakeholders will have a clear understanding of the goals and
objectives of the project. For the biennium, project advocacy materials will be
developed in English, Spanish and Japanese.
In collaboration with the United Nations University (UNU), video
documentation of strategies for reducing health inequity will be conducted at one
project site. The video documentation will be converted into a case study using
methods and techniques developed by UNU. The video will be made available to a
wider audience through different distance education programmes at regional and
country levels.
A range of advocacy acli\ siics will be implemented at global, regional,
national and local levels. For example, advocacy campaigns by the Knowledge
Network on Urban Settings may be ciireeled at global, regional or national audiences.
Regular town meetings and scienlilrc seminars will be conducted in the local
communitv.
Partnerships will be established, nurtured and sustained. A framework for
developing and evaluating effective partnerships to reduce health inequity will be
demonstrated through a historical and analytical narrative of the public-private
partnership model for health of 1 iyogo -Kobe City, Japan.
Finally, educational materiiils. checklists and rapid assessment guidelines on
emerging models and innovative strategies that seek to reduce health inequity will be
developed. These materials will contribute to enabling municipal-level decision
makers in health and other sectors to generate innovative policy ideas and options for
V'
■
■
:
■
.
■
:
■
Updated by I L April 2006
11
reducing health inequity. Examples of these include: tobacco and alcohol tax
measures for health promotion foundations; alliances between industries, the
community and academia; community-based programmes for older persons and
mental health promotion in the workplace.
Approach
Product
Develop and implement a
communication and advocacy plan
for the strategies.
Communication and advocacy plan for the
strategies.
Video documentation of projects of the
Urban Health Field Research Sites.
Profiles of promising approaches.
Information exchange, networking,
meetings and other advocacy activities.
Establish and sustain
partnerships for reducing health
inequity
A framework for developing effective
partnerships to reduce health inequity
Develop education materials and
rapid assessment guidelines on
reducing health inequities
A set of educational materials, checklists
and rapid assessment guidelines on how
health inequity may be reduced
2.1.3 Future directions
It is anticipated that these Core Project objectives will serve to guide the work
of the WHO Centre for Health Development over its next ten years of life. It is
recognized that from biennium to biennium the approaches to achieving these
objectives may vary somewhat and the products associated with them may vary
significantly. For example, new methodologies and tools will be developed; tools will
be added, adapted, or enhanced. Urban health field research sites may be expanded to
cover adjacent urban areas or new countries. Other foundational mechanisms such as
the Prolead initiative w ill continue to be an integral part of the project.
■I
Healthy Urbanization Project of WKC center for Health
and Development
Background
Following a decision by the Executive Board of the World Health Organization in 1995, a Memorandum
of Understanding between the World Health Organization (WHO) and the Kobe Groupl established the
WHO Centre for Health Development (WKC). As an integral part of the Secretariat of WHO, the WKC
has a global mandate to conduct research into the health consequences of social, economic,
environmental and technological changes and their implications for health policy development and
implementation.
In 2004-2005, the Centre undertook a process of consultation with its partners and the scientific
community to gain perspective on its future work for the period 2006-2015. An Ad hoc Research
Advisory Group (RAG) and associated Sub-groups were convened to delineate the most important
research questions related to Ageing and Health, Urbanization and Health, and Technological
Innovation and Environmental Change and Health.
These consultation lead to development of a research framework for the WHO Centre for Health
Development. This framework served as an important scientific reference in the development, by WHO
and the Kobe Group, of the ten-year extension of the Memorandum of Understanding to 2015 and the
Centre's research plans for the future that are reflected in the Plan of Work for 2006-2007.
The Memorandum of Understanding (MOU) between WHO and the Kobe Group for 2006-2015 was
signed on 15 June 2005. This MOU ensures the Centre's programmatic and financial future for the next
ten years, providing a stable budget for its scientific work that averages about USS 5.4 million per year.
About Kobe Center
As WHO Kobe Centre is the hub of the Knowledge Network on Urban Settings (KNUS) of the
Commission on Social Determinants of Health, the Project and the KNUS will work in tandem to develop
new knowledge on slum dwellers as a priority exposed urban population. The future work of the Centre
will have the following strategic foci:
Monitoring and responding to “felt needs ’ - aiming to complement the findings of epidemiological
and public health research with information about the needs felt by exposed populations.
Packaging knowledge from a health equity perspective to inform policy and practice - Aiming to
reduce health inequity by improving health governance.
Developing new knowledge to address existing and emerging areas of vulnerability - Aiming to
identify and advocate effective responses and interventions in relation to driving forces.
The work will be carried out with a major emphasis on urban settings, mindful of the "globalization
urbanization interface" that exists in these settings, with the overall aim of reducing health inequity
by optimizing the impact of social determinants of health on exposed populations
HHI
HI
I hr H ffO Centre for Heaifh DevelofonefU, in colhihorafioH
'•vilh H I IO Re^ionol (unt ( o tut try Offices, amf through its
project oh "flc'dhfiy f. rtxii) i~inioti." aims to iiifeijrafe evidencehtised good practices and public health methods that optimize
the impact of social determinants oh health and promote
health equity in Hational policies and health systems of
Member States.
Rationale
At the local level, the project will bring added value through new ways of working between and among
sectors, leadership development and community participation and empowerment. At the national level,
the project will provide new knowledge and evidence that may accelerate the adoption of principles of
social determinants of health and health equity in national policy, programmes and practice. At the
global level, the project will contribute to international understanding and strengthen the imperative for
action on social determinants of health.
Figure 2: Expected outputs from action research interventions
| Local levej^__ //
Interventions At
Various Social
Determinants of
Health
Improved
governance
t
Improved
health
equity
i
""n
k
National level
i Global level
Menn output
Main oi.it put
Main output
• Im pfDVG health
Gul-Gfne-
•Adoption of
principles of SDH
and equity principles
in national health
policy
•Z\ction on social
determinants of
health
♦International
understanding and
global action on
Social Detenu inants
of Health
•Promote health
Asldcd-zdufe
•flew ways of
•working
* Leadership
development
•Reefing lesshefcfess
iEirpcAaed)
Goal
The overall goal of the project is to promote health equity in urban settings, particularly among exposed
populations through actions in areas that relates to the project objectives:
Objectives
1. Developing strategies: Building an evidence
(
base, generating policy ideas, evaluating current
experiences and interventions, developing public health methodologies for health inequity assessment
and evaluation and deriving new knowledge on social determinants and health inequity.
2. Demonstrating the applicability of strategies: Demonstrating how "generic” municipal strategies
can be applied and combined with tactical and contextspecific interventions to reduce health inequity.
3. Capacity building: Building capacity at t a level of the individual, the organization and the system
through leadership training and applied prcjeuis.
4. Policy advocacy: Developing and apf/yiug principles of strategic communication and advocacy to
influence health governance at all levels and enhance understanding of how the impact of social
determinants can be optimized to reduce health inequity.
...
-
Staff will work in and across these areas of emphasis in a multi-disciplinary fashion to develop specific
products. In addition, to provide effective liaison with other WHO programmes and offices, as well as
with other organizations, they will serve as designated Focal Points for the following Areas of Work:
1. Surveillance, prevention and management of chronic, non-communicable
2. Diseases
3.
Health promotion
Tobacco and environment
Gender, women and health
Policy-making for health in development
Health system policies and service delivery
Human resources for health
Health information, evidence and research policy
10. Emergency preparedness and response
11. Mental health and substance abuse
12. Ageing and life course
4.
5.
6.
7.
8.
9.
-
Project partners The Healthy Urbanization Project will be implemented in partnership with a wide range of stakeholders
at global, regional, national and local levels. The proposed institutional partners of the project at the
global level will include the Alliance for Healthy Cities, International Network of Health Promotion
Foundations, the SEAMEOTROPMED Network and the La Trobe University School of Public Health.
Partners at the regional level will include the different Regional offices of the World Health Organization
and other international agencies. Partners at the country level will include Ministries of Health,
transportation, education, welfare, civil society and other stakeholders. Partners at the local level will
include local governments, non governmental organizations, communities, people's organizations and
others that will emerge as the site-specific projects are developed and implemented.
Model
The model of the “Evidence-Informed Policy and Practice Pathway"3 (Brown and Zwi, 2005) provides
the basis for the research design of the Core Project. According to this model, policy ideas, evidence,
use of evidence and capacity to implement evidence-based policies are interlocked in a series of
decision-making steps that are characteristic of how events unfold in practice. Policy
Polic y
idon
Sourcing tho
EVIDENCE
•K novk’teOgc
•R
•Politics
•E conomlcs
USING the
EVIDENCE
t‘. •»».•-? .4.
ikj. inturp i utirw),
upptylrig
•Ml - n wuys U’HlSrtIMMI
CONSIDERING
CAPACITY
TO
IMPLEMENT
031
•Inti iv mini
•Of'jjanisationai
•Sy^tern .'Policy
________ _
Guiding principles and approaches
....
... ..
.
.
,
The project will be guided by the following principles:
1. “Learning by doing," in particular the use of participatory and action-research
methods to optimize social determinants and promote health equity;
2. Respect for local contexts and responsiveness to local needs in the design,
development and adoption of project interventions and strategies:
3. Community participation and the involvement of beneficiaries and stakeholders at all stages of the
project (i.e. planning, implementation and evaluation);
4. Empowerment of beneficiaries and stakeholders through capacity building;
5. Integration with existing initiatives that strengthen health systems at the
national and local level;
6. Linkage to initiatives in support of global imperatives such as Health for All, the Millennium
Development Goals, the Commission on Social Determinants of Health, the Commission on
Macroeconomics and Health and Sustainable Development;
7. Utilization of vulnerability assessment and reduction approaches to address health issues that result
from the convergence of social and environmental determinants: and
8. Cost-sharing and resource mobilization at all levels to complement fixed
budgets that are provided by the WHO Kobe Centre.
Present plans, 2006-2007
Objective 1 - Develop strategies to reduce health inequity in urban settings
Approaches and products
Building the evidence base
Closer examination of existing evidence will be a key component for developing strategies to reduce
health inequity in urban settings. Knowledge will be collated, analyzed, synthesized and organized to
enable researchers, implementers and decision-makers to gain easy access to information on the
associations and pathways between social determinants and health inequity in urban settings. In
particular, the evidence base will try to capture the policy ideas emanating from attempts to bridge
equity gaps through municipal health governance.
Ensuring local participation and ownership of research
Research activities will emphasize principles of community and stakeholder participation and ownership.
People's participation in planning, implementation and evaluation of research activities will be ensured.
Thus, at the early stages of the projeci. participatory and consultative processes will guide the
identification of exposed populations, prioritization of issues and concerns and the pursuit of
opportunities and imperatives for influencing health governance at the local level.
Strengthening public health at the local level
The role of the public health sector at the city and municipal level in enhancing health governance will
be highlighted in the project. As both social and environmental determinants of health necessitate action
and responsibility from many actors (e.g. transportation, housing, education, welfare, finance, police and
law enforcement), public health officers may need to play a more important role as catalysts for change
than as implementers in the locality and will need to steer highly complex political processes toward
healthy public policy.
Highlighting the interaction between local and national determinants
The project will also develop tools to assist municipal planners in assessing long-term development
decisions. In particular, work will be initiated to develop models that render visible the impact of broad
determinants on the health of exposed populations in future scenarios, using projections and trends of
urbanization in the first instance, and demographic and environmental change as well. An example of
this might be the effect of heat waves on exposed populations in urban settings.
Contributing to global action on social determinants of health
the Project and the KNUS will work in tandem to develop new knowledge on slum wellers as a priority
exposed urban population. The Project will collaborate with the KNUS to produce new knowledge on
interventions to address the health conditions of people who live in slums and informal settlements.
Approach
Prod net
Build an evidence base of experiences and
current interventions
An evidence base on how health
inequity is reduced through municipal
level inters ent ions that address social
determinants of health
Evaluate selected experiences and cui rcnt
inteiventions against existing theoretical
frameworks and conceptual models that
describe the relationship between social
A review of grey and published
literature on promising and successful
interventions
dctenninanis of health and health in- quiiy
in urban settings
Strategies to enable municipal level
action to reduce health inequity in
urban settings
Develop methodologies to determine
health needs of exposed population, in
urban settings
Checklistb for assessing and
evaluating health equity in urban
settings using ‘'fell needs” of exposed
populations as reference
Develop methodologies lor projectiivj
future sccn:uios in relation l>determinants of health and their impsci -n
exposed populations in urban sellinc .
Models fvi forecasting and scenai io
building >-n the future of cities and
municipalities based on demographic
and environmental change,
urbanization and health with reference
to ‘■fell needs”
Develop ineilmdologics for aluaiihu
health incquiiy at theciix or municipal
level
Core sei <T indicators to evaluate
health inequity in cities and
municipalities (Pox eny-Heal th-\ew
I Jrban Sellings Index)
Dex elop nev. knvwvIeJgeon redueme
health inequity in urban sellings
Syntheses of evidence on effeclixe
inier\'cnli< -ns for reducing health
inequity in urban sellings
A glossary of terms and key concepts
Objective 2 - Demonstrate the applicability of strategies for reducing health inequity among
exposed populations in urban settings
Approaches and products
Urban Health Field Research Sites will be established in selected urban settingsG to create learning
environments tor local decision-makers tc apply generic municipal- level strategies and further evolve
localized and context-specific and tactical interventions to reduce health inequity. Local project steering
____________________ -
'■■■
committees will be organized and workshops will be conducted. Social, community and political
mobilization will be done to ensure multi-sector stakeholder participation in the application of strategies.
Local project steering committees will be organized and workshops will be conducted. Social,
community and political mobilization will be done to ensure multi-sector stakeholder participation in the
application of strategies.
Approach
Establish I rban Health Field Rc^e
II
Sites that will serve as learning
environments for local decision-ni.ikei->
and communities for the application
strategies lor reducing health inequits
Apply the strategies for reducing ll•.•;lllh
inequity
Prod net
Three I !iban Health Field Research
Sites u here the sirategics lot reducing
health inequits w ill he applieJ
1 hree research units based in WR
offices w ilh capacity to coordinate
stakeholder activities and oversee
implementation of the strategies at the
local level
.Application of the strategies in three
Urban Health Field Research Sites
Objective 3 - Build capacity for reducing health inequity in urban settings
Approaches and products
Capacity building, or the “development of sustainable skills, organizational
structures, resources and commitment to health improvement in health and other sectors, to prolong
and multiply health gains many times over", will be a critical part of the project. Teams of leaders who
are key players in health governance at the local level will be organized and engaged in a health
promotion leadership training programme using the WHO Prolead model
The learning sessions are organized into three modules featuring didactics, workshops and field visits.
Topics covered by the training will include leadership principles,
Prolead III aims to enhance the practical skills of teams across five categories
that may be needed to improve governance for the promotion of health: intrapersonal qualities; inter
personal qualities; cognitive skills; communication skills; and, task-specific skills.
Prolead III guiding principles include:
a. Emphasizing applied skills, not just theoretical knowledge;
b. Training in a highly interactive manner, drawing on personal experience to reinforce team
learning;
c. Encouraging strategic thinking in the promotion of health,
d. Emphasizing the use of good governance principles in decision-making;
e. Using applied field projects to ieinforce classroom learning, multiply training benefits, and
generate results;
f. Providing opportunities for mentoring and technical support;
g. Soliciting feedback as a means o! improving the learning process.
Approach
Conduci leadership dcvelopmcni
menloiing and training on using ih.stralegie in reduce health inequir. in
urban sellings
Prod net
Trained learns <T leaders who are
undertaking projeuls to reduce heal I h
inequiiy in the three urban health field
research sites
Objective 4 - Advocate the reduction of health inequity in urban settings
Approaches and products
ajO-a..,.
A strategic communication and advocacy plan will be developed to ensure that different audiences and
stakeholders will have a clear understanding of the goals and objectives of the project. For the
biennium, project advocacy materials will be developed in English, Spanish and Japanese
In collaboration with the United Nations University (UNU), video documentation of strategies for
reducing health inequity will be conducted at one project site. A range of advocacy activities will be
implemented at global, regional, national and local levels. For
Approach
Develop and implement a
communication and advocacy plan
for the st rategies.
Product
Communication and advocacy plan for the
strategies.
Video documentation of projects of the
Urban Health I icld Research Sites.
Profiles of promising approaches
Information exchange, networking,
meetings and other advocacy activities.
Establish and sustain
partnerships for reducing health
inequity
A framework lor developing eiYective
partnerships to reduce health inequity
Develop education materials and
rapid assessment guidelines on
reducing health inequities
A set of educational malerials, checklists
and rapid assessment guidelines on how
health inequity may be reduced
J
PROJECT IMPLEMENTATION
2006-2007 Timeframe
Sustaining
Action
Through
Advocacy
Situation
Analysis
3 v.-eeks
3—5 moritlis
Social
Mobilization
For
In tersect oral
Action
St rateciy
d^velopmeiit
Through
ActionResearch
4—4.5 months
........... ,
--'A
PROJECT MANAGEMENT
Management and support structure
FaciB fates
uinn n uni cat io ns aenws.
countries & regions
/ / WKC \
/ Global Project
/
WKCIIeallby
Urbanizatioa Project
.Secretarial
Steering Comm.
\
\
Coordination at
Regional <5 National tereh
______
I .oca! Project
Steering CoHimilifc
LOCAL PRO
Introduction
It is anticipated that these Core Project objectives will serve to guide the work
of the WHO Centre for Health Development over its next ten years of life.
Project Steering Committee Meeting
30 May-2 June 2006
India: In Bangalore, access to quality health care, safe water and sanitation, and proper garbage
disposal, as well as the provision of ample parks and play areas, safe roads and transportation, and a
city free of crime, violence and drugs, are ail being addressed by the municipality using an inter-sectoral
participatory approach.
Dr Muthukrishnan Vijayalakshmi, Health Officer, Bangalore City Corporation, Bangalore, presented a
paper on Health Promotion in Bangalore. India. Although this was not a scoping paper, it did provide the
audience with a sense of the important social determinants in Bangalore. Dr. Vijayalakshmi started her
presentation arguing that urbanization in Bangalore happens because citizens are looking for a better
life. The pace, scope and depth of urbanization was resulting in inadequate food and shelter,
overcrowding, insufficient water and sanitation facilities and pollution, which again pushed the
population into use of harmful substances, and insecurity.
Bangalore has adopted the healthy cities approach and identified six main intervention
areas:
1) Access to quality health care - especially uroan poor; 2) Safe water supply & proper sanitation;
3) More organized disposal of waste (collection, segregation & transportation):
4) Ample public parks & play areas;
5) Safe roads & safe transportation; and
6) Freedom from crime, violence and drugs
The six issues are being addressed through environmental health interventions, preventive health
measures, health promotion approaches, education and training. These initiatives are proving
successful and are being implemented using an intersectoral and participatory approach. However,
there are still major challenges such as solid waste management, which consume the majority of the
budget, and HIV/AIDS with its high prevalence among the working class.
The ensuing discussion concentrated on environmental health issues and how Bangalore had
managed to sustain a recycling initiative and build on already existing initiatives. In responding to a
question related to resettlement, Dr Vijayalakshmi described how the government was constructing
houses and the importance that development initiatives in other sectors be aligned with those of the
Ministry of Health. The important success factors included education, good housing and employment as
well as strong political will reflected in a commitment to the healthy cities approach.
Following on the regional presentations, a major question for the participants was:
What have we learned and what can we transplant into the Healthy Urbanization Project?
Bangalore, India
The group from India started their work by defining the characteristics of future Prolead participants.
These participants must be individuals who are working with health related issues, known to have
demonstrated leadership potential, currently employed and engaged in a technical or professional area
of work such as finance, planning, transport, housing, health policy, law enforcement, working at a level
where policy and practice are reinforcing each other. It is advisable that Prolead participants come from
the following three domains: WHO, government or nongovernmental organizations. The Bangalore
research site will have 4-6 research teams with three members per team. Each team will be encouraged
to have an appropriate gender and age balance. There should also be a sense of continuity with the
work of the three previously trained Prolead fellows. The activity timeline for the Bangalore project was
outlined as follows:
• 30 June 2006: Completion of appointment of SSA.
• 4-6 July 2006: WKC Focal Point (Ms Loo) visits Bangalore to
• Review the interim scoping paper/meet with stakeholders:
• Gain an understanding of BMP;
• Present the Project to the Commissioner;
• Orient SSA staff (project document, work and financial plans, office supplies,
• Communications, recording and reporting, etc);
• Catalyze establishment of a Bangalore working body at the local level, comprised of BMP (two
clinical and public health), SSA. kaT ng institution,
one from an NGO, one former Prolead feh< v and the Commissioner.
• Mid-July 2006 call for expression of inter; si for Project participants
• 31 July 2006: deadline for submission of scoping paper.
• 31 August 2006: deadline for selection of Prolead participants: and training
institution identified
• 1-30 September 2006: Preparations for Prolead. Module 1 (training venue, food,
materials, programme, etc).
• October 2006: Prolead, Module 1.
• Commencement of city projects.
• March 2007: Prolead, Module 2.
• Continuation of city projects.
• November 2007: Prolead, Module 3.
• Phasing out/closure of city projects.
• December 2007: Bangalore core project evaluation.
-
Annex 5, Plan of Action, Bangalore
Objective: ■ >ptiiiilzing IIk? social dob-miiii. mis ol health in uilmn setlinqs
Site: Bangalore. India
Total budget: i it) {jCO USIj
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Quarterly irK-tfiiV) , >:.<municalicn, etc
Dr Davison Munodawafa, Regional Adviser in Health Promotion and Education, WHO Regional Office
for South-East Asia (SEARO)
Healthy Urbanization Learning Circles will undertake capacity building
activities over a 9-12-month period that is organized around four modules9:
• Module 1: Overview of Healthy Urbanization. Situation Analysis
• Module 2: Healthy Urbanization Challenges. Strategy Development and Project
Proposal Writing
• Module 3: Healthy Urbanization Opportunities: Social Mobilization for
Intersectoral Actions.
• Module 4: Mainstreaming Healthy Urbanization: Sustaining Action through
Advocacy
...
I
Research sites - BHUP -£ f
a healthy Be^“
■ Will work through 7 centres allocated in 14
low resource settings:
■ Pobbathi MH
■ Vasanthnagar Disp.
■ Vidyapeeta HC
■ Robertson Road HC
■ Moodalapalya HC
■ Mathikere HC
■ Shanthinagar MH
1
a
INDIA
I-' ' -
3®
Xr":
....
^Population : 1,080,264,388[ July 2004 J
1 billion,80 million
<$>7th largest country:Geographical
area:3,287,590 sq kms
<$GDP:603.3 billion$
I
Namaste
'
Bangalore city
^Geographical area spread over 225 kms
^Bangalore metropolitan area has a
population of 6.5 million[census 2001]
[present estimates:8 million]
^Urban poor constitutes 30% of the
population[2.1 million][present
estimates 2.4 million]
^Estimated 1 million floating population
d
Prolead II :Module 1 :
A Health Governance Initiative
[WHO Center for Health Development,Kobe,
Japanq--- t
Country report: India
13:00 to 13:20 ,Day 1,Monday,25thJuly,
Bangkok,Thailand
Team: Mr. P R Ramesh, Dr A G Harikiran , Dr Srinivasan.v
I ■
Bangalore:now:the other face
> Overcrowding
^Overpopulation
^Slums/urban poor
•^Inadequacy of
Infrastructure
3>City struggling to
cope
Bangalore: then
Garden city
•^Pensioners paradise
J
i
Bangalore Health Infrastructure
^>250 large hospitals and nursing homes
^>5000 family practitioners
^10 Tertiary care hospitals
> Bangalore city corporation
48 UFWCS/health centers,6 referral
hospitals and 24 maternity homes
Bangalore:now
^Silicon valley of India
4-Information technology
capital
<$>Bio technology capital
Service industry center
Education center for
medicine,engineering
Rapid infrastructure
development
Key Health Challenges in Bangalore City
''i-
Leading causes of death in Bangalore
1. Cardiovascular diseases: 16212
2. Injury /external causes:8723
3. Infections/parasitic diseases:7887
4. Perinatal complications:6649
5. Genito urinary diseases:4007
Health Challenges/ Health Issues Priority in
Trisector Dialogue Workshop[llth January 2003]
<t> Air pollution
^Accidents and trauma
^Violence against senior citizens
^Violence against women
^Cardiovascular diseases
^Toilets,underground drainage systems,solid
waste management
^Substance abuse
Child labor
■#HIV aids
<$> Primary health care
Bangalore-Health Infrastructure-Medical/allied
Teaching Institutions
Rajiv Gandhi university of health sciences
#5 Medical Colleges
•^ 16 Dental Colleges
<$86 Nursing Colleges
<$23 Physiotherapy Colleges
<$2 Unani Colleges
■$2 Ayurvedic Colleges
■$2 Homeopathy Colleges.
Regional occupational health centerfsouth]
Bangalore existing health system:
Government and Private Sector Role
•^Government hospitalsffree service,paid for
higher socio economic strata people]
Private sector hospitals and clinics provide
major part of the service
^Insurance:role and use steadily increasing
•t-Welfare services/health benefits/hospitals for
employees present and limited:these services
face many challenges
Health promotion action in
Bangalore:Bangalore healthy city initiative
trisector dialogue
'Citizens and governance program:tri
sector dialogue'^ collaborative effort of
CAMHADD [NGO],Bangalore city
corporation, Sri Jayadeva institute of
cardiology January 2003
Health Promotion Activities:Bangalore:
Preventive Cardiology Center at Shantinagar:
BMP,CAMHADD, SJIC,RVDC:November 2003
❖ First of Three Centers Of
Trisector Partnership
❖ Target group:4000
Pourakarmikas
■
[Sanitary workers]
❖ Unique challenges
❖ Services provided
Health promotion activity
and health education
Screening and referral services.
❖ Services :free for the
employees
Broad determinants/Underlying causes to health
challenges to Bangalore city
^LIFESTYLE CHANGES
❖ Political factors
❖ Population
❖ Financial limitations:low budgetary allocation for
health[ low priority for health promotion or
preventive activities.]
❖ Inadequate prioritization and long term planning
❖ Lack of multisectoral coordination and utilization
and orientation of available resources.
Broad determinants/Underlying causes to health
challenges to Bangalore city
Poverty
Nobel laureate:Amartya Sen said ' the
great Bengal famine was not caused by
shortage of food but the lack of paying
capacity among the masses"
Health Promotion Actions:^^galore:
Preventive Medicine and Healthy Lifestyle Clinic:
Karnataka state police, CAMHADD :November 2005
>Third Center of Trisector Partnership
^Target group: Employees of 'Karnataka
State Police'
^Services
Health promotion activity and health
education
Screening and referral services.
-^Services :free for the employees
Health Promotion Actions:Bangalore City
Corporation: Parks and Playgrounds
^One Park - each Ward
^Over 250 Parks
redeveloped
& Adopt A Park Scheme’
Government-Citizen
partnerships Bangalore
Agenda Task Force (BATF)
^360 Play Grounds
developed
BANGALORE HEALTHY CITY SUMMIT
: FEBRUARY 2004
bmp,camhadd and sjic
Development of centers of
excellence
Promotion of healthy
environment
To promote school and
community based health
initiatives
Preventive health care
through ' healthy lifestyle
clinic'
T
tn -
a
W'
*
Ml
Health Promotion Actions:Bangalore:
Preventive Medicine and Healthy Lifestyle Clinic:
KSRTC, CAMHADD January 2005
Second Center of
Trisector Partnership
^Target group:16000
employees of
'Karnataka State
Road Transport
Corporation
L
t
-^Wv.
, J. Ji
Health Promotion ActionsrBgngglore City
Corporation: ¥093 Classes at schools
^Yoga classes are conducted in all Corporation schools
Physical Trainers or Trained Teachers will conduct Vs
hr Yoga classes everyday
^Over 8500 High school students and 2800 Primary
school students
Health Promotion Actions:Bangalore City
Corporation-. Mi4 Pay Meal Programme
-r
Yb--------- -------
1
^■Mid Day Meal from
ISCKON temple for about
22,000 students.
-p:
# Budget: Rs.l crore
^Completed 3 successful
years
^•Cost:3-6 rupees per meal
■^Outcome: Drop out rates
■
have come down
Health Promotion Actions:Ban^alore City
Corporation: Trinity smart car4
ey------ ------
Health Promotion Actions:Bangalore City
Corporation: Pay Care Facility for
ti r;4erpriviIege4 E14ers
I jawM—
Smart card :A unique Trinity
smart card has been issued to
all families of V.V.Puram
ward [PILOT]
Gradually this facility will be
made available to all Other
99 wards of Bangalore city
corporation
Access not only to treatment
facilities but a range of
health promotion
activities/screening programs.
‘Sandhya kirana” a unique
day care facility exclusively
for the low income elders
:1 9th feb 2004 at 2 centers
in Bangalore:BMP and
nightingales medical trust,
an NGO.
support system for the
unprivileged elders .
• ■ "T
■ i
Health promotion activity:Bangalore:CVD
risk management program
health Promotion Actions:Bangalore City
Corporation: Gymnasium
1------- ------
$>One fitness center/
WHO "CVD risk management premise
study in Bangalore"
At 10 primary health centers of the
Bangalore city corporation
Gymnasium at each
ward
One Trained
professional is been
appointed as coach
Health Promotion Actions in
Bangalore:Finance
Primary funding:organization employing the
target population[Bangalore city
corporation,KSRTC,police department]
Additional support:other participating
institutions,NGO [CAMHADD.etc] '
Lack of earmarked budgetary allocations for
health promotion activity,donor
funds,corporate sponsorship or social health
insurance.
>1
M
Health Promotion Actions;Bangalore City
Corporation; Health Education
Programmes:
1S8&
>i
Voluntary organizations like
Freedom Foundation/
Samraksha and KSAPS are
counseling and screening
pregnant mothers in 15 BMP
Hospitals for HIV/AIDS
‘NAMMA BENGALURU’: A
Health education program
Scope for improvement
Development of a system for integration and
coordination between participating stake
holders[government,private sector and civil
societyjtowards common goals
•^Training and skill upgradation towards
utilization of non traditional funding options.
^Development and integration of present
efforts towards sustainable programs
^Evaluation
^Infrastructure and systems development
^Integration between health care delivery and
medical education
l
.■ "J. *.-’*•*•
J
"
I
I
*
■ I'
• 31
i a
I.
BI H
!
Research Programme 2006-2007
Healthy Urbanization Project: Optimizing the
impact of social determinants of health on exposed
populations in urban settings
In the context of urbanization and globalization, the problem of health inequity in
cities and urban municipalities must be confronted. The Healthy Urbanization
Project is an integrated, interdisciplinary, multi-sector initiative that will frame
the WHO Kobe Centre's work over the next ten years, and anchor the
development of specific products in the immediate 2006-2007 biennium. This
core project for the Centre for 2006-2015 will be carried out with a major
emphasis on urban settings, mindful of the "globalization-urbanization interface"
that exists in these settings, with the overall aim of reducing health inequity by
optimizing the impact of social determinants of health.
Objective 1 - Develop strategies to reduce health inequity in urban
settings
Approach 1.1. Build an evidence base of experiences and current
interventions.
Product 1.1.1. An evidence base on how health inequity is reduced through municipal
level interventions that address the social determinants of health
Approach 1.2. Evaluate selected experiences and current interventions
describe the relationship between social determinants of health and
health inequity in urban settings
Product 1.2.1. A review of grey and published literature on promising and
successful interventions
Product!.2.2. A glossary of terms and key concepts
Product 1.2.3. Strategies to enable municipal level action to reduce
health inequity in urban settings
Approach 1.3. Develop methodologies to determine the health needs of
exposed populations in urban settings
Product 1.3.4. Checklists for assessing and evaluating health equity in
urban settings using the "felt needs" of exposed populations as a
reference
Approach 1.4. Develop methodologies for projecting future scenarios in
relation to determinants of health and their impact on exposed
populations in urban settings
Product 1.4.1. Models for forecasting and scenario building on the future
of cities and municipalities based on demographic and environmental
change, urbanization and health with reference to ’’felt needs"
>
Approach 1.5. Develop methodologies for evaluating health inequity at
the city or municipal level
Product 1.5.1. Core set of indicators to evaluate health ineguity in cities
and municipalities (a poverty-health-new urban settings index)
Approach 1.6. Develop new knowledge on reducing health inequity in
urban settings
Product 1.6.1. Syntheses of evidence on effective interventions for
reducing health ineguity in urban settings
Objective 2 - Demonstrate the applicability of strategies for reducing
health ineguity among exposed populations in urban settings
Approach 2.1. Establish Urban Health Field Research Sites that will serve
as learning environments for local decision-makers and communities for
the application of strategies for reducing health inequity
Product 2.1.1. Three Urban Health Field Research Sites where the
strategies for reducing health ineguity will be applied
Product 2.1.2. Three research units based in WR offices with capacity to
coordinate stakeholder activities and oversee implementation of the
strategies at the local level
Approach 2.2. Apply the strategies for reducing health inequity
Product 2.2.1. Application of the strategies in three Urban Health Field
Research Sites
Objective 3 - Build capacity for reducing health inequity in urban settings
Approach 3.1. Conduct leadership development, mentoring and training
on using the strategies to reduce health inequity in urban settings
Product 3.1.1. Trained teams of leaders who are undertaking projects to
reduce health ineguity in the three urban health field research sites
Objective 4 - Advocate the reduction of health ineguity in urban settings
Approach 4.1. Develop and implement a communication and advocacy
plan for the strategies
Product 4.1.2. Video documentation of projects at the Urban Health Field
Research Sites
Product 4.1.3. Profiles of promising approaches
Product 4.1.4. Information exchange, networking, meetings and other
advocacy activities
Approach 4.2. Establish and sustain partnerships for reducing health
inequity
Product 4.2.1. A framework for developing effective partnerships to
reduce health inequity
Approach 4.3. Develop education materials and rapid assessment
guidelines on reducing health inequities
Product 4.3.1. A set of educational materials, checklists and rapid
assessment guidelines on how health inequity may be reduced
I
IW
MMi
Healthier People in Healthier Environments
9S
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A
II
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Healthy
Urbanization
, A-.
' z' ? ;
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» »®K
Guidelines for Action
HEAL THY URBANIZA TION:
Optimizing the Impact of Social Determinants of Health on
Exposed Population in Urban Settings
III 8»ir
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WHO Centre for Health Development
I.H.D. Centre Building, 9th Floor, 5-1, 1-Chome
Wakinohama-Kaigandori, Chuo-ku, Kobe, 651-0073, Japan
Tel+81 78 230 3100 Fax:+81 78 230 3178
URL: http://www.who.or.jp/
IM
■HSR
eWorld Health,
r/?_
’Organization i.tic.
j
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TABLE OF CONTENTS
Section
Page No.
FOREWORD
3.0
4.0
3
1.0 INTRODUCTION
4
1.1 Background ......................................
1.2 Purpose..............................................
1.3 Structure of the Guidelines ............
1.4 Guiding principles and approaches
4
5
6
6
2.0 OPERATIONAL FRAMEWORK
7
2.1 Rationale....................................
2.2 Project Partners - 2006-2007 .
2.3 Methodologies and approaches
7
9
9
PROJECT MANAGEMENT
14
3.1 2006-2007 Timeframe .....
3.2 Capacity building modules
3.3 Advocacy and the future ..
3.4 Allocation of funds............
14
15
17
17
PROJECT MANAGEMENT
19
4.1 Management and support structure ..,
4.2 Monitoring, evaluation and reporting
19
23
Annexes:
Annex 1: Terms and concepts
Annex 2: Site-specific project details
Annex 3: Description of factors of the Healthy Urbanization Framework
Annex 4: Proposed template for planning
Annex 5: Proposed template for reporting - first site visit (Country Team Adviser)
Annex 6: Proposed template for reporting - third site visit (Country Team Adviser)
Annex 7: Proposed template for reporting - quarterly progress report (Local Coordinator)
Annex 8: Proposed template for reporting - bi-annual progress report (Local Project Team)
Annex 9: Proposed template for reporting - end-of-project evaluation (Local Project Team)
Annex 10: Terms of Reference for Country Team Adviser
Annex 11: Terms of Reference for Local Coordinator
Annex 12: Letter of Exchange
iii
FOREWORD
Following a decision by the Executive Board of the World Health Organization in 1995, a
Memorandum of Understanding between the World Health Organization (WHO) and the Kobe
Group1 established the WHO Centre for Health Development (WKC). As an integral part of the
Secretariat of WHO, the WKC has a global mandate to conduct research into the health
consequences of social, economic, environmental and technological changes and their
implications for health policy development and implementation.
The 2004-2005 biennium was pivotal for the WHO Centre for Health Development. It was a
period of transition and transformation that afforded the opportunity to reflect and build on the
Centre’s past achievements, learn from its shortcomings and chart a course for the next decade in
response to the WHO Director-General’s call for a Centre that stands for excellence in research
on health in development. A participatory process was used to chart the research future of the
Centre. This process reflected the views of the Centre’s Kobe Group partners and the 2004 Ad
Hoc Research Advisory Group in developing a Research Framework focused on understanding
the complex dynamics of the driving forces that shape health in development.
In 2005, the Centre focused on consolidating the key elements of the transition and
transformation process that started in 2004. A new Memorandum of Understanding (MOU)
between WHO and the Kobe Group for 2006-2015 was signed on 15 June 2005. This MOU
ensures the Centre’s programmatic and financial future for the next ten years, providing a stable
budget for its scientific work that averages about USS 5.4 million per year. New strategic
directions for research work were developed and agreed to. A detailed Plan of Work for 20062007 was prepared consistent with these new directions. The staffing and management of the
Centre were streamlined to develop a sharper focus on stakeholder needs and interests.
In November 2005, the Advisory Committee of the WHO Kobe Centre enthusiastically endorsed
the ongoing work of the Centre and its plans for the future. They recommended to the late
Director-General, Dr J. W. Lee, hat he approve the recommendations of the 2004 Ad Hoc
Research Advisory Group, the strategic directions for future research proposed by the Centre for
the period 2006-2015, and the proposed Plan of Work for 2006-2007. In December 2005, the
Director-General approved the recommendations of the Advisory Committee.
These Guidelines for Action will inform the work of the WHO and its project partners who are
involved in the Centre’s project on “Healthy Urbanization: Optimizing the Impact of Social
Determinants of Health on Exposed Populations in Urban Settings. ” The workplan for 2006—
2007 completes the transitional and transformational processes that began in 2004-2005 and
frames the research activities for implementation over the period 2006-2007. The manual is
intended to provide strategic direction and implementation guidance. It is a dynamic document
that should be informed and improved upon by experience.
Dr Soichiro Iwao
Director
WHO Kobe Centre
1 The Kobe Group is comprised of Hyogo Prefecture, Kobe City, the Kobe Chamber of Commerce and
Industry and Kobe Steel, Ltd.
V
The WHO Centre for Health Development, in collaboration
with WHO Regional and Country Offices, and through its
project on i(Healthy Urbanization, ” aims to integrate evidence
based good practices and public health methods that optimize
the impact ofsocial determinants on health and promote
health equity in national policies and health systems of
Member States.
-s
»
3
vi
I
I
1
Healthvl^lKi
Urbanization
Learning
Circle
Introduction
-•
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Sliilltlilil
i World Health
K
J___ *____________
1.0 INTRODUCTION
1.1
Background
Following a decision by the Executive Board of the World Health Organization in
1995, a Memorandum of Understanding between the World Health Organization (WHO)
and the Kobe Group established the WHO Centre for Health Development (WKC). As
an integral part of the Secretariat of WHO, the WKC has a global mandate to conduct
research into the health consequences of social, economic, environmental and
technological changes and their implications for health policy development and
implementation. In this context the vision of the WHO Kobe Centre is:
Healthier People in Healthier Environments
In pursuing this vision, the Centre’s mission is to nurture, sustain and promote innovation
and excellence in public health research on health in development.
Over the next ten years, the research programme of the WHO Kobe Centre is focused
on urbanization and health equity. Through its project on “Healthy Urbanization:
Optimizing the Impact ofSocial Determinants of Health on Exposed Populations in
Urban Settings'’, the Centre hopes to contribute to the generation of new knowledge and
stimulate action to confront the issue of health inequity in urban settings in both
developing and developed countries. The overall goal of the project is to promote health
equity in urban settings, particularly among exposed populations through actions in areas
that relates to the project objectives:
■
Developing strategies: Building an evidence base, generating policy ideas,
evaluating current experiences and interventions, developing public health
methodologies for health equity assessment and evaluation and deriving new
knowledge on social determinants and health inequity.
■
Demonstrating the applicability of strategies: Demonstrating how “generic”
municipal strategies can be applied and combined with tactical and context
specific interventions to promote health equity.
■
Capacity building: Building capacity at the level of the individual, the
organization and the system by creating a learning environment for stakeholders,
leadership training, applied projects and international exchange of experience.
■
Policy advocacy: Developing and applying principles of advocacy,
communication and social mobilization to influence health governance at all
levels and enhance understanding of how a social determinants approach can
integrated in national health systems.
I
Purpose
1.2
These “Guidelines for Action” are intended for use by the Centre and its
stakeholders in developing and implementing action research at the local level related to
“Healthy Urbanization” objectives for the period 2006—2007. This phase of the project
will test approaches in Healthy Urbanization Field Research Sites to inform a wider
group of stakeholders in the future. Included among the Centre’s partners are:
■
Local stakeholders in selected urban sites [e.g., city health officers, civil society
partners, government, non-governmental organizations and other agencies and
organizations at the local and national level]; and.
■
WHO Country and Regional Offices.
Action research projects aimed at strategic problem-solving will focus on governancerelated interventions that optimize social determinants in ways that improve health and
promote health equity as shown in Figure 1. New knowledge will be generated through
research activities that will be embedded at several points in the process as indicated by
the red circles.
.... -' ■
I
Social
Deteniiinants
Governance
■
■
'
Improve (
Interventions
Figure 1: The focus of action research interventions
These are where action research
interventions will be focused.
2
1.3
Structure of the Guidelines
These Guidelines present the reader with a step-wise approach to the
implementation of the Healthy Urbanization Project. The document has four sections that
emphasize different aspects of action on the project. In order to suite the needs of
specific audiences, Section 1 may be combined with any of the other sections as
appropriate.
Section 1 - Provides the purpose of the Guidelines; the background of the
project; and guiding principles to be followed in implementing the project.
Section 2 - Provides definitions of key terms and concepts; the overall rationale
for the project; a summary of the project partners 2006-2007; and suggested
methodologies and approaches to implementation.
Section 3 - A 2006-2007 timeframe for project activities; a brief description of
Project capacity building modules; site-specific project details; and selected
issues related to advocacy and the future.
Section 4 - A description of the project management and support structure;
and considerations related to monitoring, evaluation and reporting.
Annexes - Providing templates for planning and reporting.
1.4
Guiding principles and approaches
The project will be guided by the following principles:
I. “Learning by doing,” in particular the use of participatory and action-research
methods to optimize social determinants and promote health equity;
2. Respect for local contexts and responsiveness to local needs in the design,
development and adoption of project interventions and strategies;
3. Community participation and the involvement of beneficiaries and stakeholders
at all stages of the project (i.e. planning, implementation and evaluation);
4. Empowerment of beneficiaries and stakeholders through capacity building;
5. Integration with existing initiatives that strengthen health systems at the
national and local level;
6. Linkage to initiatives in support of global imperatives such as Health for All,
the Millennium Development Goals, the Commission on Social Determinants of
3
Health, the Commission on Macroeconomics and Health and Sustainable
Development;
7. Utilization of vulnerability assessment and reduction approaches to address
health issues that result from the convergence of social and environmental
determinants; and
8. Cost-sharing and resource mobilization at all levels to complement fixed
budgets that are provided by the WHO Kobe Centre.
4
HealthvMlBi
Urbanization
Learning
Circle
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Operational Framework
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2.0 OPERATIONAL FRAMEWORK
2.1
Rationale2
The Healthy Urbanization Project will address strategic local health issues in
urban settings through action research projects with a focus on governance-related
interventions that optimizes the impact of social determinants in ways that improve health
and promote health equity. Outputs of the project are expected at local, national and,
later, global levels. At the local level, the project will bring added value through new
ways of working between and among sectors, leadership development and community
participation and empowerment. At the national level, the project will provide new
knowledge and evidence that may accelerate the adoption of principles of social
determinants of health and health equity in national policy, programmes and practice. At
the global level, the project will contribute to international understanding and strengthen
the imperative for action on social determinants of health (Figure 2).
~ A more in-depth discussion of the concepts underlying the Healthy Urbanization Project can be found in
the WKC document Concepts underlying the Healthy Urbanization Project: Optimizing the Impact of
Social Determinants ofHealth on Exposed Populations in Urban Settings, 2006.
5
Figure 2: Expected outputs from action research interventions
Local level
Interventions At
Various Social
Determinants of
Health
Improved
governance
//
National level
Global level
Main output
Main output
Main output
t
•improve health
outcome
Improved
health
equity
•Promote health
equity
•Adoption of
principles of SDH
and equity principles
in national health
policy
•Action on social
determinants of
health
•international
understanding and
global action on
Social Determinants
of Health
Addedyalue
•New ways of
working
•Leadership
development
•Feeling less helpless
(Empowered)
Social determinants of health can be modified and influenced, resulting in different health
outcomes as noted in Figure 3. In any particular situation, the overall goal is to optimize
the impact of social determinants in ways that result in high and equitable outcomes
(indicated by the green box) and minimize impacts that result in poor health outcomes
and low equity (indicated by the red box).
Figure 3: Impact of social determinants on health outcomes
HEALTH OUTCOME
Social
Determinants of
Health
High
Equitable
Inequitable
6
Low
2.2
Project partners - 2006-2007
The Healthy Urbanization Project will be implemented in partnership with a wide
range of stakeholders at global, regional, national and local levels. The proposed
institutional partners of the project at the global level will include the Alliance for
Healthy Cities, International Network of Health Promotion Foundations, the SEAMEOTROPMED Network and the La Trobe University School of Public Health. Partners at
the regional level will include the different Regional offices of the World Health
Organization and other international agencies. Partners at the country level will include
Ministries of Health, transportation, education, welfare, civil society and other
stakeholders. Partners at the local level will include local governments, non
governmental organizations, communities, people’s organizations and others that will
emerge as the site-specific projects are developed and implemented.
2.3
Methodologies and approaches
2.3.1 Developing strategies (Project Objective 1)
Two frameworks for assessing Healthy Urbanization are presented here. While
the Urban Health Assessment Framework show in figure 4 below is recommended for
national level assessment, we propose the spider diagram shown in figure 5 as an
assessment tool for municipal level assessment of healthy urbanization.
A Framework for Assessing Healthy Urbanization - The WHO Regional
Office for the Americas has developed an urban health assessment framework (Figure 4)
to function as a practical-theoretical tool to provide reliable and comprehensive
information for decision makers, local governments, researchers, local communities, and
public and private sectors to effectively and appropriately address the challenges and
opportunities to improve the urban health conditions in cities. 3
As urban health is a relatively new concept, there is little consensus on definitions
and frameworks. Yet there is a common understanding that health and quality of life are
influenced by urban living conditions as well as lifestyles. Cities are facing great
challenges in dealing with the urbanization and its consequences, such as increasing
health inequities and the emergence and deterioration of slums and informal settlements;
health inequities are observed within the city, from block to block and household to
household. It is argued that the inequalities among individuals and cities are the result of
local dynamics relating to economic, political, social and health conditions. The
municipal level can act on these matters but effective intersectoral collaboration is needed.
This framework emerges from the following underlying assumptions:
3 This framework was developed by the WHO Regional Office for the Americas (the Pan American Health
Organization) - Ms Katia de Pinho Campos, Regional Adviser in Urban Health, based in Mexico.
7
1. Cities may impact positively or negatively on the health and quality of life of the
population. We need to identify HOW (policies and programs), WHY (factors
and conditions) and WHERE (neighbourhood, areas) in order to take effective
action;
2. Health is not merely the absence of the disease. It is a positive and holistic
concept that means a complete state of well-being, physical and mental health;
therefore, a multisectorial approach is required.
3. The concepts represented in this framework are not new. The framework allows
for putting together the evidence that is known, and organizing it in such a way
that authorities, decision-makers, civil society, the community and the private
sector can have a comprehensive picture of the dynamics of the city and
understand what, why, where and how decisions are taken;
4. Local authorities may lack comprehensive yet localized diagnostics to make
informed decisions and to monitor and evaluate actions;
5. This framework has been developed for the Americas Region and adaptations are
necessary both within and outside the Region.
Figure 4 shows the framework presented for assessing the determinants of health
and quality of life in urban settings4.
Urban Health Assessment Framework
A proposal for diagnosing and monitoring the health,
quality of life andnurnan development in the cities
of the Americas
Alert
Pressure
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Figure 4: PAHO/WHO Urban Health Assessment Framework (A work in progress)
4 See Annex 2 for explanation of the different factors: local force, pressure, alert, action/vulnerability,
impact and action.
8
The ultimate purpose of the Urban Health Assessment Framework (UHF) is to
provide reliable and comprehensive information for decision and policy makers, local
governments and authorities, researchers, local communities, and public and private
sectors. Functioning as a strategic framework, the UHF aims to effectively and
appropriately identify and address strength, weakness, challenges and opportunities to
improve the urban health conditions in cities.
The UHF is a considered as a work in progress. It consists of conditioning phases
such as external forces, local forces, pressure, alert, action/vulnerability, impact and
reaction. Each conditioning phase is represented by macro determinants of urban health
such as demographic, economic, governance, social and physical environments as well as
health. Each determinant is denoted by major factors according to its respective
conditioning phase.
The framework starts with external forces represented by the effects of
globalization and national policies that affect local decision-making and ultimately the
health of people in the city. These external forces impact on localforces, represented by
the economic and governance factors. These in turn exert pressure on the demographic
pattern in the city, which provokes an alert situation in relation to various macro
determinants such as the physical environment, the social environment and health. The
outcomes of urbanization depend on the level of response and the actions taken. Yet if
these actions are deficient or absent, the city might face a vulnerability condition,
represented by the risk factors. This will eventually impact on the physical, social and
health environments of the city and its population.
The Healthy Urbanization Spidergram - This simple, powerful tool has been
developed based on WKC experience as a mean to measure social perceptions about the
eight elements of healthy urbanization. It can be appropriate for use at the municipal
level to:
•
understand “felt needs” of a group in relation to urbanization as a social
determinant;
•
define a baseline on social perception within groups from the same setting and to
compare how one group feels about urbanization as a social determinant in
relation to another;
•
identify key areas for intervention based on subjective perceptions of lopsided
development within an urban setting;
•
have a basis for analyzing a social gradient in perceptions about the urbanization
process;
•
measure how group perceptions can be used as a variable that can be linked to
health outcomes;
•
Serve as a starting point for complementary quantitative measurement.
5 The Healthy Urbanization Project Optimizing the impact ofsocial determinants ofhealth on exposed
populations in urban settings. Kobe, WHO Centre for Health Development, 2006.
9
Figure 5: Healthy Urbanization Spider Diagram
Environmental sustainability
Engages all sectors
Energy Efficiency
Elimination of extreme
I I
...... ^irKffn poverty
I
I I I
I I
I
I I I
I I I
I
Enforcement of safety
I i ------ and.security------
Empowerment of individuals
------- and communities-------
Equity-based health systems
Expression of cultural diversity
2.3.2 Demonstrating the applicability of strategies (Project Objective 2)
Action research - “Action research consists of ... research methodologies which
pursue action and research outcomes at the same time ... It also has some characteristic
differences from most other qualitative methods. Action research tends to be:
cyclic -- similar steps tend to recur, in a similar sequence;
participative — the clients and informants are involved as partners, or
at least active participants, in the research process;
o qualitative — it deals more often with language than with numbers; and
o reflective -- critical reflection upon the process and outcomes are
important parts of each cycle.”
o
o
Monitoring and evaluation - In relation to the Healthy Urbanization Field
Research Sites, monitoring and evaluation is expected to have a distinct participatory
flavor. “One of the negative connotations often associated with evaluation is that it is
something done to people. One is evaluated. Participatory evaluation, in contrast, is a
process controlled by the people in the program or community. It is something they
6 Dick, B. (2000) A beginner's guide to action research [On line].
http://www.scu.edu.au/schools/gcm/ar/arp/guide.htinl, accessed 2 June 2006.
10
undertake as a formal, reflective process for their own development and empowerment.”
2.3.3 Capacity building (Project Objective 3)
The capacity building component of the Healthy Urbanization Project provides a
structure for implementation of activities at the healthy urbanization field research sites.
In addition to training, activities may include action research projects, technical
assistance, monitoring group learning, technology transfer, field visits and international
exchange. The proposed capacity building component is composed of three modules on
healthy urbanization. Participants are expected to carry out projects that will address
social determinants of health using health promotion approaches and tools introduced
during the didactic portion of the course. The programme is flexible, dynamic and can be
adapted to local contexts by including appropriate training and capacity-building
materials, methods and approaches that are most suited to local needs. It aims to enhance
practical skills among teams across five categories (intra-personal qualities, interpersonal
qualities, cognitive skills, communication skills and task-specific skills). Opportunities
for cross-regional sharing and learning are also provided.
2.3.4 Policy advocacy (Project Objective 4)
Activities will be undertaken to ensure that new knowledge and good practices are
linked and integrated with national health systems development and wider social and
political processes. The project will create opportunities to advocate for healthy public
policy and more responsive health systems, particularly in relation to:
■
Effective management of inter-sectoral collaboration to ensure maximum
impact and the judicious use of limited resources for health;
■
Decision-making that harmonizes competing interests to achieve the
higher goal of health equity as a social good.
■
Empowerment of communities to ensure:
o
o
o
o
o
Identification of real problems and needs;
Judicious use of available resources;
Ownership and sustainability;
Timely action for improvement; and
Community-based management.
7 M Patton. Qualitative Evaluation Methods, (2nded). 1990, p. 129.
11
HealthyfSltAi
Urbanization
Learning
Circle
f
v
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fi
iflslIS
■
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Project implementation
3.0 PROJECT IMPLEMENTATION
3.1
2006-2007 Timeframe
Sustaining
Action
Through
Advocacy
Situation
Analysis
3 weeks
3-5 months
Social
Mobilization
For
Intersectoral
Action
Strategy
development
Through
ActionResearch
4-4.5 months
13
3.2
Capacity building modules
Capacity building in the Healthy Urbanization Project will be undertaken
through the organization of “Healthy Urbanization Learning Circled.
Healthy Urbanization Learning Circles are networks of multi-sectoral and
interdisciplinary teams that will undertake action research projects at the city level
through a guided process that will introduce public health methodologies for action to
improve governance, optimize the impact of social determinants and promote health
equity in the urban settings.
Healthy Urbanization Learning Circles will use the “Evidence-Informed Policy
and Practice Pathway8 (see figure 6) as a model for influencing policy and practice
throughout municipal decision-making processes. Policy ideas provide the starting point
for the sourcing of evidence. Sources of evidence are multiple and varied. Using the
evidence includes interpreting and applying knowledge in specific contexts. Capacity to
implement is considered from the perspective of the individual, the organization and the
system.
Figure 6: Evidence-Informed Policy and Practice Pathway
Policy
idea
EVIDENCE
•ftascarch
■Follkt
•Economics
USING lhe
EVIDENCE
tilrodusing, Inlaiprafcrig,
▼
•fin utYl'dy* MllKaMon
CONSIDERING
CAPACITY
TO
IMPLEMENT
■
HndMOvnl
’Policy
DOI: WJ 37t/jctimal.pmed^3020166.^001
Bowens, Zwi AB (2005). Pathways to “Evidence-Informed” Policy and Practice: A Framework for
Actions. PLOS Med 2(7):el66
14
Healthy Urbanization Learning Circles will undertake capacity building
activities over a 9-12-month period that is organized around four modules9:
•
Module 1: Overview of Healthy Urbanization: Situation Analysis
•
Module 2: Healthy Urbanization Challenges: Strategy Development and Project
Proposal Writing
•
Module 3: Healthy Urbanization Opportunities: Social Mobilization for
Intersectoral Actions.
•
Module 4: Mainstreaming Healthy Urbanization: Sustaining Action through
Advocacy
Healthy Urbanization Learning Circles will be guided by the following principles:
•
Emphasizing applied skills, not just theoretical knowledge;
•
Training in a highly interactive manner, drawing on personal experience to
reinforce team learning;
•
Encouraging strategic thinking in the promotion of healthy urbanization;
•
Emphasizing the use of good governance principles in decision-making;
•
Using action research projects to reinforce classroom learning, multiply
training benefits and generate results;
•
Providing opportunities for mentoring and technical support through national
and international networking; and
•
Soliciting feedback as a means of improving the learning process.
General criteria for participants in the Healthy Urbanization Learning Circles are
provided as preliminary guidance, but local groups are strongly encouraged to develop
appropriate criteria to meet the needs of the sites. It is proposed that participants are:
•
•
•
•
•
•
Recognized as having a commitment to the improvement of health in the city;
Known to value social justice and equity;
Respected as influential members of the community;
Engaged in work that promotes positive social values;
Highly motivated and will exercise leadership in their sphere of influence;
Representatives of different gender and sectors who are stakeholders in social
determinants of health.
9 The curriculum and training materials of the Healthy Urbanization Learning Circles will include materials
that have been developed and tested through “Prolead”, a health promotion leadership training template that
was initiated at the WHO Western Pacific Regional Office in 2002 and was further expanded by the WHO
Centre for Health Development in collaboration with the Regional offices of the Eastern Mediterranean
Region and the Southeast Asian Region.
15
3.3
Advocacy and the future
Healthy Urbanization builds on a wide range of health and development
initiatives that link health to broad determinants that are social, political, cultural and
po itical as shown in the Figure 7. The project hopes to advance the agenda of Healthy
Cities strengthen the health equity perspective in cities and municipalities and create a
critical mass of urban stakeholders who are better prepared to promote health in a rapidly
urbanizing and globalized world.
H y
In March 2005, the Director-General launched the WHO Commission on Social
Determinants of Health. Over the next two years, the work of the Commission will be
supported by a number of Knowledge Networks that focus on various social
determinants-related themes. In this regard, the WHO Centre for Health Development
has been selected as the hub of the Knowledge Network on Urban Settings (KNUS) The
ZL0/nnh-7e
has
made an integral part of the Healthy Urbanization Project in
2006 2007. The focus of the KNUS’ work lies at the heart of promoting health equity in
urban settings, particularly among exposed populations. This work will inform and
enhance on-going activity in the Healthy Urbanization Field Research Sites, as well as
the related work of identifying, assessing, adapting and developing tools and models to
influence health governance decision-making in ways that promote health equity
Correspondingly, the action research carried out in the Healthy Urbanization Field
Research Sites will inform the work of the KNUS, providing examples and relevant
experience aimed at influencing social determinants of health to promote health equity
1 he Sites will also serve to directly connect selected KNUS members to key urban
settings as a possible mechanism for enriching the related thematic papers that are being
developed for the Commission on Social Determinants of Health.
3.4
Allocation of funds
Funding in the amount of about US$ 114 500 for each Healthy Urbanization Field
Research Site will be available from the budget of the WHO Centre for Health
Development. An indicative allocation of these funds is shown in Table 4. It is also
expected that some in-kind support will be provided by the local project stakeholders. In
addition, Local Project Steering Committees are encouraged to mobilize funds from other
sources and partners with shared local interests.
Mangoing the release of funds
WKC will issue a “HQ Fund Authorization to Charge” for the funds agreed in the
budget for the implementation of each Healthy Urbanization Field Research Site This
authonzation will be issued from WHO/HQ Geneva to the WHO Country Representative
k C nhurOl!gh the RegI0naI Offlce- The authorization of funds will not necessarily be for
the full budgeted amount but divided into appropriate portions. As the amounts will
exceed US$20 000, only the Allotments and AMS codes will be provided and the WR
will be responsible for the creation of obligating documents (APWs and Internal
16
communication) and issuance of sticker numbers in accordance with WHO procedures.
Disbursal of funds will follow normal WHO procedures applicable in each Country
Office. A copy of all obligation documents must be provided to WKC as soon as
approved.
Table 4: Resource allocation for each Healthy Urbanization Field
Research Site in 2006-2007
BUDGET ITEM
BUDGET AMOUNT (USS)
Recruitment of Local Project Research
Coordinator (18 months)
54000
Team research projects (APW) X
1,500/team
10 500 10
Supplies and equipment
8 000 11
Local costs and social mobilization
5000 12
Capacity building
30 000 13
WKC Country Team Advisers
00 14
Agreements for Performance of Work
ESTIS websites
4000 15
In collaboration with UNEP
Project Scoping Paper
300016
10 It is estimated that site research teams will be comprised of about 3-4 members each and that there will
be about 4-6 teams per site. It is recognized that this may vary somewhat from site to site depending on
local circumstances.
11 To support the establishment of a local project office (located in the WHO Country Representative’s
offices where possible).
12 For communications costs, videoconferences, meetings, etc.
This estimate is based on three training sessions over the course of the project. The participants in these
sessions will be the research teams. As indicated in Footnote 15, this will involve about 20 or so
participants per Site.
A WKC Country Team Adviser(s) will visit the site about three times. Interim communications and
advisory services will also be provided.
15 Local contract(s) to support project work.
16 Local contract(s) to support project work.
17
Healthyl^tM
Urbanization
Learning
Circle
Project management
4.0 PROJECT MANAGEMENT
4.1
Management and support structure
The general relationship between the various levels of project management is
depicted in Figure 6.
Facilitates
communications across
countries & regions
WKC
Global Project
Steering Comm.
WKC Healthy
Urbanization Project
Secretariat
Coordination at
Regional & National levels
Local Project
Steering Committee
LOCAL PRO
Introduction
Figure 6: The general relationship between levels of project stakeholders
The Terms of Reference and composition of the WKC Healthy Urbanization
Project Secretariat, the Global Project Steering Committee and the Local Project Steering
Committee are shown in Tables 5.
19
Table 5:
Membership and responsibilities of committees and
teams
COMMITTEE/TEAM
WKC Healthy
Urbanization Project
Secretariat
Global Project Steering
Committee
MEMBERSHIP
TERMS OF REFERENCE
1. Director, WHO Kobe Centre
L Oversee project implementation
2. Team Leader, Urbanization
2. Develop technical, organizational,
and Health Equity
political and financial guidelines for
3. Technical Officer, Health
project implementation
Governance Research
3. Raise and manage human and
4. Technical Officer, Best
financial resources for the project.
Practice Research
4. Undertake planning processes
5. Technical Officer,
i elated to further development and
Knowledge Management
implementation of the project.
6. Technical Officer, Policy
5. Coordinate activities between the
Advocacy
WHO Kobe Centre, the WHO
7. WKC Country Team
Regional Offices (and Country
Advisers to the Healthy
Offices, as appropriate), the Healthy
Urbanization Field Research
Urbanization Field Research Sites
Site projects
and local project teams.
8. Responsible Officer,
6. Engage partners in collaborative
Information and
research and capacity-building
Communications Support
activities.
9. Administrative Officer
7. Document processes and activities
and
’ .
8. Assess, monitor and evaluate the
project.
1. The WHO Regional
Advisers
designated as Healthy
Urbanization Project
Focal Points
2. The WHO Country
Representatives from
countries with Healthy
Urbanization Field Research
Sites
3. The City Focal Points from
Research Sites
4. The Local Project Research
Coordinators
20
1. Provide leadership and strategic
guidance to the development of the
Healthy Urbanization Project.
2. Create opportunities for sharing of
research results and lessons
learned among the Healthy
Urbanization Field Research Sites.
Table 5:
Membership and responsibilities of committees and
teams (Cont’d)
COMMITTEE/TEAM
MEMBERSHIP
TERMS OF REFERENCE
Global Project Steering
Committee (Cont’d)
5. Members of the WKC
Healthy Urbanization
Project Secretariat
3. Provide leadership and
strategic guidance to the
development &
implementation of the
Healthy Urbanization
Project.
4. Create opportunities for &
facilitate the sharing of
research results and
lessons learned among the
Healthy Urbanization Field
Research Sites.
5. Critically assess the work
and financial plans for the
Healthy Urbanization Field
Research Sites.
6. Explore global and
regional opportunities to
enhance the work of the
Healthy Urbanization
Project, and
7. Agree on common inputs,
targets and indicators for
monitoring, assessment
and evaluation of projects
and outcomes of the
Healthy Urbanization Field
Research Sites.
8. Review and enrich the
implementation guidelines
as prepared by the Healthy
Urbanization Project
Secretariat, particularly in
relation to Healthy
Urbanization Field
Research Sites
21
Table 5:
Membership and responsibilities of committees and
teams (Cont’d)
COMMITTEE/TEAM
Local Project Steering
Committee
MEMBERSHIP
1.
Designated WKC Healthy
Urbanization Project
Secretariat Focal Point
2. WHO Regional Adviser
designated as Healthy
Urbanization Project Focal
Point
3. WHO Country office focal
point
4. Local Research Project
Coordinator
5. WKC Country Team
Adviser
6. Ministry of Health Focal
Point for the WKC Healthy
Urbanization Project
7. The City Focal Point
8. Other local stakeholders as
the Committee may deem
appropriate
22
TERMS OF REFERENCE
1. Ensure timely
implementation of the
local project action plans.
2. Explore other sources of
funding and resources to
enhance project
implementation.
3. Assess and report on
project outcomes to the
Global Project Steering
Committee and the WKC
Healthy Urbanization
Project Secretariat, as
appropriate.
4. Engage local academic
and other institutional
partners to participate in
the project as required.
5. Oversee implementation
of the local projects.
6. Collaborate with local
stakeholders in
development of detailed
work and financial plans
for the Healthy
Urbanization Field
Research Site.
7. Prepare project activity
and implementation plan
reports as required.
8. Mobilize local and
national stakeholders to
support the project.
4.2
Monitoring, evaluation and reporting
Monitoring, assessment and evaluation in relation to the local projects will be
approached from a co-learning perspective, mindful of the “learning-by-doing”
philosophy that underpins project implementation. From this perspective, judgment is
suspended as we jointly learn, with our partners, how to improve health and reduce health
inequity, particularly among exposed populations. In this process, the timely gathering,
documentation and dissemination of information is critical - before, during and after the
project (Figure 7).
Figure 7: Process, Outcome and Impact framework for the Healthy
Urbanization Learning Circles.17
Evidence Gathering, Documentation and Dissemination Cycle
Formative
Assessment
What is the status?
What do we want to change?
What do we know?
What do we need to know'll
Impact
PROJECT
implementation
Measuring the changes in the
short- intermediate^ and long-term
What are the
indicators?
1.
2.
3.
4.
Etc.
Process
Who are we trying to
'reach?
How are we doing it?
Who else must act?
Outcome
What are the changes?
• Policy
• Legislation
• Values (knowledge, attitudes
& practice)
Time Frame: Before - During - After
17 Dr. Davison Munodawafa, Regional Adviser for Health Promotion & Education, WHO Regional Office
for South-East Asia, June 2006.
23
Reporting
m>m fM"Ss “I
“"’T
eonel
13 Z7 7port base<i “ ““
visit (3SX 32“
Si»
<1™.'ll S'
fo"0™8 ,te ,hird Si,e
L“al Pr‘*M R“"‘h Coordinate
’
Local Project Team - A bi-annual (June and December) progress renort
inc u ing assessment and evaluation components, to the Project Steering
Comm.ttee, through the WHO Country Representative, on pro ect
8
piementation, and an end-of-project evaluation report (fomlts included as
Annex 6 and Annex 7 respectively).
formats included as
Tgam Leader Urbanizationand Health Equity, WKC - Based on the above
Pro^Eval’
Lea<der Wi" Prepare 30 °Vera" Healthy Urbanization
roject Evaluation Report for the Director, WKC, and relevant Healthy
Urbanization Project stakeholders.
«eaitny
‘
The WRof .he Local
oject Research Coordinator, will be responsible for providing WKC with
basisT^ nanC1!< rePOrtS °n thC fUnds °bligated and disbursed on regulaJ
basis as per agreed on each sites.
regular
24
I
:;?;h
Healthvt-^f fci
Urbanization
Learning
Circle
liliiil
■
I
I
fill®
111 111
Wt#
Annexes
I
■I
111
1SI&
'SB
I
lll^
ni
SB,
iil
■
i
fe
II
World Health
Organization
«
Annex 1: Terms and concepts
A common understanding of a number of terms and concepts is important to the
successful implementation of the Healthy Urbanization Project and effective crosscultural communications about its components. Among others, these include the
following:
■
Social determinants - Broadly defined as “the causes behind the causes” of poor
health outcomes as they relate to both social and environmental consequences of
human actions. The “causes behind the causes” of poor health outcomes are often
social in nature and include housing, education, employment conditions, access to
transportation, access to health care and early childcare. These in turn are driven
by structural determinants such as gender, age, socioeconomic status, ethnicity
and belief systems and faltering social support systems that underpin family and
community life. These are the outcomes of the wider economic and political
structures and systems such as globalization and rapid, unplanned urbanization
that influence social and community networks as well as well as individual
lifestyle factors.
■
Governance - Governance is defined as the management of the course of events
in a system.18 In relation to health, it can be seen as the process of allocating
health resources and promoting, protecting and expanding health assets. The
power to decide how health resources and assets are allocated may rest in multiple
‘nodal’ systems. There is a wide array of state, (national, regional and local) and
non-state (civil society, non-profit organizations, media, business and industry)
players that influence health governance.
■
Exposed populations - This term refers to a population at risk of unfavorable
social conditions over a designated period of time in a specific geographical area.
■
Health equity - “...equity in health can be defined as the absence of disparities in
health (and in its key social determinants) that are systematically associated with
social advantage/disadvantage... Equity in health means equal opportunity to be
healthy, for all population groups. Equity in health thus implies that resources are
distributed and processes are designed in ways most likely to move toward
equalizing the health outcomes of disadvantaged social groups with the outcomes
of their more advantaged counterparts.” 19
Urbanization - is defined as “the social process whereby cities grow and
societies become more urban”. Different countries have different definitions of
what a city, a town or an “urban area” is using parameters such as density or
population size. Three interrelated characteristics of urbanization make it
different from what it was in the past: 1) the rapid rate of urban growth and its
effect on municipal governments; 2) the upsurge in slums and informal
Burris S (2004). Governance, microgovernance and health. Temple Law review. 77: 335-358
19 Braveman and Gruskin, http://iech.bmiiournals.com/cgi/content/full/57Z4/254, accessed 1 June 2006.
25
settlements and the effect on the urban economy; and, 3) the proliferation of
informal settlements and their impact on the urban environment and the
environment’s impact on slums and informal settlements. Combined, these
conditions give rise to settings characterized by a radical process of change with
positive and negative effects, increased inequity, greater environmental impacts,
expanding metropolitan areas and fast-growing slums and informal settlements.
■
Millennium Development Goals (MDGs) - “The eight Millennium
Development Goals (MDGs) ... form a blueprint agreed to by all the world's
countries and all the world’s leading development institutions. They have
galvanized unprecedented efforts to meet the needs of the world s poorest.
1.
2.
3.
4.
5.
6.
7.
8.
■
Eradicate extreme poverty and hunger.
Achieve universal primary education.
Promote gender equality and empower women.
Reduce child mortality.
Improve maternal health.
Combat HIV/AIDS, malaria and other diseases.
Ensure environmental sustainability.
Develop a global partnership for development.
Optimizing impacts — How people interact with their social and physical
environments results in pressures, changing status of health and quality of life and
exposure to positive and negative factors that have a direct impact on health. In
the context of the Healthy Urbanization Project, “optimizing impacts” of social
determinants refers to modifying the way in which people interact with their
social and physical environments to achieve optimum health outcomes.
20 http://www.un.org/millenniumgoals/, accessed 1 June 2006.
26
Annex 2: Site-specific project details
San Joaquin, Santiago, Chile
The main health problems noted are mistreatment of children, ageing, obesity,
poor housing conditions, tobacco, alcohol and a poverty-drugs cycle, mental health
disorders, pollution and a growing sense of insecurity. This had led to inequities in areas
such as education and gender, as well as inter-generational inequities. Despite these, the
scoping paper noted certain opportunities that could be further explored. These
opportunities are related to strengthening the demand side of governance and services,
and include political will and stability, effective participation by all relevant stakeholders,
including children, which is shown by the recent initiatives of an effective life skills
program for children and participatory budgeting and planning that has happened in 10
municipalities in the health sector. In addition there are both national and local programs
to promote these initiatives. For social inequities to diminish there must be effective and
sustainable intersectoral collaboration.
Suzhou City, China
TO BE ADDED
Bangalore, India
Bangalore has adopted the healthy cities approach and identified six main
intervention areas:
1)
2)
3)
4)
5)
6)
Access to quality health care - especially urban poor;
Safe water supply & proper sanitation;
More organized disposal of waste (collection, segregation & transportation);
Ample public parks & play areas;
Safe roads & safe transportation; and
Freedom from crime, violence and drugs.
The six issues are being addressed through environmental health interventions,
preventive health measures, health promotion approaches, education and training. These
initiatives are proving successful and are being implemented using an intersectoral and
participatory approach. However, there are still major challenges such as solid waste
management which consumes the majority of the budget, and HIV/AIDS with its highest
prevalence among the working class.
27
Hyogo Prefecture-Kobe City, Japan
This paper directly contextualised four major identified social determinants of
health.
1) Eating environment with a focus on children and the elderly,
2) Ageing of people displaced by disasters,
3) Working environment, and
4) Social support for parenting.
For each social determinant of health, relevant stakeholders and actions underway
or proposed to remedy these problems were identified and the final conclusion was that
more attention needs to be given to exposed population sub-groups based on evidence
emerging from the health sector on health disparities as well as to strengthening
intersectoral collaboration between stakeholders.
28
Annex 3: Description of factors of the Healthy Urbanization Framework
External Forces__________
Globalization and National
Public Policies
Local Force
Pressure
Economic:
l.GDP
2.Income
distribution
3. Employ,ment
by Industry
4. Government
revenue and
expenditure
Governance
Type of
21
Demographic:
Migration
Immigration
Sub
urbanization
Urbanization
Population
density
Dependent
population
Ethnicity
Age and sex
Gender
Culture
Religion
Fertility Rate
Age structure
Alert
Action
Physical
Environment
Housing deficit
Unsafe housing
Vehicular fleet
Use and
condition of
public
transportation
Access to
potable water
and basic
sanitation
Energy
consumption
Poor green and
recreational
spaces
Polluted
industries
Protective
factors______
Environment:
Land use and
soil protection
Emergency
disaster
preparedness
Environmental
literacy
Vulnerability
Risk factors
Environmental:
Water, air and
soil
contamination
Social
Environment:
Physical:
Land-use
Physical:
Noise exposure
Impact
Elderly, women, children, disabled and chronically ill.
29
Adverse
Favorable:
Environmental:
Disasters
Polluted urban
run-off and storm
Water runoff
Environmental:
Clean water, air
and soil
Available green
and recreational
spaces
Clean industries
Physical:
Physical:
Urban slums and | Traffic safety
External Forces__________
Globalization and National
Public Policies
Local Force
Pressure
government
Citizen’s
perception of
political will
Community
Participation in
public policies
Community
perception of the
use of public
resources
Corruption
perception Index
Qualities of
public policies
Level of
intersectoral
collaboration of
public policies
Alert
Action
Physical
Environment
Unemployment
Poor solidarity
and thrust
High rates of
community
transition
Segregation
Discrimination
Vulnerable
groups21
Informal jobs
Number of
schools
Enrolment in
early child care
and education
Enrolment in
primary and
secondary
education
Out-of-school
children
Distance house
to school
Teaching staff in
primary and
Protective
factors
planning
Traffic signs
Traffic laws
Safe housing
Impact
30
Vulnerability
Risk factors
Mobility
Adverse
Favorable:
informal
settlements
Vehicular traffic
Healthy housing
External Forces__________
Globalization and National
Public Policies
Local Force
Pressure
Alert
Action
Physical
Environment
secondary
education
Trained teachers
Health:
Urban un-insured
Access and
quality of
primary,
secondary and
tertiary care
Emergency care
Number of
health
professionals per
inhabitant
Morbidity
Food security
Protective
factors
Vulnerability
Risk factors
Adverse
Favorable:
Social:
NGOs and
community
councils
Participatory
programs
Partnership
between public
and private
sectors22
Community
support
programs23
Family and
community
support
Policy
Social:
Poorjob
condition
Drop-outs
Primary and
secondary school
completion rates
Social:
Violence24
Child labor
Poverty
Education25
Inequality
Human
Development
Index
Social:
Healthy schools
Safety well-being
High social
capital
Tertiary
education
completed
Reduction of
urban poverty
High HDI
Personal
satisfaction
Expectation of
future growth
Impact
'■ This partnership can be expanded to cover civil society, community and educational institutions.
Jobs, food security and education.
24 Theft, kidnapping, domestic violence, abuse of elderly, women and children.
‘ Literacy, and school completion rates (primary, secondary and tertiary).
26 Social and income.
31
External Forces__________
Globalization and National
Public Policies
Local Force
Pressure
Alert
Action
Physical
Environment
Protective
factors
enforcement
Vulnerability
Risk factors
Adverse
Favorable:
Health:
Health literacy
Preventative
health services
and programs
Immunization
Health:
Unsafe sexual
behavior
Teenage
pregnancy
Substance and
alcohol abuse
Tobacco use
Lack of exercise
Diet
Health
inequalities
Health:
Mortality rates
Malnutrition
External causes
Infant and
maternal
mortality
Health:
Equity in health
Healthy life
expectancy
Healthy life style
Impact
32
Annex 4: Proposed Template for Planning
Agreed Objective:
No.
I.
Objective
Who
Target/Indicator
Budget
Output I
Activities
1.1
1.2
1.3
1.4
1.5
2
2.1
2.2
2.3
2.4
Output 2
Activities
2.5
Output 3
3.1
3.2
3.3
3.4
Activities
3.5
33
Expenses
Balance
Ql
Q2
Q3
Q4
Critical
Assumption/
Comments
Annex 5: Proposed Template for reporting - First visit (Country
Team Adviser)
Initial Assessment Report:
Contents
i. Abbreviations and Acronyms
ii. Executive Summary
1. Introduction
2. Assessment of The Overall Healthy Urbanization Project and Summary of Key
Findings.................................
2.1. The Healthy Urbanization Framework
2.2. Key findings
2.3. Conclusions
3. Progress Towards Objectives
3.1 Developing strategies
3.2 Demonstrating the applicability of strategies
3.3 Capacity building
3.4 Policy advocacy
4. General Assessment of the sectors invoived 'in HULC processed and’their contribmion
to health equity in urban settings
5. Monitoring: Indicators and Milestones
5.1. Indicators and targets
5.2. Monitoring of healthy urbanization and health equity and
implementation of plans.
6. Major Recommendations
7. Issues of Particular Interest for the Future Policy Advocacy and mainstreaming
8. Process Action Plan
9. References
Annexes:
Annex 1
Annex 2
Annex 3
Annex 4
Annex 5
Terms of Reference
Itinerary
List of Persons Met
Assessments of Financial Management and Procurement
HULC indicators
34
Annex 6: Proposed Template for reporting- Third visit (Country
Team Adviser)
Evaluation report:
Acknowledgements
Glossary of terms
Executive Summary
1 Background to the Evaluation
1.1 Introduction
1.2Tasks of the Evaluation
I. 3Activities of the consultant
2 Healthy Urbanization Project Overview
2.1 Project Rationale
2.1 Implementation Approach
3 Evaluation Approach
3.1 Methods and Techniques
4 Context
5 Progress Towards Objectives
5.1 Developing strategies
5.2 Demonstrating the applicability of strategies
5.3 Capacity building
5.4 Policy advocacy
7 Institutional Futures
7.1 Strengths:
7.2 Constraints and Issues
7.3 Creating a Sustainability Strategy
7.4 Co-ordination with the Health Sector
7.5 Package and Brand the HULC Approach
8 Monitoring Information System
8.1 Description of Monitoring and Evaluation System
8.2 Findings from the evaluation
9 Analysis of the Project Objectives
9.1 Consistency in Principles and Approach
9.2 Indicators and Means of Verification
10
Review of the Curriculum
10.1 Scope of Review
10.2 Description of the Curriculum Guides
10.3 Strengths
10.4 Observations and Potential Areas for Improvements
11
Summary of Recommendations
II. 1 General Recommendations :
11.2 Recommendations to Improve Overall HULC
11.3 Recommendations related to Mainstreaming and Sustainability
11.4 Recommendations relating to Monitoring and Evaluation
Appendices
Bibliography
35
Annex 7: Proposed Template for reporting - Quarterly Progress
Report (Local Coordinator)
Heading:
Date:
To: Team Leader, Urbanization and Health Equity
Through: the WHO Country representative
Copy: Regional Focal Point (Name and position)
Name and position of the writer
Progress Report: Healthy Urbanization Project, Country:
Report No.
1. Purpose Statement:
2. Background:
3. Work Completed:
4. Strengths, Weaknesses, Opportunities, Constraints and Challenges:
5. Planned Next Work Scheduled:
(Specify the dates of the next segment of time in the project and line out a schedule of
the work you expect to get accomplished during the period. It is often a good idea to
arrange this section by dates which stand for deadlines. To Finish the progress report, you
might add a sentence evaluating your progress thus far).
36
Annex 8: Proposed Template for reporting - Bi-annual Progress
Report (Local Project Team)
Heading:
Date:
To: Project Steering Committee
Through: the WHO Country representative
Copy: Regional Focal Point (Name and position)
Name and position of the writer
Progress Report: Healthy Urbanization Project, Country:
Report No.
1. Purpose Statement:
2. Background:
3. Work Completed:
4. Strengths, Weaknesses, Opportunities, Constraints and Challenges:
5. Conclusion:
5. Recommendation:
37
Annex 9: Format for reporting - End-of-Project Evaluation Report
(Local Project Team)
Project Title
1. Executive Summary
2. List of Abbreviations
3. Introduction and Background
4. Country context
5. The 8 Healthy Urbanization components
6. Preconditions and Benchmarks
7. Programme Achievements
8. Programme review and summary of progress
9. Lessons Learned
9.1 General Context
9.2 Design and Formulation
9.3 Stakeholders
9.4 Selected activities
10. Conclusion
11. Recommendation
12. List of reference
38
Annex 10: ‘‘Terms of Reference” for Country Team Adviser
Scope and Purpose
for
Country Team Adviser,
Background
In consultation with its Kobe Group partners, WHO recently completed a twoyear transformation of the WHO Centre for Health Development, resulting in an agreed
vision of “Healthier People in Healthier Environments”. The main operational feature of
this vision is action research aimed at improving health and promoting health equity in
urban settings in the face of rapid urbanization. The Centre’s Healthy Urbanization
Project (HUP) for 2006-2015, Healthy Urbanization: Optimizing the impact ofsocial
determinants of health on exposed populations in urban settings, takes a collaborative
approach that informs and enhances WHO regional and country efforts to support
Member States. The Healthy Urbanization Project confronts health equity issues by
developing an evidence base of effective strategies and interventions; demonstrating the
applicability of these strategies in various settings, and building public health leadership
capacity to promote health equity through governance and policy interventions. In
collaboration with WHO regional and country offices, the HUP is engaging six field
research sites in 2006-2007: Santiago, Chile; Bangalore, India; Kobe, Japan and Suzhou,
China. Additional sites are expected to be included in late 2006 and 2007.
Scoping papers have been prepared at each site. Three such papers have already
been written and were presented at the Healthy Urbanization Project Steering Committee
meeting held in Kobe from 30 May to 2 June 2006. The HUP is embarking on a
capacity-building and leadership project which will involve major stakeholders from each
selected site.
Country description:
Objective
Under the general guidance of the Team Leader, Urbanization and Health Equity
(UHE), and under the direct supervision of the WKC focal point, the Country Team
Adviser in close collaboration with WHO Country Representative and city focal point,
will support and guide the design, implementation, evaluation and documentation process
of the Healthy Urbanization Project in the municipality of.
Outputs
•
Technical advice provided to the WKC team (the Team Leader and WKC focal point
in particular) on international experiences (e.g. best practices, examples of local
policy initiatives, opportunities for networking) that may be applicable to the Healthy
Urbanization Field Research Site during the conduct of the different training
modules;
39
•
Technical support through the identification of strategies and opportunities for linking
local action to national, regional and global initiatives, as well as WHO and other UN
initiatives, that could facilitate greater international exchange and collaboration;
•
Progress reports on the issues, challenges and opportunities for improving;
implementation of activities of the local Healthy Urbanization Learning Circle after
each training module;
•
A final report (20-25 pages) for the WHO Kobe Centre with the following format:
1. Summary of the project including a brief descriptic:
ion of the outcome of project
activities
(4-5 pages)
2. National context and opportunities for linking local action to national policy and
action
(3-4 pages)
3. Opportunities for synergy with current WHO country and regional programmes as
well as the work of other agencies in the country (3-4 pages)
4. Lessons learned (5-6 pages)
5. Implications and key recommendations toward the development of a global
platform for action on Healthy Urbanization (5-6 pages)
Scope of work
•
Assisting in the identification of best practice examples that are relevant to the
training programme for the Healthy Urbanization Learning Circle;
•
Ensuring that governance issues are highlighted in projects and interventions;
•
Mentoring the WKC focal point and participants of the Healthy Urbanization
Learning Circle;
•
Providing insight and recommendations on the conduct of local training activities;
•
Acting as a resource person on technical matters and areas of expertise for the site as
well as other Healthy Urbanization Field Research Sites;
•
Preparation of progress and end of project reports;
•
Performing other duties from time-to-time as agreed by the Director, WHO Kobe
Centre, the Team Leader and the WKC focal point.
In addition to the tasks related to the research sites the Country Team
"
Adviser is expected
Promote the Healthy Urbanization Project among key stakeholders;
Prepare for and participate in the meeting of the Global Project Steering Committee;
■
Distill what is of true international value and provide feedback to KNUS on best
practices and potential membership in the Breakthrough Circle.
40
Timing and reporting
The Country Team Adviser will perform the work and be contracted on ad hoc
basis between September 2006 and December 2007, a total of 16 months. For each
designated assignment the Country Team Adviser will be issued with a specific task and
output sheet for the specific project period. The Country Team Adviser is expected to
submit a soft copy and three hard copies of the final report together with any photographs
taken in accordance with the standard operating procedures required from the funding
mechanism undertaken. The final report shall be delivered not later than three weeks
after the completion of the last assignment.
Personal Qualifications
•
Advanced University Degree (Master’s Degree or equivalent) in health or related
fields.
•
Minimum 10 years of work experience in implementing health projects.
•
Minimum of 5 years of experience in doing social science research.
•
Excellent skills in written and oral English and the language spoken at the Healthy
Urbanization Field Research Site.
•
Excellent writing skills.
•
Strong capacity to relate to and interact with a large number of actors at regional,
national and local levels.
Duration of Assignment
The Healthy Urbanization Field Research Country Team Adviser for
is engaged on an ad hoc basis from September 2006 until December
2007. Separate contracts with specific terms of reference will be prepared for each
period.
Submission of Reports to WKC
The Country Team Adviser is expected to submit three hard copies of the report
together with any photographs taken at the site(s) and soft copies upon completion of
each assignment in accordance with the standard operating procedures required from the
funding mechanism undertaken.
Specific Terms of Reference for Country Team Adviser’s first visit to
Date:
Reference is made to the agreement during the Steering Committee Meeting for
the Healthy Urbanization Project (former Core Project) held in Kobe from 30 May to 2
June 2006. It was agreed that Country Team Advisers would be assigned to assist the
41
WKC focal point person at each of the four research sites. This person is expected to
<He°.Z n "nd ba,Cks“p "" WKC
■'■e leadership^apael.y talldiag e„urse
CiSeOIULC)-'1 implementation°f Cities of the
1. consult with national counterparts and the Ministry of Health and other line agencies
discuss linking local action and results of local research to national policy;
2- develop and formulate a framework for all team sites on integrating health eauitv in
Chile!1cXOarirndZndPj'1Cy h^0"3'
SPeCifiC Suggestions Per site for
Vziiuc, Vanina, inaia and Japan;
WKC (1?am Leader f“ ,l,e Conization and Health
1
Prices, examples of ,□ po^SL^
4. manage technical support through the identification of strategies and opportunities for
linking local action to national, r—:—'
opportunities tor
r)e.8i°nal. and IoCal ,n,tiatives> as well as WHO and
other UN initiatives, that could facilitate
---------- ; greater international exchange and
collaboration;
5.
^1=
6. undertake other tasks as assigned.
42
Annex 11: “Terms of Reference” for Local Coordinator
Background
In consultation with its Kobe Group partners, WHO recently completed a twoyear transformation of the WHO Centre for Health Development, resulting in an agreed
vision of: “Healthier People in Healthier Environments”. The main operational feature of
this vision is action research aimed at improving health and promoting health equity in
urban settings in the face of rapid urbanization. The Centre’s core project for 2006-2015,
Healthy Urbanization: Optimizing the impact ofsocial determinants of health on exposed
populations in urban settings, is taking a collaborative approach that informs and
enhances WHO regional and country efforts to support Member States. The project
confronts health equity issues by developing an evidence base of effective strategies and
interventions; demonstrating the applicability of these strategies in various settings; and
building public health leadership capacity to promote health equity through governance
and policy interventions. In collaboration with WHO Regional and Country Offices, the
Healthy Urbanization Project (HUP) is engaging four field research sites in 2006-2007:
Santiago, Chile; Bangalore, India; Kobe, Japan; and Suzhou, China. Two additional sites
are being negotiated with WHO AFRO and WHO EMRO. Scoping papers are first
prepared at each site. Three such papers have already been written and were presented at
the Healthy Urbanization Project Steering Committee meeting held in Kobe from 30 May
to 2 June 2006. The HUP involves a capacity building and leadership project which will
involve major stakeholders from each selected site.
Country specific description:
Objective
Under the general guidance and direction of the Team Leader, Urbanization and
Health Equity (UHE), WHO Kobe Centre and the supervision of the WHO Country
Representative, the Healthy Urbanization Field Research Site (HUFRS) Local
Coordinator will coordinate, facilitate and undertake action research in
Outputs
facilitation of the Healthy Urbanization Learning Circle (HULC);
well-executed action research in(see workplan);
quarterly progress reports in English describing both technical and administrative
progress and shortcomings;
one final report in English which will include background information, objectives,
research design, data collection methods and tools, data analysis, research results and
recommendations for further actions;
effective intersectoral collaboration between relevant stakeholders in
(see workplan);
effective and efficient project management and administrative systems (see workplan).
43
Scope of work
The work shall comprise but not necessarily be limited to:
Coordinate and undertake research on health inequity at the field research
sites;
• Support, facilitate and help coordinate HUP-related activities with the
WKC-designated focal point;
• Set up, maintain and promote the use of communication systems and
mechanisms that facilitate clear and timely dialogue among key stakeholders;
• Coordinate project work with other relevant organizations, groups and
individuals having shared interests in urbanization and health equity issues;
• Represent the WHO Kobe Centre at local and national meetings as required;
• Develop and foster a team approach to the work of the project;
• Assist in the translation of documents and text;
• Provide general administrative (including that of obtaining necessary
clearances) and logistical support to the project; and
• Perform any other duties that arise from the implementation of HULC as
FHJTRS^*^
Country RePresentative and the focal point of the
•
Local Coordinator will also
■
■
■
■
be responsible for updating the ESTIS website for HULC proj ects
coordinate the selection process of HULC participants
review any translations
coordinate with the designated local contractual partner undertaking the
capacity-building project
Timing and reporting
The Healthy Urbanization Field Research Site Local Coordinator will perform the
work and be employed between 1 September 2006 and 31 December 2007, a total of
16 months. The final report shall be delivered by the end of the contract.
Personal Qualifications
•
•
•
•
•
Advanced University Degree (Master’s Degree or equivalent) in health or related
fields.
Minimum 3 years of work experience in participatory social science research.
Excellent skills in written and oral English and the language spoken at the urban
health field research site.
Excellent writing skills.
Strong capacity to relate to and interact with a large number of actors at regional,
national and local levels.
44
Compensation
The level remuneration of the Local Coordinator should be determined according
to local market conditions in. The type of contractual arrangement should
be determined locally according to needs. The total cost of the contract should not
exceed the budgeted US$ 3000 including remuneration and all associated costs.
45
Annex 12:
Letter Of exchange” (Draft under discussion with HQ Legal)
Letter of Exchange
Between
[Name of city] Field Research Site
and
WKC center for Health Development
1. The WHO Kobe Centre for Health Development’s vision of “Healthier People in
Healthier Environments” will be achieved through a research programme that focuses on
urbanization and health equity. The Centre’s Healthy Urbanization Project (HUP) for
2006-2015, Healthy Urbanization: Optimizing the impact of social determinants of health
on exposed populations in urban settings, is taking this vision forward in a collaborative
approach that confronts health equity issues in urban settings. This will be done through
development of effective strategies and municipal level public health interventions;
demonstration of the applicability of these strategies in field research sites; building
capacity among stakeholders and advocacy for health equity.
2. In collaboration with WHO Regional and Country Offices, Healthy Urbanization Field
Research Sites are to be established. These field research sites will conduct action
research projects to derive local knowledge to inform global, national and local policy
and action. In each field research site, multi-sectoral teams will work together through a
‘learning by doing’ approach to address social determinants of health through improving
health governance. These teams will be part of a “Healthy Urbanization Learning Circle”
that will be engaged in capacity building activities, training and action-research.
2. The city of [name of city] was chosen after extensive consultations between the WHO
regional and country offices and with other relevant stakeholders. In order to define the
parameters for research and action, the WHO Kobe Centre for Health Development has
collaborated with a relevant institution to develop a scoping paper that outlines the
current situation and local context in preparation for project operations.
[name of city] has agreed to partner with WKC in implementing this project in order to
reduce health equity in the urban setting.
The specific objectives of the project are to:
1)
2)
3)
4)
Derive evidence of effective strategies and interventions through action research;
Select and train change agents to support action on social determinants of health:
Integrate and link local knowledge on health governance with national policy and
action;
Strengthen capacity to undertake inter and intrasectoral collaboration;
46
5)
6)
Develop a comprehensive and realistic plan of action that will include target
setting, monitoring and evaluation of activities; and
Support the development and financing of systems and institutions that will
ensure sustainability of efforts.
3. To achieve these objectives WKC agrees to provide [name of city] field research site
with the relevant in-kind support over a period of 18 months.
♦ •
WKC will not be responsible for any fees or payment other than in-kind support or
mutually agreed upon between [name of city] research site, the WHO country and
regional office and WKC.
Any problems or discrepancies in the implementation of this letter of agreement along
with alterations deemed to be necessary for the success of the project before or during the
implementation will be assessed and solved jointly by the Project Steering Committee
and the WKC as necessary and appropriate.
This letter of agreement will take effect from the date of its signature by all appropriate
partners. Any modification or revision must be approved in writing both by the WHO
country and regional offices as well as WKC.
Agreement
Today,
, 2006, we:
Healthy Urbanization Field Research Site, represented by
and
WKC, represented by
Attachments:
Scope of work and responsibilities
Consistent with the overall goal and objectives of this initiative [name of city] field
research site and WKC agree to the following responsibilities:
WKC will:
In relation to the project management and technical services,
•
•
provide the project deliverables in collaboration with the WHO country and
regional offices and other partners such as the MoH;
collaborate with local project partners in the development, review and evaluation
as well as updating of progress, as required, of a detailed work plan; and
47
•
•
•
coordinate its implementation;
provide technical support to government and municipal agencies and other project
stakeholders in implementing and monitoring of progress of specific social
determinants of health;
establish, in consultation with the project partners, a Project Steering Committee
to provide local technical advice, as necessary and appropriate, and to serve as
advocate for the project in both the public and private sectors;
build working relationships and network with relevant Government agencies and
international organizations and external support agencies to share project
experiences and learn from these experiences of others.
• ♦
In relation to project administration, finances and reporting:
•
•
•
•
Ensure that project funds are used in accordance with the agreed work plan;
Recruit and hire qualified and trained project staff;
Prepare project documentation, reports and updates for the local research sites on
regular agreed upon interval;
Facilitate co-learning visits from time to time.
Local research Site will:
• provide local resources, such as human resources, transport and equipment as
required and appropriate to support the project for:
• develop a project plan of work;
• implement the project activities as agreed in the plan of work, and assess, on a co
learning basis, the project implementation and outcomes;
• technically and administratively support project related capacity building
initiatives;
• build working relationships and networks at the local level agencies, including the
government, local and international organizations, to share project experiences
and learn from the experiences of others.
i
48
Updated by 7 /. April 2006
1
THE CORE PROJECT
PLAN OF WORK
WHO Centre for Health Development
Kobe, Japan
Updated hy 1 / April 2006
2
1.0 Introduction
1.1
Background
In 2004-2005, the Centre undertook a process of consultation with its partners
and the scientific community to gain perspective on its future work for the period
2006 -2015. An Ad hoc Research Advisory Group (RAG) and associated Sub-groups
were convened to delineate the most important research questions related to Ageing
and I lealth, Urbanization and Health, and Technological Innovation and
Environmental Change and Health. The product of this process was “A Proposed
Research Framework for the WHO Centre for Health Development.”1 This
Framework served as an important scientific reference in the development, by WHO
and the Kobe Group, of the ten-year extension of the Memorandum of Understanding
to 2015 and the Centre’s research plans for the future that are reflected in the Plan of
Work for 2006-2007.
The Ad hoc Research Advisory Group process highlighted the growing
importance of urbanization as a cross-cutting driving force and the central role that
cities and urban municipalities are beginning to play as key drivers of
modernization and social change. There was consensus on the need for inter
disciplinary, applied research into priority public health issues affecting urban
settings, particularly in relation to exposed populations. It was recognized that the
character of these settings in the 21st century is changing rapidly, and that the
increasing complexity of the factors affecting change and their impact on health and
well-being is not well understood.
Emphasis was also placed on the need to focus on the health and well-being of
exposed populations including the poor, the elderly, women and children. In the
context of urbanization and globalization, the problem of health inequity, particularly
in relation to exposed populations, was noted in all of the discussions. For example,
of the three billion people who live in urban areas today, one billion live in slums. As
the number of people born in cities increases and as people continue to be displaced
from i ural areas, the urban slum population is expected to grow to approximately two
billion by 2030, resulting in a continuing and rapid urbanization of poverty and ill
health whose greatest impact will be felt in the developing world.
A significant amount of discussion in the Ad hoc Research Advisory Group
process in general, and in the Urbanization and Health Sub-group in particular,
revolved around the importance of the social determinants of health in relation to
health inequity and the role of health governance as a critical pathway by which
social conditions translate into health impacts.
Based on deliberations during the Ad hoc Research Advisory Group process,
related discussions with members of the Kobe Group2 and others, and the selection of
the WHO Kobe Centre as the Hub for the Commission on Social Determinants of
1 The World Health Organization Centre for Health Development. Health in Development - Healthier People in
Healthier Environments. A Proposed Research Framework for the WHO Centrefor Health Development.
Kobe, Japan, August 2004.
Comprising. Hyogo Prefecture, Kobe City, Kobe Chamber of Commerce and Industry, and Kobe Steel, Ltd.
Updated by
' April 2006
Health’s Knowledge Network on Urban Settings, the future work of the Centre will
have the following strategic foci:
□ Monitoring and responding to “felt needs” - aiming to complement the
findings of epidemiological and public health research with information about the
needs felt by exposed populations.
□ Packaging knowledge from a health equity perspective to inform policy and
practice - Aiming to reduce health inequity by improving health governance.
□ Developing new knowledge to address existing and emerging areas of
vulnerability — Aiming to identify and advocate effective responses and
interventions in relation to driving forces.
I he work will be carried out with a major emphasis on urban settings,
mindful of the “globalization-urbanization interface” that exists in these settings, with
the overall aim of reducing health inequity by optimizing the impact of social
determinants of health on exposed populations.
1.2
The presentation
The Core Project is organized around four areas of emphasis:
I. Developing strategies: Building an evidence base, generating policy ideas,
evaluating current experiences and interventions, developing public health '
methodologies for health inequity assessment and evaluation and deriving new
knowledge on social determinants and health inequity.
2. Demonstrating the applicability of strategies: Demonstrating how “generic”
municipal strategies can be applied and combined with tactical and context
specific interventions to reduce health inequity.
3. Capacity building: Building capacity at the level of the individual, the
organization and the system through leadership training and applied projects.
4. Policy advocacy: Developing and applying principles of strategic communication
and advocacy to influence health governance at all levels and enhance
understanding of how the impact of social determinants can be optimized to
reduce health inequity.
Staff will work in and across these areas of emphasis in a multi-disciplinary
fashion to develop specific products. In addition, to provide effective liaison with
other WHO programmes and offices, as well as with other organizations, they will
serve as designated Focal Points for the following Areas of Work:
■
■
■
Surveillance, prevention and management of chronic, noncommunicable
diseases
Health promotion
Tobacco
3
Updated by 7'L. April 2006
■
■
■
■
■
■
■
■
■
Health and environment
Gender, women and health
Policy-making for health in development
Health system policies and service delivery
Human resources for health
Health information, evidence and research policy
Emergency preparedness and response
Mental health and substance abuse
Ageing and life course
2.0 Plan of Work Details
2.1
The Core Project - Optimizing the Impact of Social
Determinants of Health on Exposed Populations in
Urban Settings
2.1.1 Objectives
Within the overall purpose of the project - to reduce health inequity in urban
settings - the specific objectives for 2006-2007 are to:
1. Develop strategies to reduce health inequity in urban settings;
2. Demonstrate the applicability of strategies for reducing health inequity
among exposed populations in urban settings;
3. Build capacity for reducing health inequity in urban settings;
4. Advocate the reduction of health inequity in urban settings.
The model of the “Evidence-Informed Policy and Practice Pathway”3 (Brown
and Zwi, 2005) provides the basis for the research design of the Core Project.
According to this model, policy ideas, evidence, use of evidence and capacity to
implement evidence-based policies are interlocked in a series of decision-making
steps that are characteristic of how events unfold in practice. Policy ideas provide the
starting point for the sourcing of evidence. Sources of evidence are multiple and
varied. Using the evidence includes interpreting and applying knowledge in specific
contexts. Capacity to implement is considered from the perspective of the individual,
the organization and the system.
' From the PowerPoint presentation of the Knowledge Network on Measurements, given at the Meeting of the
Knowledge Networks, 10-12 September 2005, Ahmedabad, India.
4
Updated by 'l l. April 2006
5
Policy
idea
Sourcing the
EVIDENCE
•Knowledge
•Research
•Ideas/lnlerests
•Politics
•Economics
Act
USING the
EVIDENCE
Introducing, interpreting,
applying
•Knowledge utilisation
CONSIDERING
CAPACITY
TO
IMPLEMENT
•Individual
•Organisational
•S yste rn /Policy
2.1.2 Present plans, 2006-2007
Objective 1 — Develop strategies to reduce health inequity in urban settings
Approaches and products
Building the evidence base
Closer examination of existing evidence will be a key component for
developing strategies to reduce health inequity in urban settings. Knowledge will be
collated, analyzed, synthesized and organized to enable researchers, implementers and
decision-makers to gain easy access to information on the associations and pathways
between social determinants and health inequity in urban settings. In particular, the
evidence base will try to capture the policy ideas emanating from attempts to bridge
equity gaps through municipal health governance. Materials to be included in the
evidence-base will come from published and grey literature and from the worldwide
experience of Healthy Cities, Local Agenda 21 cities. Sustainable Cities, Cities
without Slums, the Urban Governance Initiative and other initiatives where the
city/municipality is both the entry point and setting for achieving sustainable change
and improvement in health.
From the evidence base, research teams will systematically review evidence
and select good examples of strategies and interventions that are promising or proven
to be effective in reducing health inequities in urban settings. A glossary of terms and
concepts will be developed to promote wider discourse on the subject in the scientific
community, as well as to supplement advocacy efforts in the political domain.
Updated by :April 2006
6
Ensuring local participation and ownership of research
Research activities will emphasize principles of community and stakeholder
participation and ownership. People’s participation in planning, implementation and
evaluation of research activities will be ensured. Thus, at the early stages of the
project, participatory and consultative processes will guide the identification of
exposed populations, prioritization of issues and concerns and the pursuit of
opportunities and imperatives for influencing health governance at the local level.
Multiple pathways of causality and associations may necessitate a wide range of
interventions for enhancing health governance. The emphasis in Objective 1 however,
will be on creating enabling environments for municipal-level action.
The project will develop generic municipal-level strategies for reducing health
inequity but will also construct a framework for tactical actions that facilitate
achieving rapid results in relation to the specific and unique contexts of urban settings
through collaborative research and other means. For this reason, selected urban areas
are initially proposed as field research sites for 2006-2007, where these will be
applied in: China, Chile, Japan and India. Sites in African and the Eastern
Mediterranean regions will follow. Project steering committees will be organized for
each urban health field research site and will include representatives from regional
and country offices of WHO, national and local representatives and stakeholders as
well as key partner research institutions from the local community. Other sites will be
involved in subsequent biennia.
Strengthening public health at the local level
The role of the public health sector at the city and municipal level in
enhancing health governance will be highlighted in the project. As both social and
environmental determinants of health necessitate action and responsibility from many
actors (e.g. transportation, housing, education, welfare, finance, police and law
enforcement), public health officers may need to play a more important role as
catalysts for change than as implementors in the locality and will need to steer highly
complex political processes toward healthy public policy. While the research
objective is focused on reduction of health inequity, the key products of the project
will be public health methodologies that enhance the performance of local health
officials in the new role they must play in the face of rapid urbanization.
In particular, tools will be developed to derive the “felt needs” of exposed
populations who may otherwise be excluded from regular census activities or routine
public health reporting systems. Felt needs can then be used as a reference point for
assessing the responsiveness of public health policies, programmes and practices in
contexts where health inequity is manifest.
In conjunction with public health methodologies for deriving felt needs,
checklists to ensure that health equity principles are embedded in public policies,
programmes and practices will be developed, field-tested and pilot-tested in the field
research sites. These checklists will demonstrate how municipal development
decisions may affect human, social, economic and ecological capital (together
Updated by 77. April 2006
7
referred to as “community capital”4) and what possible impacts these would have on
exposed populations such as disaster survivors, women and children exposed to
abuse, violence and HIV-AIDS. workers suffering from depression or individuals
predisposed to suicide.
Highlighting the interaction between local and national determinants
The project will also develop tools to assist municipal planners in assessing
long-term development decisions. In particular, work will be initiated to develop
models that render visible the impact of broad determinants on the health of exposed
populations in future scenarios, using projections and trends of urbanization in the
first instance, and demographic and environmental change as well. An example of this
might be the effect of heat waves on exposed populations in urban settings.
Work will also be initiated for the development of a core set of indicators that
countries, cities and municipalities can use to assess how socioeconomic factors and
rapid urbanization are interacting to produce changes in health and quality of life in
their cities through the development of a Poverty-Health-New Urban Settings Index.5
Contributing to global action on social determinants of health
As WHO Kobe Centre is the hub of the Knowledge Network on Urban
Settings (KNUS) of the Commission on Social Determinants of Health, the Project
and the KNUS will work in tandem to develop new knowledge on slum dwellers as a
priority exposed urban population. The Project will collaborate with the KNUS to
produce new knowledge on interventions to address the health conditions of people
who live in slums and informal settlements. The KNUS will convene meetings to
draw on the knowledge of international experts on this subject. Some of the activities
of the network will include the writing of historical and analytic narratives on
countries that have demonstrated success and the scaling up and documentation of
interventions in one field project sites. The KNUS will also forward policy
recommendations to the Commission.
Approach
Build an evidence base of experiences and
current interventions
Product
An evidence base on how health
inequity is reduced through municipal
level interventions that address social
determinants of health
Evaluate selected experiences and current
interventions against existing theoretical
frameworks and conceptual models that
describe the relationship between social
A review of grey and published
literature on promising and successful
interventions
A glossary of terms and key concepts
____ __________
4 Hancock?. People, partnerships and human progress: building community capital. Health Promotion
International, September 2001, 16,3.
5 The notion o f “New Urban Settings” (NUS) was introduced by the Sub-group on Urbanization of the Ad hoc
Research Advisory Group. It refers to urban settings that are characterized by a radical process of change with
positive and negative effects, increased inequities, greater environmental impacts, expanding metropolitan areas
and fast-growing slums.
Updated by 'l l April 2006
8
determinants of health and health inequity
in urban settings
Strategies to enable municipal level
action to reduce health inequity in
urban settings
Develop methodologies to determine
health needs of exposed populations in
urban settings
Checklists for assessing and
evaluating health equity in urban
settings using “felt needs” of exposed
populations as reference
Develop methodologies for projecting
future scenarios in relation to
determinants of health and their impact on
exposed populations in urban settings
Models for forecasting and scenario
building on the future of cities and
municipalities based on demographic
and environmental change,
urbanization and health with reference
to “felt needs”
Develop methodologies for evaluating
health inequity at the city or municipal
level
Core set of indicators to evaluate
health inequity in cities and
municipalities (Poverty-Health-New
Urban Settings Index)
Develop new knowledge on reducing
health inequity in urban settings
Syntheses of evidence on effective
interventions for reducing health
inequity in urban settings
Ob jective 2 - Demonstrate the applicability of strategies for reducing health
inequity among exposed populations in urban settings
Approaches and products
Urban Health Field Research Sites will be established in selected urban
settings to create learning environments for local decision-makers to apply generic
municipal- level strategies and further evolve localized and context-specific and
tactical interventions to reduce health inequity. Local project steering committees
will be organized and workshops will be conducted. Social, community and political
mobilization will be done to ensure multi-sector stakeholder participation in the
application of strategies.
Research units will be set up in offices of WHO Representatives with full-time
staff under special services agreements. The research units will coordinate research
activities but will also play a coordinating role in the implementation of local projects
to reduce health inequity. Technical advice and support will be provided for local
projects.
6 China, Chile, Japan and India.
Updated hy 7 /. April 2006
Approach
Establish Urban Health Field Research
Sites that will serve as learning
environments for local decision-makers
and communities for the application of
strategies for reducing health inequity
Apply the strategies for reducing health
inequity
9
Product
Three Urban Health Field Research
Sites where the strategies for reducing
health inequity will be applied
Three research units based in WR
offices with capacity to coordinate
stakeholder activities and oversee
implementation of the strategies at the
local level
Application of the strategies in three
Urban Health Field Research Sites
Objective 3 - Build capacity for reducing health inequity in urban settings
Approaches and products
Capacity building,7 or the "development of sustainable skills, organizational
structures, resources and commitment to health improvement in health and other
sectors, to prolong and multiply health gains many times over”, will be a critical part
of the project. Teams of leaders who are key players in health governance at the local
level will be organized and engaged in a health promotion leadership training
programme using the WHO Prolead model.8 Each team will design and implement a
specific project to optimize the impact of social determinants and reduce health
inequity in urban settings. Projects will also emphasize strengthening infrastructure
and financing for the promotion of health in the city/municipality in order to ensure
the sustainability of interventions to reduce health inequity. The course is conducted
over a nine-month period with 160 hours of group learning sessions. The learning
sessions are organized into three modules featuring didactics, workshops and field
visits. 1 opics covered by the training will include leadership principles,
communication and social mobilization skills, health sector reform, total quality
management, governance, social determinants and health inequity, management of
change and organizational development, among others.
Prolead III aims to enhance the practical skills of teams across five categories
that may be needed to improve governance for the promotion of health: intra
personal qualities; inter-personal qualities; cognitive skills; communication skills;
and, task-specific skills.
Hawe P, King L, Noort M, Jordens C & Lloyd B. indicators to help with capacity building in health
promotion. NSW Health: 1999
Prolead III. A Health Governance Initiative builds on a leadership development model that started in 2003 in
the WHO Western Pacific Region as a collaborative effort between the WHO Western Pacific Regional Office,
the Southeast Asian Ministers of Education Organization Tropical Medicine Network (SEAMEO-TROPMED
Network), the School of Public Health at La Trobe University (Australia), and the Field Epidemiology Training
Program Alumni Foundation, Inc., with the support of the Japan Voluntary Fund.
Updated by 77. April 2006
10
Prolead III guiding principles include:
■
■
■
■
■
■
■
Emphasizing applied skills, not just theoretical knowledge;
Training in a highly interactive manner, drawing on personal experience to
reinforce team learning;
Encouraging strategic thinking in the promotion of health;
Emphasizing the use of good governance principles in decision-making;
Using applied field projects to reinforce classroom learning, multiply
training benefits, and generate results;
Providing opportunities for mentoring and technical support;
Soliciting feedback as a means of improving the learning process.
Approach
Conduct leadership development,
mentoring and training on using the
strategies to reduce health inequity in
urban settings
Product
Trained teams of leaders who are
undertaking projects to reduce health
inequity in the three urban health field
research sites
Objective 4 - Advocate the reduction of health inequity in urban settings
Approaches and products
A strategic communication and advocacy plan will be developed to ensure that
different audiences and stakeholders will have a clear understanding of the goals and
objectives of the project. For the biennium, project advocacy materials will be
developed in English, Spanish and Japanese.
In collaboration with the United Nations University (UNU), video
documentation of strategies for reducing health inequity will be conducted at one
project site. The video documentation will be converted into a case study using
methods and techniques developed by UNU. The video will be made available to a
wider audience through different distance education programmes at regional and
country levels.
A range of advocacy activities will be implemented at global, regional,
national and local levels. For example, advocacy campaigns by the Knowledge
Network on Urban Settings may be directed at global, regional or national audiences.
Regular town meetings and scientific seminars will be conducted in the local
community.
Partnerships will be established, nurtured and sustained. A framework for
developing and evaluating effective partnerships to reduce health inequity will be
demonstrated through a historical and analytical narrative of the public-private
partnership model for health of Hyogo-Kobe City, Japan.
Finally, educational materials, checklists and rapid assessment guidelines on
emerging models and innovative strategies that seek to reduce health inequity will be
developed. These materials will contribute to enabling municipal-level decision
makers in health and other sectors to generate innovative policy ideas and options for
Updated by 71. April 2006
11
reducing health inequity. Examples of these include: tobacco and alcohol tax
measures for health promotion foundations; alliances between industries, the
community and academia; community-based programmes for older persons and
mental health promotion in the workplace.
Approach
Develop and implement a
communication and advocacy plan
for the strategies.
Product
Communication and advocacy plan for the
strategies.
Video documentation of projects of the
Urban Health Field Research Sites.
Profiles of promising approaches.
Information exchange, networking,
meetings and other advocacy activities.
Establish and sustain
partnerships for reducing health
inequity
A framework for developing effective
partnerships to reduce health inequity
Develop education materials and
rapid assessment guidelines on
reducing health inequities
A set of educational materials, checklists
and rapid assessment guidelines on how
health inequity may be reduced
2.1.3 Future directions
It is anticipated that these Core Project objectives will serve to guide the work
of the WHO Centre for Health Development over its next ten years of life. It is
recognized that from biennium to biennium the approaches to achieving these
objectives may vary somewhat and the products associated with them may vary
significantly. For example, new methodologies and tools will be developed; tools will
be added, adapted, or enhanced. Urban health field research sites may be expanded to
cover adjacent urban areas or new countries. Other foundational mechanisms such as
the Prolead initiative will continue to be an integral part of the project.
Healthy Urbanization Project of WKC center for Health
and Development
Background
Following a decision by the Executive Board of the World Health Organization in 1995, a Memorandum
of Understanding between the World Health Organization (WHO) and the Kobe Groupl established the
WHO Centre for Health Development (WKC). As an integral part of the Secretariat of WHO, the WKC
has a global mandate to conduct research into the health consequences of social, economic,
environmental and technological changes and their implications for health policy development and
implementation.
In 2004-2005, the Centre undertook a process of consultation with its partners and the scientific
community to gain perspective on its future work for the period 2006-2015. An Ad hoc Research
Advisory Group (RAG) and associated Sub groups were convened to delineate the most important
research questions related to Ageing and Health, Urbanization and Health, and Technological
Innovation and Environmental Change and Health.
These consultation lead to development of a research framework for the WHO Centre for Health
Development. This framework served as an important scientific reference in the development, by WHO
and the Kobe Group, of the ten-year extension of the Memorandum of Understanding to 2015 and the
Centre's research plans for the future that are reflected in the Plan of Work for 2006-2007.
The Memorandum of Understanding (MOU) between WHO and the Kobe Group for 2006-2015 was
signed on 15 June 2005. This MOU ensures the Centre’s programmatic and financial future for the next
ten years, providing a stable budget for its scientific work that averages about US$ 5.4 million per year.
About Kobe Center
As WHO Kobe Centre is the hub of the Knowledge Network on Urban Settings (KNUS) of the
Commission on Social Determinants of Health, the Project and the KNUS will work in tandem to develop
new knowledge on slum dwellers as a priority exposed urban population. The future work of the Centre
will have the following strategic foci:
Monitoring and responding to “felt needs ’ - aiming to complement the findings of epidemiological
and public health research with information about the needs felt by exposed populations.
Packaging knowledge from a health equity perspective to inform policy and practice - Aiming to
reduce health inequity by improving health governance.
Developing new knowledge to address existing and emerging areas of vulnerability - Aiming to
identify and advocate effective responses and interventions in relation to driving forces.
The work will be carried out with a major emphasis on urban settings, mindful of the “globalization
urbanization interface" that exists in these settings, with the overall aim of reducing health inequity
by optimizing the impact of social determinants of health on exposed populations.
i he WHO Centre for Healrh Developtnetm in coHuboraTioH
witfi If tl() Regiofuti and < otmtty Offices, nttd through its
project oh “fleatthy I rbani-atioH." aims to integrate evidence
based good practices and public health methods that optimize
the impact of social determinants on health and promote
health equity in national policies and health systems of
Member States.
Rationale
At the local level, the project will bring added value through new ways of working between and among
sectors, leadership development and community participation and empowerment. At the national level,
the project will provide new knowledge and evidence that may accelerate the adoption of principles of
social determinants of health and health equity in national policy, programmes and practice. At the
global level, the project will contribute to international understanding and strengthen the imperative for
action on social determinants of health.
Figure 2: Expected outputs from 'action research interventions
Local level
Interventions At
Various Social
Determinants of
Health
Improved
governance
t
Improved
health
equity
//
| National level
j Global level
Mairi output
Main output
Main output
♦Improve health
outcome
•Adoption of
principles of SDH
and equity principles
in national health
policy
♦Action on social
determ inants of
health
♦international
understanding and
global action on
Social Detemri inants
of Health
•Pr-iinotc health
cciu i i)
Adsltr J .Zlilufe
’ I lew ways of
•.writing
• Leadership
development
• Feeling less he^ess
(Err,:OA«rad)
Goal
The overall goal of the project is to promote health equity in urban settings, particularly among exposed
populations through actions in areas that relates to the project objectives:
Objectives
1. Developing strategies: Building an evidence base, generating policy ideas, evaluating current
experiences and interventions, developing public health methodologies for health inequity assessment
and evaluation and deriving new knowledge on social determinants and health inequity.
2. Demonstrating the applicability of strategies: Demonstrating how “generic" municipal strategies
can be applied and combined with tactical and contextspecific interventions to reduce health inequity.
3. Capacity building: Building capacity at the level of the individual, the organization and the system
through leadership training and applied projects.
4. Policy advocacy: Developing and applying principles of strategic communication and advocacy to
influence health governance at all levels and enhance understanding of how the impact of social
determinants can be optimized to reduce health inequity.
Staff will work in and across these areas of emphasis in a multi-disciplinary fashion to develop specific
products. In addition, to provide effective liaison with other WHO programmes and offices, as well as
with other organizations, they will serve as designated Focal Points for the following Areas of Work:
Surveillance, prevention and management of chronic, non-communicable
Diseases
Health promotion
Tobacco and environment
Gender, women and health
Policy-making for health in development
Health system policies and service delivery
8. Human resources for health
9. Health information, evidence and research policy
10. Emergency preparedness and response
11. Mental health and substance abuse
12. Ageing and life course
1.
2.
3.
4.
5.
6.
7.
Project partners The Healthy Urbanization Project will be implemented in partnership with a wide range of stakeholders
at global, regional, national and local levels. The proposed institutional partners of the project at the
global level will include the Alliance for Healthy Cities, International Network of Health Promotion
Foundations, the SEAMEOTROPMED Network and the La Trobe University School of Public Health.
Partners at the regional level will include the different Regional offices of the World Health Organization
and other international agencies. Partners at the country level will include Ministries of Health,
transportation, education, welfare, civil society and other stakeholders. Partners at the local level will
include local governments, non governmental organizations, communities, people's organizations and
others that will emerge as the site-specific projects are developed and implemented.
Model
The model of the “Evidence-Informed Policy and Practice Pathway”3 (Brown and Zwi, 2005) provides
the basis for the research design of the Core Project. According to this model, policy ideas, evidence,
use of evidence and capacity to implement evidence-based policies are interlocked in a series of
decision-making steps that are characteristic of how events unfold in practice. Policy
Polic y
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Guiding principles and approaches
The project will be guided by the following principles:
1. "Learning by doing," in particular the use of participatory and action-research
methods to optimize social determinants and promote health equity;
2. Respect for local contexts and responsiveness to local needs in the design,
development and adoption of project interventions and strategies:
3. Community participation and the involvement of beneficiaries and stakeholders at all stages of the
project (i.e. planning, implementation and evaluation);
4. Empowerment of beneficiaries and stakeholders through capacity building;
5. Integration with existing initiatives that strengthen health systems at the
national and local level;
6. Linkage to initiatives in support of global imperatives such as Health for All, the Millennium
Development Goals, the Commission on Social Determinants of Health, the Commission on
Macroeconomics and Health and Sustainable Development;
7. Utilization of vulnerability assessment and reduction approaches to address health issues that result
from the convergence of social and environmental determinants; and
8. Cost-sharing and resource mobilization at all levels to complement fixed
budgets that are provided by the WHO Kobe Centre.
Present plans, 2006-2007
Objective 1 - Develop strategies to reduce health inequity in urban settings
Approaches and products
Building the evidence base
Closer examination of existing evidence will be a key component for developing strategies to reduce
health inequity in urban settings. Knowledge will be collated, analyzed, synthesized and organized to
enable researchers, implementers and decision-makers to gain easy access to information on the
associations and pathways between social determinants and health inequity in urban settings. In
particular, the evidence base will try to capture the policy ideas emanating from attempts to bridge
equity gaps through municipal health governance.
Ensuring local participation and ownership of research
Research activities will emphasize principles ol community and stakeholder participation and ownership.
People's participation in planning, implementation and evaluation of research activities will be ensured.
Thus, at the early stages of the project, participatory and consultative processes will guide the
identification of exposed populations, prioritization of issues and concerns and the pursuit of
opportunities and imperatives for influencing health governance at the local level.
Strengthening public health at the local level
The role of the public health sector at the city and municipal level in enhancing health governance will
be highlighted in the project. As both social and environmental determinants of health necessitate action
and responsibility from many actors (e.g. transportation, housing, education, welfare, finance, police and
law enforcement), public health officers may need to play a more important role as catalysts for change
than as implementers in the locality and will need to steer highly complex political processes toward
healthy public policy.
Highlighting the interaction between local and national determinants
The project will also develop tools to assist municipal planners in assessing long-term development
decisions. In particular, work will be initiated to develop models that render visible the impact of broad
determinants on the health of exposed populations in future scenarios, using projections and trends of
urbanization in the first instance, and demographic and environmental change as well. An example of
this might be the effect of heat waves on exposed populations in urban settings.
Contributing to global action on social determinants of health
the Project and the KNUS will work in tandem to develop new knowledge on slum welters as a priority
exposed urban population. The Project will collaborate with the KNUS to produce new knowledge on
interventions to address the health conditions of people who live in slums and informal settlements.
Approach
Prod net
Build an ex idence base of experiences and
current ink r\ enlions
An evidence base on how health
inequity k reduced through municipal
level inter’, ent ions dial address social
determinants of health
Evaluate selected experiencesand current
inteiveniions against existing theoretical
frameworks and conceptual models that
describe the relationship between cial
A review of grey and published
literature on promising and successful
interventions
determinant-, of health and health incquiiv
in urban set lings
Strategies to enable municipal level
action to reduce health inequity in
urban sellings
Develop methodologies lo determine
health needs of exposed population in
urban sellings
Checklists for assessing and
evaluating health equity in urban
sellings using "felt needs" of exposed
populations as reference
DeveIop 11 ic t hodoI og i es fo r p rojecting
future scenarios in relation to
determinanis of health and their impaci on
exposed populations in urban setting-.
Models for forecasting and scenario
building un the lulu re of cities and
municipalities based on demographic
and environmental change,
urbanization and herd th with reference
to “felt needs”
Develop inclhodologies for evaluai inu
health inequity at the city or niunicip-al
level
Core set of indicator, to evaluate
health inequity in cities and
111 un i c i p a 11 u es (Pox e rly- Heal 1 h- N e w
Urban Sellings Index)
Develop new knowledge on reJucinu
health inequity in urban settings
Sy nt heses o f ev i de iic eon e ffec11 ve
interventions for reducing health
inequity in urban sellings
A glossarx of terms and key concepts
Objective 2 - Demonstrate the applicability of strategies for reducing health inequity among
exposed populations in urban settings
Approaches and products
Urban Health Field Research Sites will be established in selected urban settings6 to create learning
environments for local decision-makers to apply generic municipal- level strategies and further evolve
localized and context-specific and tactical interventions to reduce health inequity. Local project steering
committees will be organized and workshops will be conducted. Social, community and political
mobilization will be done to ensure multi-sector stakeholder participation in the application of strategies.
Local project steering committees will be organized and workshops will be conducted. Social,
community and political mobilization will be done to ensure multi-sector stakeholder participation in the
application of strategies.
Approach
Estab 1 is h I i ban I Ieal 111 I i c k I R < •;U '. I l
Sites thin X'. ill serve as learning
environments lor local deeisionand communities tor the applicai r.-n > •!
strategie- f. >r reducing health incquiix
Apply the strategies for reducing hviilth
ineq u its
Prod uct
Three I than Health hiekl Research
Sites
here the strategies lot reducing
health inequits ’.x ill be appl ic<l
I liree re-.earch units based in WR
otfives ■.■. 11h capacit \ to coordinate
stakeh* 'kier aclix ities and ovct -.ee
implementation of the strategies al the
local lex cl
.Application of the strategies in three
Urban Health f ield Research Sites
Objective 3 - Build capacity for reducing health inequity in urban settings
Approaches and products
Capacity building, or the “development of sustainable skills, organizational
structures, resources and commitment to health improvement in health and other sectors, to prolong
and multiply health gains many times over", will be a critical part of the project. Teams of leaders who
are key players in health governance at the local level will be organized and engaged in a health
promotion leadership training programme using the WHO Prolead model
The learning sessions are organized into three modules featuring didactics, workshops and field visits.
Topics covered by the training will include leadership principles,
Prolead III aims to enhance the practical skills of teams across five categories
that may be needed to improve governance for the promotion of health: intrapersonal qualities; inter
personal qualities; cognitive skills; communication skills; and, task-specific skills.
Prolead III guiding principles include:
a. Emphasizing applied skills, not just theoretical knowledge:
b. Training in a highly interactive manner, drawing on personal experience to reinforce team
learning;
c. Encouraging strategic thinking in the promotion of health;
d. Emphasizing the use of good governance principles in decision-making;
e. Using applied field projects to reinforce classroom learning, multiply training benefits, and
generate results;
f. Providing opportunities for mentoring and technical support;
g. Soliciting feedback as a means of improving the learning process.
Approach
Conduct leadership development,
mentoring and training on using the
strategies to reduce health inequity in
urban settings
Prod net
Trained teams of leaders who are
undertaking projects to reduce health
inequity in the three urban health field
research sites
Objective 4 - Advocate the reduction of health inequity in urban settings
Approaches and products
A strategic communication and advocacy plan will be developed to ensure that different audiences and
stakeholders will have a clear understanding of the goals and objectives of the project. For the
biennium, project advocacy materials will be developed in English, Spanish and Japanese.
In collaboration with the United Nations University (UNU), video documentation of strategies for
reducing health inequity will be conducted at one project site. A range of advocacy activities will be
implemented at global, regional, national and local levels. For
Approach
Develop and implement a
communication and advocacy plan
for the strategies.
Product
Communication and advocacy plan for the
strategies.
Video documeniation of projects of the
I Irban Health f ield Research Sites.
Profiles of premising approaches
111 fo rm alio n exchange, ne t wo rk i n g.
meetings and I'lher advocacy activities
Establish and sustain
partnerships for reducing health
inequity
\ framework lor developing effective
partnerships to reduce health inequity
De vel o p cd u cal i cm m a t e r i a I s a nd
rapid assessment guidelines on
reducing health inequities
A set of educational materials, checklists
and rapid assessment guidelines on hoxs
health inequity may he reduced
PROJECT IMPLEMENTATION
2006-2007 Timeframe
Sustaining
Action
Through
Advocacy
Situation
Analysis
3 weeks
3—5 month s
Social
Mobilization
For
Intersectoral
Action
Strategy
development
Through
ActionR esea rch
4—4.5 months
PROJECT MANAGEMENT
Management and support structure
I'aciB tsti's
i'uraiHunivaUon.% acruss
countries & regions
WKC
Global Project
Steering Coma.
WKt Ikshby
I lri»a
Project
Stcrvtarijil
('twrtlutiitian at
Re^iaitnf <S Xaiiental /fiWx
Local Project
Stccrinu Committee
LOCAL PRO
Introduction
It is anticipated that these Core Project objectives will serve to guide the work
of the WHO Centre for Health Development over its next ten years of life.
Project Steering Committee Meeting
30 May - 2 June 2006
India: In Bangalore, access to quality health care, safe water and sanitation, and proper garbage
disposal, as well as the provision of ample parks and play areas, safe roads and transportation, and a
city free of crime, violence and drugs, are all being addressed by the municipality using an inter-sectoral
participatory approach.
Dr Muthukrishnan Vijayalakshmi, Health Officer, Bangalore City Corporation, Bangalore, presented a
paper on Health Promotion in Bangalore, India. Although this was not a scoping paper, it did provide the
audience with a sense of the important social determinants in Bangalore. Dr. Vijayalakshmi started her
presentation arguing that urbanization in Bangalore happens because citizens are looking for a better
life. The pace, scope and depth of urbanization was resulting in inadequate food and shelter,
overcrowding, insufficient water and sanitation facilities and pollution, which again pushed the
population into use of harmful substances, and insecurity.
Bangalore has adopted the healthy cities approach and identified six main intervention
areas:
1) Access to quality health care - especially urban poor; 2) Safe water supply & proper sanitation;
3) More organized disposal of waste (collection, segregation & transportation);
4) Ample public parks & play areas;
5) Safe roads & safe transportation; and
6) Freedom from crime, violence and drugs.
The six issues are being addressed through environmental health interventions, preventive health
measures, health promotion approaches, education and training. These initiatives are proving
successful and are being implemented using an intersectoral and participatory approach. However,
there are still major challenges such as solid waste management, which consume the majority of the
budget, and HIV/AIDS with its high prevalence among the working class.
The ensuing discussion concentrated on environmental health issues and how Bangalore had
managed to sustain a recycling initiative and build on already existing initiatives. In responding to a
question related to resettlement, Dr Vijayalakshmi described how the government was constructing
houses and the importance that development initiatives in other sectors be aligned with those of the
Ministry of Health. The important success factors included education, good housing and employment as
well as strong political will reflected in a commitment to the healthy cities approach.
Following on the regional presentations, a major question for the participants was:
What have we learned and what can we transplant into the Healthy Urbanization Project?
Bangalore, India
The group from India started their work by defining the characteristics of future Prolead participants.
These participants must be individuals who are working with health related issues, known to have
demonstrated leadership potential, currently employed and engaged in a technical or professional area
of work such as finance, planning, transport, housing, health policy, law enforcement, working at a level
where policy and practice are reinforcing each other. It is advisable that Prolead participants come from
the following three domains: WHO, government or nongovernmental organizations. The Bangalore
research site will have 4-6 research teams with three members per team. Each team will be encouraged
to have an appropriate gender and age balance. There should also be a sense of continuity with the
work of the three previously trained Prolead fellows. The activity timeline for the Bangalore project was
outlined as follows:
• 30 June 2006: Completion of appointment of SSA.
• 4-6 July 2006: WKC Focal Point (Ms Loo) visits Bangalore to
• Review the interim scoping paper/meet with stakeholders;
• Gain an understanding of BMP;
• Present the Project to the Commissioner;
• Orient SSA staff (project document, work and financial plans, office supplies,
• Communications, recording and reporting, etc);
• Catalyze establishment of a Bangalore working body at the local level, comprised of BMP (two
clinical and public health), SSA, training institution,
one from an NGO, one former Prolead fellow and the Commissioner.
• Mid-July 2006: call for expression of interest for Project participants.
• 31 July 2006: deadline for submission of scoping paper.
• 31 August 2006: deadline for selection of Prolead participants; and training
institution identified
• 1-30 September 2006: Preparations for Prolead, Module 1 (training venue, food,
materials, programme, etc).
• October 2006: Prolead, Module 1.
• Commencement of city projects.
• March 2007: Prolead, Module 2.
• Continuation of city projects.
• November 2007: Prolead, Module 3.
• Phasing out/closure of city projects.
• December 2007: Bangalore core project evaluation.
Annex 5, Plan of Action, Bangalore
Objective: >pti(iiixing the? social deh'ihiiii.hiIs of health in urban sellings
site; Pa ng afore India
Total budget rin&OOUSU
Ite
Activity
compo
n«r» t«
rirnttfr-aiinc
i’Qua rtnrv j
200<5
2
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r
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f i hit fr ame
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pro|«»7t»
•Z’
3
r*-~
urn
Ju nd«
From
Ad<lition»l
funds reejtiircd
and source
(USD)
Arnt
4
sj:..
30 000
Suggio sliotis
*v>iac'.«
0
I’M*
Kll.ntlMKl
ci
< <fr>c»r
charge
Working
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asa
10 woo
W orl*. irxj
group
Mi Mini* 1
Mor.1ul«* stwirta
f
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qunrtwr OG
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projivctw to
aptimx** SDH
px« rtic • p&ffi t»
t
J
"»4 000
0
rnm'it
t«grv*wrnv»ni
WKC ..nd
V/R India
• Iwlf
•Smunlh
ooordirKalion
of nctivitiw*
t*iwl\xw«n
WKC and
country twama
Lncxal cost!
«nd prop*, i
iruatailixMli* *i
vSl.ippIliWA
and
quzutMrl
“. 000
S-SA
Aagulnr
i wpor l on
pr<.xy«asai
« 000
•SSA
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3 000
NIM HANS
(Dr Gi.iri.rai)
N/A
y
mnrat tig
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menlKMi.
< rsnapct
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f*%«r»^Mrcr
h
Proposed dates for Training
India
calllcr
(Bangalorei partid^",B
31
Kxprig
pperdiw
31 August
Sdoction nl
ftart,a^'itils
Ctatobei
Proleal
(Ml)
March
Prole ad
(M2)
1 -30 Saltan ha
PrM:«i nlr.ri d
RnkMid
hfovember
Prolaad
(M3)
Cv:«mhar
I vduiilbn
Quarterly in&iX i ivj. cx.rrrnunicalian, etc
Dr Davison Munodawafa, Regional Adviser in Health Promotion and Education, WHO Regional Office
for South-East Asia (SEARO)
Healthy Urbanization Learning Circles will undertake capacity building
activities over a 9-12-month period that is organized around four modules9:
• Module 1: Overview of Healthy Urbanization: Situation Analysis
• Module 2: Healthy Urbanization Challenges: Strategy Development and Project
Proposal Writing
• Module 3: Healthy Urbanization Opportunities: Social Mobilization for
Intersectoral Actions.
• Module 4: Mainstreaming Healthy Urbanization: Sustaining Action through
Advocacy
Slums selected for Healthy Urbanization Project
Name of the medical
officer & contact
_______ number_____
Shanthi Nagar Maternity Dr. Sandhya
9845244350_________
Home
Materniry Dr. Chethana
Pobbathi
22975673___________
Home
Mathikere Health Center Dr.Parimala
9845184942_________
Vidyapeth Health Center Dr. Usha Deve
22975776___________
Dr. Parimala
Moodlepalya
9844031180_________
Dr. Nayantara Patil
Roberson road
22975890
Name of health center
1
2
4.
5.
6.
7.
Vasanthnagar
Dispensary
______________
Dr.Sathish
9448244888
Name of the slum
Vinayaka nagar 5a
stan— J
Parvathipura
BK Nagar
Akkyappa garden
Hittimaduve, slum
near Ayappa temple
Kanakanagara slum
Netaji Hut
Near Ashoka
theatre.________
Ambedkar Salum,
Harijan slum,
Gulberga slum
& IJ
Bangalore, India
The group from India started their work by defining the characteristics of future Prolead
participants. These participants must be individuals who are working with health-related
issues, known to have demonstrated leadership potential, currently employed and
engaged in a technical or professional area of work such as finance, planning, transport,
housing, health policy, law enforcement, working at a level where policy and practice are
reinforcing each other. It is advisable that Prolead participants come from the following
three domains: WHO, government or nongovernmental organizations. The Bangalore
research site will have 4-6 research teams with three members per team. Each team will
be encouraged to have an appropriate gender and age balance. There should also be a
sense of continuity with the work of the three previously trained Prolead fellows.
The activity timeline for the Bangalore project was outlined as follows:
• 30 June 2006: Completion of appointment of SSA.
• 4-6 July 2006: WKC Focal Point (Ms Loo) visits Bangalore to
> review the interim scoping paper/meet with stakeholders;
> gain an understanding of BMP;
> present the Project to the Commissioner;
> orient SSA staff (project document, work and financial plans, office supplies,
communications, recording and reporting, etc); Headquarters Political
TechnicalRegional level Political TechnicalLocal/ Municipality level Political
TechnicalCommunity level Participatory Learning, Planning, Budgeting and
Action processes Social marketing Validation Social marketing Validation
> Catalyze establishment of a Bangalore working body at the local level,
comprised of BMP (two clinical and public health), SSA, training institution,
one from an NGO, one former Prolead fellow and the Commissioner.
• Mid-July 2006: call for expression of interest for Project participants.
• 31 July 2006: deadline for submission of scoping paper.
• 31 August 2006: deadline for selection of Prolead participants; and training institution
identified
■ 1-30 September 2006: Preparations for Prolead, Module 1 (training venue, food,
materials, programme, etc).
• October 2006: Prolead, Module 1.
• Commencement of city projects.
• March 2007: Prolead, Module 2.
• Continuation of city projects.
• November 2007: Prolead, Module 3.
• Phasing out/closure of city projects.
• December 2007: Bangalore core project evaluation.
Final Report, 1 August 2006
Annex 8, Proposed dates for Training
Proposed timeline
Global/
Inter-regional
28-29 October
Alliance for Healthy
Cities, Suzhou, China
2006
Qtr 2
1-3 November
2nd KNUS meeting,
Tanzania
2007
Qtr 3
Identification of participants
and advisory group (ASAP)
JapanI
(Hyogo & Kobe)
Identification Of
i
Qtr4
t
October
in Japanese
j
Qtr 1
Qtr 2
Qtr 3
Qtr 4
March
Prolead
(M2)
Quarterly meeting, communication, etc.
Chile
(Santiago)
Identification of
participantsand
training institute
week
June
Prolead
(M2)
Quarterly meeting, communication, etc.
Mid-July
India
call for
(Bangalore) participants
31 July
scoping
paper due
31 August
Selection of
participants
October
Prolead
(M1)
March
Prolead
(M2)
1-30 September
Preparation of
Prolead
November
Prolead
(M3)
December
Evaluation
Quarterly meeting, communication, etc.
38
Annex 5, Plan of Action, Bangalore
Objective: Optimizing the social determinants of health in urban settings
Site: Bangalore, India
Total budget: 110 500 USD
Items
Activity
compo
nents
1
Capacity
building
Timeframe
(Quarters)
Timeframe
(Quarters)
2006
2007
2
3
4
art
yo
ct
Project
development
and
implementati
on
City
projects
■Special
service
agreement
Recruit
ment
national
staff
Local cost
and project
mobilization
quarter!
y
meeting,
commu
nication,
transpo
1
2
3
Nov
Prolead
modules
J
u
n
e
Mor
Mile
stone
Maxim
um
funds
from
WKC
(USD)
4
Additional
funds required
and source
(USD)
Amt
Prolead
curr
done;
Pax
identified
30 000
Conduct
of
Prolead
Module 1
10 500
Obligatio
n No.
sent to
WR
54 OOO
Officer
in
charge
Suggestions
source
0
O
5 OOO
Working
group
including
SSA
Module starts
from 4rd
quarter 06
Working
group
Prolead
participants
4—6 city
projects to
optimize SDH
WKC and
WR-lndia
■Smooth
coordination
of activities
between
WKC and
country teams
SSA
Regular
report on
progress
315
■Supplies
and
equipment
Office
supplies
8 000
O
SSA
N/A
-Scoping
paper
Researc
h
3 OOO
O
NIMHANS
(Dr Gururaj)
N/A
Bangalore Healthy Urbanization Project
an urban health research site
A partnership project of
BMP, WKC Japan, WHO India and SEARO
Dear Sir,
Thankyou for attending the launching of Healthy
Urbanisation project on 4th December .We wi!! be too happy if you can
attend a meeting on the day mentioned below to have a detailed
discussion on the same so that we can implement it effectively in
Bangalore.
Time:
3 P.M
Date:
Thursday,14th December 2006
Venue:
Pobbathi Maternity Home, 1st floor,
Sajjan Rao Circle.
Tour’s Sincerely,
Dr.P.S.Thandavamurthy,
Local coordinator.
Dr. Thelma Narayana
I
#359, Srinivasa Nilaya
Jakkasandra
1st main, 1st Block
Koramangala
Bangalore-34
Ph. 25531518,25525372
\3\
Notes of BHUP Meeting on January 16,h, 2007 at 3.00 p.m., Dassappa Maternity Home
1) Agenda: Further clarification about the project with Jostacio Memo Lapitan of the
Urbanisation and Emergency Preparedness Programme. WHO Centre for Health
Development (WHO Kobe Centre).
2) 2) The meeting started one hour late at 4.00 p.m. as Dr. Lapitan (a Filipino, working with
WKC) had just arrived. Dr. Thandava Murthy (TM) introduced the project, by again saying
that it was not a BMP project and repeated the same details as in the earlier meetings. After
the introduction, the floor was thrown open for questions.
3) We raised the following issues:
a. If it is not a BMP project, why is there so much BMP involvement? Also the
brochure says that it is a “partnership project of BMP with WKC. Japan WHO
(SEARO & India). TM accepted that it was a BMP project.
b. Methodology used for selection of seven areas for the project. TM replied that the
BMP Commissioner chose one area from different directions.
c. The logic behind composition of HULC members (NGO, BMP Dr., Suchimitra and
PG student). Dr. Lapitan said that it was based on previous projects’ experience in
developing countries.
d. The ethicality of burdening link workers and other community workers (who
themselves are from “low-resource settings”) to do additional work without
compensation. (Earlier a BMP doctor had confided in us that link workers had not
been paid their honorariums from last August). Dr. Lapitan said that BMP informed
them that voluntary agencies were already working in the area and would provide
voluntary service for the project. But regarding payment to field workers, he said
that it could be reconsidered. USD 1500 was kept aside for each HULC and some
of that money could be used for it.
e. HULC members have been requesting for communication stating the nature of
partnership, scope of work and the terms of joining the project. Dr. Lapitan asked
the BHUP coordinators to make a note of the points and send a letter to the HULC
partners.
f. What are the policy components of the “research and action project”?
g- The selection method and competence of SHINE to do the training on this issue.
4) TM suggested that we along with Dr. Anuradha of Samara Project, IIM, Dr. Nadakumar of
Ramiah Meedical College and others draft a letter stating the scope of project, nature of
partnership, etc. after the meeting concluded. We met a small group after the meeting, and
gave them points on what should be included in the letter. The BHUP team were given a
copy of the suggested points, which included details of project, budget, expected outcomes,
responsibilities, inputs required (human resources, time, materials) and so on.
5) After the meeting, we met with Dr. Lapitan, introduced ourselves and discussed with him
about the project. We also met Dr. TM and thanked him for the open dialogue. He told us
that he was very happy that we had raised the issues. He also said that he was expecting
that we would raise questions on why only USD 1500 was kept for each HULC. Many
BMP doctors while leaving the hall came and thanked us for raising these issues and said
“somebody needs to raise these issues, as they are always ignored”.
Notes of BHUP Training on January 22, 2007 at 9.30 a.m.
Urban Health Training Centre
1) The first module training sessions were scheduled to be held from 23-25th Jan. It was later
rescheduled to 22-23rd, and 25th Jan. SJC called up one of the local co-ordinators,
Kameshwari on the previous evening (21st) to confirm whether the meeting was still
happening on the same dates, she said that there had been some change and that we had to
speak to Dr. Thandava Murthy, the senior local coordinator to discuss it. She refused to
give further information. Dr. Thandava Murthy did not answer his phone in spite of both
NT and SJC calling repeatedly. SJC later spoke to Dr. Vijayalakshmi, the Chief Health
Officer of BMP who also did not give any information. He later called up Ms.
Vijayalaksmi Bose, the WHO consultant for the project, who said that BHUP had sent our
letter to WHO for clearance, since we had raised many questions.
2) SJC and NT went to Urban Health Training Centre on January 22, 2007. They met Dr.
Thandava Murthy who said that we could not participate in the programme as our name
was not cleared by WHO, and that our communication to them had been forwarded to
WHO, since we had raised many questions.
■
*
3) NT spoke to -Dr. -Lapitan
and told him that
our names were not‘ amongr the list of
participants, and that we were being kept out for raising questions. NT asked him whether
they were informed of it, and if so, whether as a WKC representative, he would approve of
groups being kept out for raising queries in a research project. He just said that SHINE had
sent the list of participants and that they were not involved in it.
4) Later SJC and NT met Ms. Vijayalaksmi Bose, who said that we had been very
confrontational in our approach. She said that she knew Dr. lhelma who was not
confrontational at all, and she did not know whether the rest of CHC was “rabid . (She
later said that she withdrew her comment about CHC being rabid, but she stood by the fact
that we were confrontational). She said that she had observed us at other meetings and
found that we raised these issues too frequently, in a manner which would make BMP wary
of us. (Note: The only meetings where she was present were the BHUP launch meeting on
December 4, 2006 and January 6, 2007, in which SJC participated. But he did not even
speak once at the first meeting as there was no opportunity for dialogue. In the other
meeting, all the participants raised several queries about the project, including SJC. The
only other meeting she was present was during the introductory meeting on 711 Dec in
which TN and SJC participated. So, there is no basis for her observation).
5) We told her that we had only raised questions about the methodology and implementation
of the project, as it was a research project. And there was no other opportunity where we
could be confrontational. She said that she could not comment on this issue, since she was
not there, nor had we sent a copy of the letter to her.
6) We raised the point that the least “professionalism” that could have been shown was to
have informed us that we were not to attend the training, after giving us a letter inviting us
for the same. She said that she was sorry regarding that.
7) The participants at the meeting including a doctor of BMP, Mr. Sundaram of SJJ and Dr.
Anuradha said that they were very upset with us being kept out. Sundaram and Anuradha
said that they would raise it in the meeting.
(Prepared by Naveen and Chander, 22 Jan, 2007)
DRAFT
IIMB LETTERHEAD
January 9, 2007
Dr. P.S. Thandava Murthy
Local Co-ordinator
Bangalore Health Urbanization Project (BHUP)
Pobbathy Health Centre
Sajan Rao Circle, V.V. Puram
Bangalore - 560 004
Dear Dr. Murthy,
Thank you for your letter dated XXX and for the invitation to join the Healthy
Urbanization Learning Circle (HULC).
We are happy to be involved in discussions regarding the HULC and the Bangalore
Healthy Urbanization Project. However, please note that we cannot formally accept the
invitation to join the HULC until a scope of work and an agreement is finalized for the
same.
Dr. Anuradha, Clinical Director and Ms. Kalyani Subbiah, Project Director of my
research program (The Samata Health Study) will participate in the HULC Managers
Meet being scheduled on the 16th of January, 2007. I will be attending the Welcome
Reception along with both of my colleagues on the 18th January evening.
We look forward to a very fruitful association with BHUP and are eager to finalize the
agreement and scope of work for the same at the earliest.
Sincerely,
Suneeta Krishnan, Ph.D
Visiting Faculty, Center for Public Policy
Indian Institute of Management, Bangalore
and
Adjunct Assistant Professor
Dept, of Obstetrics, Gynecology and Reproductive Sciences
University of California, San Francisco
Notes of conversation with Shanmuga Sundaram, SJJ and Dr- Sunita Krishnan, IIM regarding the BHUP training programme organized by SHINE
First day of training - 22 Jan '07 (As reported by Shanmuga Sundaram )
1) Training did not contain anything related to the technical aspects of the action research
project. Tlie whole day session was conducted by Mr. Sheshadri alone, who just read out
the various concepts from the project module.
2) Ms. Kameshwari, local co-ordinate of BHUP, who is apart of the core tesn is also from
SHINE.
Second day of training - 23 Jan *07 (As reported by Di\ Sunita Krishnan)
1) This morning, as Ms. Kalyani from Sam ata project, UM entered the training hall, Ms.
Kameshwari called her aside and asked her to introduce herself as a ‘suchimitra’ and not
as aNGO representative. Ms. Kalyani refused to do so, and went in to attend the session.
2) The topic today was about communication, and Mr. Sheshadri was talking “rubbish”.
3) He was often reciting slokas in between and was promoting CDs of slokas and other
religious materials during the training. The WHO observers were silent all through the
sessions.
4) Ms. Kalyani, wlw represented IIM walked out of the training as she was not comfortable
and she could not get anything useful from the training.
5) IIM team is deciding to pull out of the project.
6) Being a WHO project, the activities going on in the name of “social determinants” need
to be taken up at the WHO level.
(As reported by Shaninnga Sundaram)
1) All examples of Mr. Sheshadri about poverty are from R^nayana, Mahabharata and from
Germany.
2) His explanation of poverty was comparison of a rich man from Germany (with whom he
stayed yeai’s ago) with the life style of president of India, and that even among the rich,
we are poor.
3) Hie whole day session was again conducted by Mr. Sheshadri alone.
SJC’s telephonic conversation with Ms. Vijayalakshini Bose (VB) and Dr, Thandava
Murthy (TM)
1) SJC spoke to VB first and asked for a written communication st ating the reasons for not
including CHC’s name in the participants list, even after sending us a. letter ‘thanking us
for accepting to join the project *a
2) VB responded that she was infonnedthat we had raised many queries, but she had not
seen a copy of our letter, and requested us to fotward the copy of our letter to her, so tliat
she could respond.
3) SJC then spoke to TM, asking for the written communication, when he said that he would
send if . But he had sent the letter to WHO for approval, and he would get back to us, once
he got a response from them.
Bangalore Healthy Urbanization Project
an urban health research site
A partnership project of
BMP, WKC Japan, WHO India and SEARO
AGENDA
2:00pm to 2:10pm
2:10pm to 3:15pm
Welcome remarks by CHO,BMP.
Detail discussion on the BHUP
Project by
Dr.P.S.Thandava Murthy
Notes of BHUP Meeting on January 16th, 2007 at 3.00 p.m., Dassappa Maternity Home
1) Agenda: Further clarification about the project with Jostacio Memo Lapitan of the
Urbanisation and Emergency Preparedness Programme, WHO Centre for Health
Development (WHO Kobe Centre).
2) 2) The meeting started one hour late at 4.00 p.m. as Dr. Lapitan (a Filipino, working with
WKC) had just arrived. Dr. Thandava Murthy (TM) introduced the project, by again saying
that it was not a BMP project and repeated the same details as in the earlier meetings. After
the introduction, the floor was thrown open for questions.
3) We raised the following issues:
a. If it is not a BMP project, why is there so much BMP involvement? Also the
brochure says that it is a “partnership project of BMP with WKC, Japan WHO
(SEARO & India). TM accepted that it was a BMP project.
b. Methodology used for selection of seven areas for the project. TM replied that the
BMP Commissioner chose one area from different directions.
c. The logic behind composition of HULC members (NGO, BMP Dr., Suchimitra and
PG student). Dr. Lapitan said that it was based on previous projects’ experience in
developing countries.
d. The ethicality of burdening link workers and other community workers (who
themselves are from “low-resource settings”) to do additional work without
compensation. (Earlier a BMP doctor had confided in us that link workers had not
been paid their honorariums from last August). Dr. Lapitan said that BMP informed
them that voluntary agencies were already working in the area and would provide
voluntary service for the project. But regarding payment to field workers, he said
that it could be reconsidered. USD 1500 was kept aside for each HULC and some
of that money could be used for it.
e. HULC members have been requesting for communication stating the nature of
partnership, scope of work and the terms of joining the project. Dr. Lapitan asked
the BHUP coordinators to make a note of the points and send a letter to the HULC
partners.
f. What are the policy components of the “research and action project”?
g. The selection method and competence of SHINE to do the training on this issue.
4) TM suggested that we along with Dr. Anuradha of Samata Project, IIM, Dr. Nadakumar of
Ramiah Meedical College and others draft a letter stating the scope of project, nature of
partnership, etc. after the meeting concluded. We met a small group after the meeting, and
gave them points on what should be included in the letter. The BHUP team were given a
copy of the suggested points, which included details of project, budget, expected outcomes,
responsibilities, inputs required (human resources, time, materials) and so on.
5) After the meeting, we met with Dr. Lapitan, introduced ourselves and discussed with him
about the project. We also met Dr. TM and thanked him for the open dialogue. He told us
that he was very happy that we had raised the issues. He also said that he was expecting
that we would raise questions on why only USD 1500 was kept for each HULC. Many
BMP doctors while leaving the hall came and thanked us for raising these issues and said
“somebody needs to raise these issues, as they are always ignored”.
P.T.O
Notes of BHUP Training on January 22, 2007 at 9.30 a.m.
Urban Health Training Centre
’ ; were scheduled to be held from 23-25th Jan. It was later
1) The first module training sessions
rescheduled to 22-23rd7 and 25th Jan. SJC called up one of the local co-ordinators,
Kameshwari on the previous evening (21st) to confirm whether the meeting was still
happening on the same dates, she said that there had been some change and that we had to
speak to Dr. Thandava Murthy, the senior local coordinator to discuss it. She refused to
give further information. Dr. Thandava Murthy did not answer his phone in spite of both
NT and SJC calling repeatedly. SJC later spoke to Dr. Vijayalakshmi, the Chief Health
Officer of BMP who also did not give any information. He later called up Ms.
Vijayalaksmi Bose, the WHO consultant for the project, who said that BHUP had sent our
letter to WHO for clearance, since we had raised many questions.
2) SJC and NT went to Urban Health Training Centre on January 22, 2007. They met Dr.
Thandava Murthy who said that we could not participate in the programme as our name
was not cleared by WHO, and that our communication to them had been forwarded to
WHO, since we had raised many questions.
3) NT spoke to Dr. Lapitan and told him that our names were not among the list of
participants, and that we were being kept out for raising questions. NT asked him whether
they were informed of it, and if so, whether as a WKC representative, he would approve of
groups being kept out for raising queries in a research project. He just said that SHINE had
sent the list of participants and that they were not involved in it.
4) Later SJC and NT met Ms. Vijayalaksmi Bose, who said that we had been very
confrontational in our approach. She said that she knew Dr. Thelma who was not
confrontational at all, and she did not know whether the rest of CHC was rabid . (She
later said that she withdrew her comment about CHC being rabid, but she stood by the fact
that we were confrontational). She said that she had observed us at other meetings and
found that we raised these issues too frequently, in a manner which would make BMP wary
of us, (Note: The only meetings where she was present were the BHUP launch meeting on
December 4, 2006 and January 6, 2007, in which SJC participated. But he did not even
speak once at the first meeting as there was no opportunity for dialogue. In the other
meeting, all the participants raised several queries about the project, including SJC. The
only other meeting she was present was during the introductory meeting on 7 Dec in
which TN and SJC participated. So, there is no basis for her observation).
5) We told her that we had only raised questions about the methodology and implementation
of the project, as it was a research project. And there was no other opportunity where we
could be confrontational. She said that she could not comment on this issue, since she was
not there, nor had we sent a copy of the letter to her.
6) We raised the point that the least “professionalism” that could have been showni was to
have informed us that we were not to attend the training, after giving us a letter inviting us
for the same. She said that she was sorry regarding that.
7) The participants at the meeting including a doctor of BMP, Mr. Sundaram of SJJ and Dr.
Anuradha said that they were very upset with us being kept out. Sundaram and Anuradha
said that they would raise it in the meeting.
(Prepared by Naveen and Chander, 22 Jan, 2007)
jfrivatization. The international community and public health experts have
universally recognized the important role of the state in infectious disease control
through public health systems, popular education and people’s participation In
the current neo-liberal context this role needs to be re-inforced.
/
48. Newer p^blems of HIV/AIDS, SARS AND Avian flu have been addressed by
the UNESCAP over the past few years in its resolutions. The/recent 3x5
initiative of the WHO, which aims to increase access to treatment is welcome as
a timely response to the severity and magnitude of the disease and to the
treatment access\campaign. Dialogue between UNESCAP and WHO will help to
enhance coverage^and capacity building in Asia as early a/ possible. Newer
treatment protocols^ simplified procedures, etc will be ad< >pted, monitored and
constantly updated as new knowledge becomes available, after reviewing its
social applicability. M* >st importantly countries could use the existing provisions
in the WTO clauses to fcpsure adequate supply of gooci quality, generic drugs at
affordable prices. Lesso: could be learnt from Thailand, Cambodia, India and
other countries. Health education efforts regarding these diseases should not
generate fear but spread positive messages.
Methods of positive living for
persons already infected could, been encouraged^ Use of adjunct therapies such
as herbal remedies, massage and other forms/of healing that recognized not to
cause harm will be encouragedX Life skills education and women’s health
empowerment that has already beerkinitiated in most countries will be expanded
through widespread capacity building\ /
49. The region is faced with a double burden of diseases with non-communicable
diseases (NCD) and traffic accidents taknig a heavy toll. The Pacific island
countries, Japan, China, Australiyand New Zealand have already initiated health
promotion campaigns through the government voluntary sector, private sector
and professional associations Zo bring about lifestyle changes such as adequate
exercise, healthy diets, stress management, compulsory use of helmets and seat
belts, rules about drinkinef and driving etc. With/an ageing population these
measures are necessary/ to reduce the burden or\ cardiovascular diseases,
hypertension, stroke, diabetes and other NCDs. AbutId up of capacity in the
public and private sector for management of these disorders is necessary.
Ratification of the /Framework Convention for Tobacco &nntrol (FCTC) and
implementation o/bans on advertising and sponsorship o f\tobacco products,
smoking in public places and stringent curbs on smuggling, would help control
the epidemic o/tobacco related diseases, including cancers in the' .egion. Other
measures for prevention, control and care of cancer also need to be instituted.
50. The health/internet work project of the WHO has piloted the use of thh internet
and information and communication technology (ICT) for providing easy access
to research information on important public health problems to health providers
and citizens. ICT offers great potential and needs to be widely used. Internet
based public health training programmes are being designed. The use of hand
Bangalore Healthy Urbanization Project
an urban health research site
A partnership project of
BMP, WKC Japan, WHO India and SEA RO
Dear Sir
S ' 7T
ith sense of gratitude, we thank you and your Organization for accepting
to be an active team member of Healthy Urbanization Learning Circle. As you are
aware that H.U.L.C forms the live wire of the research committee of the
Bangalore Healthy Urbanization Project.
As deliberated in our meetings, you will be working with other team
members of the H.U.L.C’s. The training will be conducted by SHINE in the
presence of observers from WKC Japan, WHO SEARO India. The details are as
follows:
1. HULC Managers meetings 16-1-2007 Morning
2 Welcome Reception on:
18-1-2007
3. Module 1. 23, 24, 25 Jan 2007
4. Module 2. 31,1.2 Feb 2007
Your participation is very essential in the above events to bring out the
desired changes in the findings of research work, which you will be conducting.
Look forward for your continued Co- Ordination to make BHU project a
reality.
A line of confirmation will give lot of motivation to take up new
challenges
WE WORK TOGETHER TO MAKE BANGALORE-HEALTHY PLACE TO
LIVE.
Your I
Dr. P.J l(1rMandaya< urthy
Local < o-ordifiator.
7
Ref:
r\
j <|t>
December 29, 2006
Dr. M. Vijayalaksmi
The Chief Health Officer
Bengaluru Mahanagara Pal ike
Bengaluru
Dear Dr. Vijayalakshmi,
Greetings from Community Health Cell!
My colleagues have been attending the Bangalore Health Libanization Project
(BHUP) meetings. We are very happy that social determinants and equity focus are
getting its due importance in health policy processes of the city. As you are aware,
CHC is associated with a similar process with the WHO. Dr. Thelma Narayan who is
CHC's Consultant on Public Health has been a member of the Measurement and
Evidence Knowledge Network of WHO's Commission of Social Determinants of
Health (CSDH). CHC has been working on community health, health policy and
urban health issues, especially those concerning the urban poor, since many years. As
we reach our twenty-fifth year, we are consolidating our experiences and materials
into training modules in health. Over the past three and a half years itself, we have
trained over 40 doctors and social workers on these issues, through an intensive six
months - one year community health fellowship scheme.
At the BHUP meetings, NGOs were called to take on responsibility for different
Health Urbanization Learning Circles (HULCs). Dr. Thelma had said that Shantinagar
was the closest one to our centre. As a government official you would very well know
that such serious matters as these cannot be done only on telephonic conversation.
Hence, we request you to send us a written invitation to join the project with details
about the project, nature of the partnership, expectations from us, the time
commitment needed, the expected outcomes and the financial resources available.
This would be presented at the meetings of our team and Society members (since
CHC is a registered Society) where a final decision would be taken.
We already have gathered enough materials on this project from various sources
including WHO and the website. Using this knowledge, our experience and
networking, we believe that we could contribute positively to this project. We hope
our professional involvement would be adequately compensated. Since we work on
tight programme and budget lines, substantial field work would require services of
some field staff, which needs to be paid for.
One of CHC's main thrust is on improving the public health system, and as such, we
believe strongly in working with the state. We would be very happy to work with you
on this project. Looking forward to hearing from you.
Sincerdy,
E. Prefndas
Coordinator
Page 1 <■
Naveen
From:
To:
Cc:
Sent:
Subject:
"Community Health Cell" <chc@sochara.org>
<pstmurthy@gmail.com >; <chinthaladevi@gmail.com>
<premdas@sochara.org>; <naveen@sochara.org>; <chander@sochara.org
12 January 2007 15:37
Reg. BHUP project
Dr. P.S. Thandava Murthy
Local Co-ordinator
Bangalore Health Urbanization Project (BHUP)
Pobbathy Health Centre
Sajan Rao Circle, V.V. Puram
Bangalore - 560 004
Greetings from Community Health Cell!
Thank you for inviting us to the HULC Mangers meeting on 16th January 2007 and the welcome reception on
18th January 2007. This is to inform you that Mr. S. J. Chander and Mr. Naveen Thomas will attend the
Manager’s meeting, while Dr. Thelma Narayan will attend the welcome reception.
We would like to bring to your notice that we have still not received an invitation letter outlining the nature of
partnership, scope of work and the terms of joining the project. We would like to reiterate that we cannot forme
join the HULC until we receive the formal invitation for the same.
Looking forward to hearing from you.
Sincerely,
E. Premdas
Coordinator
E. Premdas
Community Health Cell (CHC)
No. 359 (Old No. 367), Srinivasa Nilaya
Jakkasandra, 1st Main
1st Block, Koramangala
Bangalore - 560 034. India
Tel: +91-(0) 80-25531518
Telefax: +91-(0) 80-25525372
Email: premdas@sochara.org
Website: www.sochara.org
Want to establish health and equitable development as top priorities? Think that comprehensive primary healti
care and action on the social determinants of health is an urgent need. Join the People's Health Movement
http://www.phm-india.org (India)
http://www.phmovement.org (Global)
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Jan 25, 2007
Dear Dr. VIJayalakshmL Dr. Thandava Murthy and Ms. Vljayalakshml Bose,
r
mem’bersMhA^
fV**1’6'’ £UrprlSed a! ,he rscen’ tie''#|op>™nts when two of our team
In a true spirit of partnership they raised some/ssufeand questions for clarifications and dialogue Even if
demo^tiA3^1,yen,h.u^astlc’ VJetsee th,s^s
irregular and unprofessionaF^nol keeping wHh^uT
?«UmTra?Ori°Ver , ^ars has IA'Orked for a ci''il societyand people’s voice in policy making and health
r™
. d t pmunt (see
WM.,phm-india.org and www.phmovement org) Starting
9
:ain,n9 °f NG° partnerS 10 bui,d “P^yfoHhis system developmentI role, we have9
XJ? h, ih°^d ve,ry c’ose|yiVlith ,he Karnataka State Government in its Health task Force then
helped evolve the Integrated State Health Policy, the Integrated Health, Nutrition and Population Project
me Mating |3r
°ther commrt,ees and exPert groups of the MP and Orissa states and
loriiu NnkRUra He3L,h ^SS °n and PianninS Commission. At every level we have facilitated civil
society, NGO voices and participation and built their capacities to be assertive and not subservient - to
be interactive and true partners as r".:::
----’
representatives
closer
to the people. As host of the suosemem
People’s Health
Movement Global Secretariat in Bangalore we provoked the WHO to set up the WHO Commission on
Social Determinants of Health (CSDH) and are working closely with the WHO-CSDH secretariat and
various knowledge commissions, r “
X
GO engagement in India, Africa, and Latin AmericalAHth
Americ/with all
an these nubs.^ajk
nubs^ojt. Ts
o
/>
I
S’XrHthalJ" °Ur mn
S’a,e? W!,h ,h* ,on9 hl6'ory of
and accepted
uredibhity pur CHC team members were asked to stay away form
f— a—professional
'
....
training, for reasons thet
have not been communicated to us as yet. This makes affiW^ef fhe efforts at "CC
NGO
particIpatloi/VSfie
... ,,,, <
—.
—
* — ^y^'w*****1*1***11”
l-*[* TT1!- **
Qj^both sides, which can be sorted out
fmtowed bo far has been a^unfonunaidy^eMrive deveic
iopment,
^scusse^
uXKftainux
We enclose some papers as background materiK.
“ wish to point out that CHC did not offer to join
OTTWealso
the project, but there were requests at differentlevels
WHO country ofice
iflevels from .WHO
oflce downwards asking
askina us to
jrvviUXW-^
bi
With best wishes and looking forward to further dialogue.
Sincerely,
Dr. Thelma Narayan
/k Consultant£P^
___ r
Copy to: Dr Cherian Varghese, National Professf^^
Dr. Ravi Narayan
Community Health Advisor
*
Encl : BHUP
chc
CW(L 7 ocpmm u»%fcQjfc>n
o?
<5^ P^q oG Q>vo|
Mr^E Premdas
Coordinator
17. Jcui 07
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In response to this, the WHO Commission on Social Determinants of Health (CSDH)
was launched by the late Dr Lee Jong-wook, WHO Director-General in February 2005 to
tackle the "causes behind the causes of ill health". In the same year, the WHO Kobe
Centre was selected as the hub of the Knowledge Network on Urban Settings of the CSDH,
one of nine Knowledge Networks that would support the work of the Commission.
BHUP
Right project with a wrong people
Bangalore Healthy Urbanization Project (BHUP)
Action research project carried out by BHUP supported by
WKC, Japan.'
BMP is not involved in this BMP has provided place only.
Document the information through the action research. 1 he information will be given
to BMP for developing a policy framework. BMP is the second municipal council that
has a policy in a draft form. The information will be given to knowledge network on
urban setting. The Knowledge Network on Urban Settings (KNUS) is focused on
synthesizing global knowledge on social determinants of health and urbanization.
The overall goal of the project
is to promote health equity in urban settings, particularly among exposed populations
through actions in areas that relates to the project objectives:
I.
2.
4.
Developing strategies: Building an evidence base, generating policy ideas,
evaluating current experiences and interventions, developing public health
methodologies for health equity assessment and evaluation and deriving new
knowledge on social determinants and health inequity.
Demonstrating the applicability of strategies: Demonstrating how "generic”
municipal strategies can be applied and combined with tactical and context
specific interventions to promote health equity.
Capacity building: Building capacity at the level of the individual, the
organization and the system by creating a learning environment for
stakeholders, leadership training applied projectsand international exchange
of experience.
Policy advocacy: Developing and applying principles of advocacy,
communication and social mobilization to influence health governance at all
levels and enhance understanding of how a social determinants approach can
integrated in national health systems.
Developing strategies (Project Objective 1)
I’he ultimate purpose of the Urban Health Assessment Framework (UHF) is to
provide reliable and comprehensive information for decision and policy makers, local
governments and authorities, researchers, local communities, and j ablic and private
sectors. Functioning as a strategic framework, the UHF aims to effectively and
appropriately identify and address strength, weakness, challenges and opportunities to
improve the urban health conditions in cities.
Demonstrating the applicability of strategies (Project Objective 2)
Action research - “Action research consists of... research methodologies which
pursue action and research outcomes at the same time ... It also has some
characteristic differences from most other qualitative methods. Action research tends
to be:
o cyclic -- similar steps tend to recur, in a similar sequence;
o participative -- the clients and informants are involved as partners, or at least active
participants, in the research process;
o qualitative -- it deals more often with language than with numbers; and
o reflective — critical reflection upon the process and outcomes are important parts
of each cycle.”6
Capacity building (Project Objective 3)
The capacity building component of the Healthy Urbanization Project provides a
structure for implementation of activities at the healthy urbanization field research
sites. In addition to training, activities may include action research projects, technical
assistance, monitoring group learning, technology transfer, field Visits and
international exchange. The proposed capacity building component is composed of
three modules on healthy urbanization. Participants are expected io carry out projects
that will address social determinants of health using health promotion approaches and
tools introduced during the didactic portion of the course. The programme is flexible,
dynamic and can be adapted to local contexts by including appropriate training and
capacity-building materials, methods and approaches that are most suited to local
needs. It aims to enhance practical skills among teams across five categories (intra
personal qualities, interpersonal qualities, cognitive skills, communication skills and
task-specific skills). Opportunities for cross-regional sharing and learning are also
provided.
Capacity building modules
Capacity building in the Healthy Urbanization Project will be undertaken through the
organization of “Healthy Urbanization Learning Circles'".
Healthy Urbanization Learning Circles are networks of multi-sectoral and
interdisciplinary teams that will undertake action research projects at the city level
through a guided process that will introduce public health methodologies for action to
improve governance, optimize the impact of social determinants and promote health
equity in the urban settings.
Healthy Urbanization Learning Circles will use the “Evidence-Informed Policy and
Practice Pathways (see figure 6) as a model for influencing policy and practice
throughout municipal decision-making processes. Policy ideas provide the starting
point for the sourcing of evidence. Sources of evidence are rn’ltip1'' and varied. Using
the evidence includes interpreting and applying knowledge in specific contexts.
Capacity to implement is considered from the perspective of the individual, the
organization and the system.
Figure 6: Evidence-Iufoiined Policy Jtnd Practice Pathway
\
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Healthy Urbanization Learning Circles will undertake capacity building activities
over a 9-12-month period that is organized around lour modules9:
• Module I: Overview of Healthy Urbanization: Situation Aik lysi
• Module 2: Healthy Urbanization Challenges: Strategy Development and Project
Proposal Writing
• Module 3: Healthy Urbanization Opportunities: Social Mobilization for Intersectoral
Actions.
• Module 4: Mainstreaming Healthy Urbanization: Sustaining Action through
Advocacy
Healthy Urbanization Learning Circles will be guided by the following principles:
• Emphasizing applied skills, not just theoretical knowledge;
• Training in a highly interactive manner, drawing on personal experience to reinforce
team learning;
• Encouraging strategic thinking in the promotion of healthy urbanization;
• Emphasizing the use of good governance principles in decision-making;
• Using action research projects to reinforce classroom learning, multiply training
benefits and generate results;
• Providing opportunities for mentoring and technical support through national and
international networking; and
• Soliciting feedback as a means of improving the learning process.
General criteria for participants in the Healthy Urbanization Learning Circles are
provided as preliminary guidance, but local groups are strongly encouraged to
develop appropriate criteria to meet the needs of the sites. It is proposed that
participants are:
• Recognized as having a commitment to the improvement of health in the city;
• Known to value social justice and equity;
• Respected as influential members of the community;
• Engaged in work that promotes positive social values;
• Highly motivated and will exercise leadership in their sphere of influence;
• Representatives of different gender and sectors who are stakeholders in social
determinants of health.
Policy advocacy (Project Objective 4)
Activities will be undertaken to ensure that new knowledge and good practices are
linked and integrated with national health systems development and wider social and
political processes. The project will create opportunities to advocate for healthy public
policy and more responsive health systems, particularly in reLtioi o:
0® Effective in an age me nt of inter-sectoral collaboration to ensure maximum
impact and the judicious use of limited resources for health;
Decision-making that harmonizes competing interests to achieve the
higher goal of health equity as a social good.
,
2006—2007 Timeframe Situation Analysis Strategy developmentThrough ActionResearch Sustaining Action Through Advocacy Social Mobilization For Intersectoral Action
3-5 months 3 weeks 4-4.5 months
Ar^'V.:.i5
3-5 iwntiB
i
Tl
.
nte-S-b Sr'3h
Areas of concern
The structure that BMP has developed for this project
Central nodal team of 15 members chaired by the commissioner of BMP ( Dr.
Thandavamoorthi says BMP has nothing to do with this project this is BHUP.
Other members of the team members are form BMTC, NIMHANS, BWSSB, Social
welfare department, ex mayor, (CH, SHINE, WHO SEARO, WKC representative,
Vijalakshmi Bose.
Implementation team
BMP deputy commissioner
CHO, BMP, Dr. Thandavemoorthy and Kameshwari, ex Mayor, ICH, rep from 7
HU EC circles.
Field team
Health officers of BMP both public health and clinical
Superintendents of all 6-referral hospital
Pro lead team members
Dr. Srinivas and Hariharan
Filed partners
NIMHANS -1
Freedom foundation-1
Community Health Cel I-1
MS Ramiha Medical College-1
St. Johns Med ical Col lege-1
BMP-2
Bangalore Healthy Urbanization Project
an urban health research site
ft.
A partnership project of
BMP, WKC Japan and WHO
India and SEARO
HEALTHY URBANIZATION
LEARNING CIRCLES
a healthy
Report of the preparatory phase
and proposed programme implementation plan
Ms.Vijayluxnii Bose MS
Consultant (BHUP)
Dr. Cherian Varghese MD, M Phil., Ph.D.
Clusterfocal point (NMH), WHO India
T"1 December 2006
BMP-managed HULC
Composition:
• Medical Officer - selected because he/she
has knowledge of community and major
health and non-health initiatives.
• Is a BMP employee and has influence over
the area around health centre.
• Can provide leadership to the HULC.
BMP - HULC
• Local NGO representative who is
familiar with the area and the exposed
populations.
• Post-Graduate student (preferably from
Social Work or the social sciences)
who is able and willing to do action
research. (Maybe as part of thesis
work).
1
BMP-HULC
• Suchimithras - (stakeholders). Selected
because they are familiar with BMP
and work voluntarily in the
community.
• They have influence within the
community.
Other HULCS
• BMP will manage 2 HULCS.
• Others will be managed by NIMHANS, M.S.Ramaiah Medical
College.
• Community Health Centre, VOICES.
• St.John’s Hospital or Freedom
Foundation
HULC Mandate
Action research
• Following intensive training (5 days
between 22nd & 31st January).
• HULCS will develop an action research
proposal according to the seven themes
selected by BMP.
• The research will be based on social
determinants of health and needs of exposed
populations.
• Proposals will be sent by BHUP office to
WHO & WKC for review.
• HULCS will be given a small grant to carry
out action research.
• These will NOT be interventions but
recommendations for policy formulation
and ideas for better governance.
2
Practice to policy
Practice to policy
• Action research will find evidence to
support practice and identify policy
development pathways
• Research will inform existing draft health
policy.
• HULCS will report to Central Nodal Team
& Implementation team via the BHUP.
• This reporting will be done through a series
of short reports which will be presented to
the two committees for inclusion in the
policy.
• The Central Nodal team will meet quarterly.
• The Implementation Team will meet
monthly.
HULC - OUTCOMES
BHUP Responsibilities
• Identification of key social determinants
within the 7 areas identified by BMPBHUP.
• Use action research methodologies to
identify what can be changed.
• Areas where policy decisions are needed.
• Report and document these for inclusion in
the policy framework.
• Coordinate HULC training with SHine.
• Monitor progress of action research.
• Hold monthly review meetings with
HULCs.
• Convene meetings of the Central Nodal
Team and implementation team.
• Facilitate reporting by HULCS
3
HULC Responsibility
KNUS
• All 4 HULC team members will have to
undergo 9 days training (3+3+3) over a 9month period, starting end-January 2007.
• They will collaboratively develop an action
research proposal.
• Conduct research and report periodically to
Central Nodal Team & Implementation
Team.
• Create local knowledge networks
(where appropriate).
• Generate documentation that will feed
into the Local Steering Committee.
• And via the Local Steering Committee
to WKC and KNUS.
4
Bangalore Healthy Urbanization Project
an urban health research site
IL
Healthy Urbanization
4 h»a:ihy
A partnership project of
BMP, WKC Japan and WHO
India and SEARO
a healthy
Report of the preparatory phase
and proposed programme implementation plan
• h*»tthy 80'
• Healthy urbanization is
a coordinated series of
health promoting,
policy-related activities
informed by evidence
and research.
Ms.Vijayluxmi Bose MS
Consultant (BHUP)
Dr. Cherian Varghese MD, M Phil., Ph.D.
Clusterfocal point (NMH), WHO India
7ri‘ December 2006
BHUP- Major partners
• The Bangalore Healthy
urbanization project is a
partnership with the WHO Kobe
Centre, (WKC) Japan, the World
Health Organization (India
Country office (WCO) and
South East Asia Regional
Office -SEARO) and the
Bangalore Mahanagara Palike
(BMP - the Municipal
Corporation of Bangalore).
Field Research Sites-Global-^^
a haalthy
Globally, the project is known as ‘optimizing
the impact of '»oci'M determinants of health on
exposed populations in urban settings for
2006-2007’.
• 6 healthy urbanization field research sites
selected in San Joaquin (Chile), Bangalore
(India), Kobe/Hyogo (Japan), Suzhou (China),
Ariana, (Tunisia) and Nakuru, (Kenya).
•
1
The beginning..
■ hannhyB*
• Bangalore had initiated programmes towards
wellness and established healthy life style
centres in collaboration with WCO,
CAMHADD and other partners.
• The economic growth and the cosmopolitan
nature provides a good setting
• Representatives from BMP and others were
part of the ProLead training and have been
active towards health promotion.
Bangalore Healthy
Urbanization Project
1st Joint Mission
& Scoping paper
Ar
Joint WKC-WHO Mission
a Mo'thy
• WKC and WHO (SEARO and India) held consultation in
New Delhi and took a mission to Bangalore.
Discussions were held with various stakeholders.
• BMP agreed for the project and WHO India (WCO)
developed a draft plan.
• WCO identified NIMHANS as the agency for preparing
the scoping paper in consultation with partners.
• NIMHANS (Dr. G Gururaj) reviewed the existing data
and information, programmes in Bangalore and held
extensive consultations to develop the scoping paper.
/
Challerges-scoping paper
•
The challenges and areas identified were
-
Capacity and Coordination among agencies
Intersectoral collaboration between health and other agencies
Information systems
Socio-economic disparities
Access to care, especially for Non Communicable Diseases
Enhance capacity of health systems for NCD prevention and
management
Mental health and substance abuse
Health system capacity
Injury prevention and trauma care
Evidence based policies and programmes
Capacity building for individuals and institutions
Strengthen health promotion policy and practice
Governance issues
Targeted interventions
2
Bangalore Mahanagar Palika II
• Bangalore Mahanagar Palike is
the principal nodal agency that
delivers services to the city.
• BHUP works with BMP and
partners to bring about healthy
urbanization through action
research.
Bangalore Healthy
Urbanization Project
Scope of the Project
I
BHUP
• Will address strategic health issues
based on the scoping paper and
wider consultations
• Undertake capacity building
- Through action research.
• Focus on governance related
interventions.
- that optimizes impacts of social
determinants
. h»»hr H®"1*
BHUP-Social determinants of health
1. Access to care
2. Poverty (lack of income).
3. Inadequate food and shelter.
4. Improper sanitation, waste disposal and
civic amenities.
5. Insecure employment and other stresses.
6. Use of harmful substances - tobacco and
alcohol.
7. Environment pollution.
8. Poor education status.
9. Unsafe workplaces.
10. Violence and injuries
3
•
The seven selected themes
The Process ofBHUP
BHUP will address the following social
determinants with a view to influence them
through policy and programmes
1. Water and sanitation
2. Access to care
3. Violence against women and elderly
4. Lifestyle related diseases
• 7 HULCS identified
• Their capacity will be developed
• They will undertake action research and each
one will wor': on ? selected theme under the
flowing ToR
- Policy advocacy
- Capacity building
- Developing strategies
- Demonstration of applicability of strategies
5. Education
6. Transportation
7. Low and uncertain incomes
Information Systems
Bangalore Healthy
Urbanization Project
Systems & Linkages
• Tools for measuring social and health
determinants over a period of time
(baseline and over time) in well defined,
representative populations.
• Develop a framework for health
information system with inputs from
public and private hospitals.
4
BHUP Collaboration
a haasthy I
• Departments concerned with urban
improvement e.g Slum Department,
Water & Sanitation, Roads & Public
Works, Social Welfare, Electricity
Board.
• Transport, Labour, Judiciary, Women
& Children
• Medical Colleges, academic
institutions, Community Based
Organizations, Civil Society,
Corporate sector.
» bauHb/l
Bangalore Healthy
Urbanization Project
Goals & Objectives
BHUP- Goals
•
BHUP will engage BMP on a journey towards
a healthy Bengalooru
- The sleeted themes wil be studied through action
research by trained HULCs
- The outcome of the action research in terms of
capacity building, policy advocacy, strategy
development and its application will be used by
BMP and other governance structures to improve
the thematic areas studied.
Bangalore Healthy
Urbanization Project
Implementation
5
N.
Influencing
social
lenniiiants/
Scheme for BHUP
a haaany
• BMP has set up implementation
practice-policy pathways.
• Two committees
- CENTRAL NODAL TEAM
B BMP &
I Training agency
Central
nodal
team
Implementation
committee
Healthy
urbaniza;HioiK\ '■
learning
circles
(HULC)
Operations for BHUP at BMP -—
Sensitization
• High-level committee chaired by
Commissioner, BMP (members-20).
/
^'.Selected
-IMPLEMENTATION TEAM:
• Mid-level professionals (members-25)
<^htformed action and policy^>
•arch site
HULCS
• Are networks of multi-sectoral
and interdisciplinary teams that
will undertake action research
projects.
• BHUP will have? HULCS.
- Selected on the basis of:
track record of commitment to the improvement of
health in the city;
value social justice and equity;
✓ These criteria apply to all members of HULCS.
HULCs in Bangalore
» hMKhy'
• HULCS will be trained
• Will undertake action research based
on their capacities and areas of
expertise
• HULC members will implement the
interventions in the thematic areas.
• Each HULC will work on all the
thematic areas.
• Outcome of this work will pass through
implementation and nodal committees
6
HULCS
•
•
■ h««:thy
Members of HULCS will be drawn from
BMP, research institutions, providers and
civil society organizations.
Will use evidence to influence policy and
practice throughout municipal decision
making processes.
1. BMP
2. BMP
3. NIMHANS
4. MS Ramaiah Medical College
5. VOICES
6. CRS/St Johns
7. CMC
Site selection for action research "
• BHUP action research will be
through 7 health centre areas
(Pobbathy, Shanthinagar,
Vidhyapeetha, Moodapalya,
Mathikere, Robertson Road and
Vasanthnagar)
• And in 14 low resource settings.
>
Partners
• All related departments (police,
PWD, Department of Women
and Child, social welfare).
• Media.
o hMJthy
Capacity Building
Key project component
• Corporate sector.
• All stakeholders.
7
TRAINING
Sensitization
• hanithy BO'
Central Nodal Team
(Scndliialliin PackaRr)
Implementation
Team
Training gels
more
dcluilcU and
fXrd
HULCS& Field
\
Teams
• Central Nodal
Team (Highlevel committee
chaired by
Commissioner,
BMP).
HULC Training
Sensitization (Contd.)
Implementation
Team
• Half-day
sensitization and
training on social
determinants of
health, action
research,
implementation &
monitoring issues.
• Half-day
sensitization on
social
determinants of
health, policy,
governance
and advocacy
issues.
HULC members’ training needs, training
strategies, materials, pedagogy etc to be
worked out according to Guidelines for
action and local/site needs.
• Addressing social determinants of health.
• Identifying evidence-informed policy and
practice pathways.
•
8
75Training
•'7 yQ
■ »»>:lhy B'1''
• Training Design will be adapted from
the WKC modules according to site
needs.
• Designated training agency selected
by WKC upon WHO
recommendation will be responsible.
• Training for HULCS will be in
English & Kannada (local language).
Training
WKC Training
•
• 28 Trainees
•
•
•
•
•
Capacity Building
• Total number to be
sensitized =115.
• Total to be trained under
WKC adapted modules =28.
OSW1
7 young, active,
motivated and
committed individuals
from Implementation
Team.
21 trainees 7 from HULCS.
7 Health Centre
doctors.
7 Board of visitors of 7
centre hospitals.
7 from community.
Training modules
a h»aUhy
• The currently available training modules
(WKC) have been reviewed and they are
not suitable for the trainees and the
BHUP needs
• The selected training agency will have to
work with all partners and consultants to
realign the training modules to the BHUP
processes and outcomes
9
Work Completed
BHUP: Current status...
And the way forward
• Consultants at Delhi and Bangalore
• Training modules reviewed
• Scoping paper done and
recommendations reviewed
• HULC formation planned
• PIP developed
• Agencies identified
• Office at Pobbathy Maternity Centre.
-Office refurbished.
-Computers installed .
Next Steps
• Training agency selection December 2006.
• WKC Training - December 2006
• BHUP Project Launch - December 4th
2006.
-State Health Minister, dignitaries, BMP
officials, providers, professionals & civil
society organizations to be represented.
HULC Composition
a hualthy 2*®'
• Interdisciplinary group composed of
professionals and civil society
organizations/members primarily from
social sector.
• Other members of HULC to include health
centre doctor, stakeholder, members of civil
society, academics, professionals, providers
and practitioners.
10
HULC Operations
• Each HULC will select a theme/area
according to their expertise.
• The action research projects will be
developed according to the needs of the
exposed populations in the selected sites
and the social determinants of health
priorities identified by the HULC.
• Each HULC will have a nodal organization.
• This nodal organization will be responsible
for drafting the action research proposal
with inputs from other HULC members,
coordinating meetings, making
presentations to the Central Nodal Team &
the Implementation Team.
HULC Operations
(Contd.)
HULC functions
• Each HULC will appoint a nodal officer
who will monitor the functioning of the
HULC.
• Within the HULC, each participant will
have a say and bring to the action research
proposal their individual experience and
expertise.
• Following the training, HULCS will develop
action research plans for 7 months.
• Upon approval by WHO & WKC, these research
proposals will be given a small grant to enable
them to do the action research.
• HULCS will draw upon the resources of BMP
whenever necessary. E.g. answers to queries on
housing, water, sanitation etc.
11
/
HULC partner organizations
1.
2.
3.
4.
5.
•
BMP
NIMHANS
VOICES
St. John’s or Ramaiah Medical College.
CHC
Bangalore College of Social
Sciences/Social Work.
£
Oj
12
DRAFT
Bangalore Healthy Urbanization Project (BHUP)
An urban health research site
A partnership project of BMP, with WKC Japan and WHO (SEARO and India)
BITUP Operational Guidelines
Bangalore Healthy Urbanization Project (BHUP)
An urban health research site
A partnership project of BMP, with WKC Japan and WHO (SEARO and India)
Bangalore Healthy Urbanization is an [action research project that promotes health equity in
urban settings with a primary focus on basic determinants of health] The project advocates a
balance of economic, physical, political, cultural and social development to achieve over all
healthy urbanization
Background:
Being the 6th largest metropolis in India, Bangalore is a living witness to the changing face of
Indian cities. The city is an ever-increasing hub of industrial and technological growth, changing
rapidly specially during the last two decades. Urbanization, industrialization, migration,
changing lifestyles - culture - values of people, and economic growth are the hallmarks of the
city’s growth and development.
Exposed populations
With urbanization and industrialization, slums are becoming a common feature in all
cities of India. They primarily constitute the underprivileged and or the disadvantaged groups in
the urban areas. Referred to as the “exposed population” they are at a greater risk of experiencing
unfavourable social conditions over a longer period. Search for employment, opportunities for
education, changes in production and marketing practices, direct and indirect effects of
development with the ultimate quest being a search for better life among its citizens are some of
the reasons behind this growth. The major characteristics of slum population include - large
family structures, low levels of literacy, poverty, skilled and unskilled categories of work force
along with poor health status.
Bangalore Healthy Urbanization Project of Bangalore
Under BHUP, 7 Health Centers with 14 Slums have been identified. The identified
Health Centres are 1. Pobbathi Maternity Home
2. Vasanthnagar Dispensary
3. Mathikere Health Centre
4. Modalpalya Health Centre
...2
5. Shanthinagar Maternity Home
6. Robertson Road Health Centre
7. Vidyapeeta Health Centre
A sample survey was undertaken (n=3,5OOOO) in the 14 slums with a view to compile a situation
analysis of various issues that need to be addressed under the healthy urbanization project. The
specific objectives of this survey were to identify:
a.
b.
c.
d.
Key determinants of health and its associations with health outcomes.
Current health status of exposed populations.
Response of the health system and their partners through various policies and
programmes.
Developing a framework for developing and implementing future activities.
Social Determinants
(a)
(Key determinants of health and its associations with health outcomes.)
Social determinants are broadly defined as those conditions present in the living and working
environments of individuals and families and are considered as causes behind the causes of poor
health outcomes as they are linked to both social and environmental consequences of human
actions; in turn driven by structural determinants. These broadly reflect the outcomes of wider
economic/political structures and systems as well as individual life styles.
A review of available data indicate that the major social determinants in the urban poor society
of the city of Bangalore include:
•
Low standards of living as reflected by poverty and low-income levels.
•
Poor access to good education.
•
Employment related issues like under employment, unemployment, low skilled jobs, less
opportunities for growth and consequently low and uncertain incomes.
•
Overcrowding in all slum populations due to large families and small availability of
space with meager facilities to expand in the near future. The average family size is more
than 6 living in less than 400 sq. ft.
•
Inadequate water and sanitation facilities as more than half the population do not have
access to potable water and toilets.
...3
•
Marginalized status of women with regard to education, employment, rights, access to
health care and other amenities.
Issues with regard to survival and safety, especially of women and children due to gender
disparities, increasing alcohol usage and exploitation by local people. Violence against
women and children is extremely high in slum populations.
•
Problems in transportation as people have to travel long distances in the absence of
personalized modes of transport.
•
Changing life styles, value systems and culture due to changing patterns of living,
influence of visual and print media, and increasing life style related risk factors like
tobacco, alcohol and changing food habits.
•
Demographic transition, which has resulted in the growth of elderly population from
nearly 6% in 1991 to the current levels of 8% by 2005. The elderly face complex
problems with regard to several social and cultural determinants of health.
•
A wide range of belief systems and practices of individuals and families, which directly
influence the basic understanding of health and illness.
•
Socio-political context and the local governance, which have played a major role in
defining the living standards, accessibility and affordability to services and thereby health
inequalities.
Among the factors listed above, major factors of importance are -
•
Poverty, education, employment and income, water and sanitation, safety and survival,
growing elderly population and issues with local governance.
Health status of the exposed population in Bangalore slums
(b)
•
Conditions like nutritional deficiencies, some infectious diseases (gastroenteritis,
hepatitis, respiratory infections, etc.) have been on the decline, while Malaria and
Tuberculosis are still major public health problems.
•
Risk factors like tobacco usage (20-30% among adult men), alcohol consumption (20-
30% among men in 15+age groups), increasing preference to unhealthy food along with
decreased consumption of fruits and vegetables are on the increase. Physiological risk
factors like hypertension, increased glucose and lipid levels, and suicidal ideations are the
most emerging conditions.
.. .4
HIV/AIDS is on the increase, especially among the lower income societies as per available
•
data. While no specific data exists on the total burden of HIV/AIDS and high-risk sexual
behaviors in exposed population, anecdotal evidence indicates that this is on the increase.
(c)
Health Systems & Promotion Policy
In the city of Bangalore, Bangalore Mahanagar Palike (BMP) is a nodal agency responsible
for delivering services to the poor, while people are free to choose services from other local care
providers. The review of available data indicates that.
The city has nearly 10 tertiary care centres, 8 Medical College Hospitals, 500 small to
large private hospitals and nearly 5000 family practitioners providing healthcare.
• BMP under its own purview 68 urban family welfare centres, 23 maternity hospitals, 6
referral hospitals and 20 dispensaries and offers a wide range of preventive, promotive
and curative services.
• The existing system has adequately geared up to meet the challenges of communicable
diseases in terms of resources, skills and mechanisms, while the same is totally deficient
for non-communicable diseases and injuries.
• While most of the slum duelers use government hospital for treatment 30% of them take
facilities from private hospitals.
•
Health promotion policy has been developed by Bangalore Mahanagara Palike based on the
National Health Policy 2002 and the state policy to suit the specific needs of the BMP;
(d) Key Challenges for Bangalore Healthy Urbanization Project (BHUP)
1. The city of Bangalore has grown disproportionately in the last two decades. BMP estimates
that there are around 800 slums 464 officially registered. The city planners and
administrators need to seriously consider and provide essential sen’ices for adequate health
and socio economic development of these exposed communities.
2. A review of health status of these communities reveals that communicable and infectious
diseases are declining marginally, while non-communicable diseases and injuries are
increasing. The infrastructure to deal with communicable diseases is fairly established while
the capacity andfacilities to deal with the emerging problems is highly inadequate.
...5
3. Among the emerging problems, issues linked to social determinants of health are a priority.
Employment, income, education, gender issues, safety and survival concerns, local
administration and governance and others operate in complex ways resulting in changing
health patterns and often get linked to value systems, lifestyles and cultural dimensions of
people’s life.
The way forward
Based on review of available data, interactions with stakeholders and opinion of
communities, it is imperative that programmes based on reducing health inequalities and
social determinants and health promotion needs to be put in place for the healthy
urbanization project. This requires:
Establishment of a central Nodal Committee
■
Commissioner / Spl. Commissioner
■
Deputy Commissioner (Health)
■
Chief Health Officer
■
Project Co-ordinator
Chairperson;
Vice Chairman
Member
Dr. Venkatesh MOH(Shivajinagar)
to be approved
Representatives of Bangalore Metropolitan Transport Corporation (BMTC)
Slum Clearance Board, Social Welfare Board
Education Officer - BMP
Public Relations Officer - BMP
Prolead Team representatives
Institute of Child Health (Dr. Shivananda who has been traned by W H O.)
NIMHANS & designated W H O. as training Agency for BHUP
Implementation team
Health Officer, (Public Health & Clinical)
Superintendents of Referral Hospitals
Prolead team members.
Medical Officer’s of 7 identified Health Centres.
Medical Officer’s Health of 7 Health Centres (Public Health)
Through “Bangalore Healthy Urbanization Project^, the BMP seeks to confront the issue of
health inequity initially through 7 Health centres that will undertake action research projects in
14 slums where public health methodologies for action will be introduced.
...6
Bangalore Healthy Urbanization Project
an urban health research site
A partnership project of
BMP, WKC Japan and WHO
India and SEARO
a healthy
Proposed programme implementation plan
HEALTHY URBANIZATION
LEARNING CIRCLES
BMP-managed HULC
Composition:
• Medical Officer - selected because he/she
has knowledge of community and major
health and non-health initiatives.
• Is a BMP employee and has influence over
the area around health centre.
• Can provide leadership to the HULC.
BMP - HULC
• Local NGO representative who is
familiar with the area and the exposed
populations.
• Post-Graduate student (preferably from
Social Work or the social sciences)
who is able and willing to do action
research. (Maybe as part of thesis
work).
BMP-HULC
• Suchimithras - (stakeholders). Selected
because they are familiar with BMP
and work voluntarily in the
community.
• They have influence within the
community.
Other HULCS
• BMP will manage 2 HULCS.
• Others will be managed byNIMHANS, M.S.Ramaiah Medical
College.
• Community Health Centre, VOICES.
• St.John’s Hospital or Freedom
Foundation
2
HULC Mandate
• Following intensive training (5 days
between 22nd & 31st January).
• HULCS will develop an action research
proposal according to the seven themes
selected by BMP.
• The research will be based on social
determinants of health and needs of exposed
populations.
Action research
• Proposals will be sent by BHUP office to
WHO & WKC for review.
• HULCS will be given a small grant to carry
out action research.
• These will NOT be interventions but
recommendations for policy formulation
and ideas for better governance.
Practice to policy
• Action research will find evidence to
support practice and identify policy
development pathways
• Research will inform existing draft health
policy.
• HULCS will report to Central Nodal Team
& Implementation team via the BHUP.
3
Practice to policy
• This reporting will be done through a series
of short reports which will be presented to
the two committees for inclusion in the
policy.
• The Central Nodal team will meet quarterly.
• The Implementation Team will meet
monthly.
HULC - OUTCOMES
• Identification of key social determinants
within the 7 areas identified by BMPBHUP.
• Use action research methodologies to
identify what can be changed.
• Areas where policy decisions are needed.
• Report and document these for inclusion in
the policy framework.
BHUP Responsibilities
• Coordinate HULC training with SHine.
• Monitor progress of action research.
• Hold monthly review meetings with
HULCs.
• Convene meetings of the Central Nodal
Team and implementation team.
• Facilitate reporting by HULCS
4
HULC Responsibility
• All 4 HULC team members will have to
undergo 9 days training (3+3+3) over a 9month period, starting end-January 2007.
• They will collaboratively develop an action
research proposal.
• Conduct research and report periodically to
Central Nodal Team & Implementation
Team.
KNUS
• Create local knowledge networks
(where appropriate).
• Generate documentation that will feed
into the Local Steering Committee.
• And via the Local Steering Committee
to WKC and KNUS.
5
HEALTH CARE UNDER THE
BANGALORE MAHANAGARA PALIKE (BMP)
The aim of the Urban Family Welfare Centres (UFWC) and Maternity Homes (MH) is to provide
family welfare services and MCH (maternal and child health) services to people living inside the
Bangalore city corporation limits.
SERVICES OFFERED UNDER FAMILY WELFARE CENTERS (UFWCs)
Family planning methods both temporary and permanent
Immunization for children and pregnant women
Antenatal and post natal care
General health check up camps
Laproscopy camp
Sexually Transmitted Diseases clinic
Medical Termination of pregnancies
Satisfied customer meeting
SERVICES OFFERED UNDER MATERNITY HOMES
‘ Outpatient
•
Treatment of minor ailment, and immunization for women and children. Antenatal care for
women.
Inpatient
•
•
•
Deliveries
Tubectomies
Cesarean and Hysterectomies
STAFF PATTERN UNDER UFWCs
•
•
•
One medical officer
One lady health visitor for 5000 population
Three Auxiliary Nurse Midwife ( ANM ) for 15000 population
Both the LHV’s and ANMs should make home visit for identifying pregnant women and to
motivate them to attend ANC clinic follow up of women who have delivered for post natal care.
Identify children for immunization and motivate them to immunize. Identify people for family
planning.
STAFFING PATTERN UNDER MATERNITY HOMES
•
•
•
•
One doctor (gynaecologist)
One paediatrician for two maternity homes
Three staff nurses
Three ayahs
Draft as 19/06/2006
Page 3 of 9
•
•
three pourakarmikas
Three peons.
There are six referral centers in the following places, one center for four to five maternity homes
1.
2.
3.
4.
5.
6.
Siddhiah road
Ulsoor
Srirampura
Hosehall i
Goripalya
Banashakari
Following staff would be available in each of these referral centers
•
•
•
•
•
•
•
Superintendent
One surgeon
Two to three gynaecologists
One anaesthetist
One paediatrician
Five to six staff nurses
Class four workers.
INDIA POPULATION PROJECT (IPP)
India population project eight is run with rupees 40 crore is borrowed as loan form the World
Bank. The project period is spread for five years. The project covers population of .851 million
urban poor living under the Bangalore Mahanagara Palike (BMP) limits.
Aims and objectives of the project
• To deliver family welfare services and Maternal and child health services to the urban poor.
• To improve the maternal and child health services
• To reduce the fertility rate among the urban poor.
Facilities under the project
• Create one health center for every 50000 population.
• Create 64health centers to promote Nutrition, Family welfare, antenatal and post natal care,
medical checkup of school going children, immunization of mother and child, treatment of
minor ailments and specialized services.
• Strengthening the existing 37 Urban Family Welfare centers.
• Establish 60 new health centers.
• Conversion of 24 Maternity Homes as referral centers.
• Appointment of 970 link workers.
• Formation of SHE clubs
• Designing and supply of health education material and procurement of audio visual aids for
community education.
• Female education
• Income generation activities for women through SHE club.
• Environmental sanitation.
Draft as 19/06/2006
Page 4 of 9
Second Karnataka State Health Assembly
Parallel Session on Urban Health
Background paper prepared by: S.J.Chander, Community Health Cell, Bangalore
Introduction
In the era of globalization only the glamorous part of the cities have attracted the
attention of media. More the glamour the cities become for the rich and the elite more the misery
it adds to the poor who constitute a significant portion in every city. Cities have always been the
economic powerhouses and the political never centers but unfortunately neither the political
power nor the economic abundance has done much to the urban poor ever to meet the bare
minimum basic needs.
Who are these urban poor? They are generally characterized by poverty, lack of
substandard housing, overcrowding, social exclusion (especially from informal sector of
employment) and insecurity. (UN Habitat 2003). UNESCO description of the term44 fourth
world seems to fit urban poor living in slums. They are described as a sub proletariat whose
housing, sanitation, clothing, and food are inadequate; whose cause is not championed by
politicians and unions, who have limited information, education and voice; and who, because of
indifference or intolerance and the way they are affected by the law and administrative practice,
are systematically prevented from exercising the rights that the other people take for granted.
(UNESCO ‘fourth world and human rights, Paris 1980)
From the economic point of view they are considered as burden and from health point of
view, a danger (Fernand Laurant, J Introduction, Human rights in urban areas, Paris UNESCO
1983.)
Future trend and urban poverty
The experts are of the opinion that the urban areas of developing world will experience an
exponential population growth in the future as a result by 2035 developing counties will be a
home for more than half of the worlds poor. Already over 495 million urban poor people are
living in developing countries on less than 1 $ a day.1
India’s urban population is one of the largest in the world constituting over 320 million people.
The urban population has increased 8 times in the last 50 years, grown form 44 million to 320
million. Highest growth was recorded from 1951 to 1991. The number of towns increased from
around 2,843 in 1951 to approximately 5,100 in 2001. The number of cities with over one million
populations has nearly doubled since 1980, from 12 to 23, with the urban population rising from
26.8% to over 35%. Urban India has 25.7% of the national population.
In India, while the urban average growth is stabilized at 3% over the past decade urban
poverty continues to grow with the alarming slum growth rate of 5-6%. The official figure for
urban poverty was recorded as 32%. It is predicted that while it will take 10 years for the urban
Improving health outcomes among urban poor- the challenges and opportunities
Lessonsfrom India Pamily Welfare Urban Slums Project
C. N.I7. Ramana Sr. Public Health Specialist^ Uh^abeth Lule Advisor, Population and Reproductive
Health
Draft as 19/06/2006
Page 5 of 9
population to double; it would take only 5 years for the urban poor population to double. 2
Between 39-43% of India's slum population is distributed in the metropolitan cities of Calcutta,
Mumbai, Delhi and Chennai. About 1.5 million people are living in about 800 slums in
Bangalore. (India CLEN Neonatal Health Research Initiative, 2004.)
The rapid growth of cities creates a major concern on infrastructures and basic amenities to make
life comfortable both the rich and poor. The urban dwellers continue face more problems such as
inadequate housing, water, sanitation, employment opportunities and various pollutions affecting
the environment. They also become vulnerable to industrial accidents such as Bhopal Union
Carbide industry. The death rate due to accidents is twenty times more than the US. The growth
further puts pressures on the existing services such as, transportation, health care, education.1
Health of the urban poor
The widening gap between the rich and the poor accelerated by the process of
globalization has been document worldwide. The rural poor turn to cities for survival. Those who
turn to the urban areas to escape rural poverty and unemployment do not find much solace when
the land up in the urban areas. They subject themselves to double peril; firstly they become more
venerable to health problems caused undesirable living condition secondly they become target for
the politically influenced liquor barons who aggressively sell their products among urban poor.
The key factors affecting health of the urban poor are poverty and undesirable living conditions.
Poverty is defined as lack of specific consumption or not enough to eat; lack of command over
commodities exercised by a population and capability to function in a society.4 Unemployment,
irregular employment opportunities or unpredictable employment availability is key factor
responsible for the inflicting poverty status. As result the basic minimum necessities for
maintaining health is under stake leading to poor dietary intake, poor housing and illiteracy. The
second major problem affecting the health of the urban poor is their poor living condition. One
wonders why there is an undesirable environmental practice among the poor. The truth is not that
all the urban poor do not desire better living conditions, there is lack of awareness on health and
disease and their rights. They do not know who is responsible for providing better living
conditions for them. They elected representatives are accessible once in five years, before they
are elected. As result of poor living condition they fall prey to communicable diseases and
infectious diseases. Lack of regular employment opportunities and recreational facilities have led
the men to fall prey to social problems such as alcoholism and tobacco consumption. As
consequences of these problems the adolescent girls and women become more vulnerable sexual
abuse, violence and stress. The major portion of the income that the man earns goes in for
alcohol, depriving the families the money for nutritious food and educational needs.
All Slums are Not Equal: Child Health Conditions Among the Urban Poor Indian Pediatrics 2005;
42.\235-244,Siddharth Agarwal & Shivani Taneja
1
http://www.photius. com/countries/india/society/india_societyjhe_growth_of cities, html
Data as ofSeptember 1995
~
4 Understanding the poor cities in India andformulating appropriate anti poverty actions, discussion paper
Jor south Asia urban city and management course, Goa, India. 2000.
Draft as 19/06/2006
Page 6 of 9
While there is inadequate response to improve the key determinants such as employment, water
and sanitation and housing that can promote the health of the urban poor, the services for
managing the life crisis affecting their mental, physical and social health is pitiable. India
Family Welfare Urban Slums Project in its report admits that urban water supply and sanitation
sector in the country is suffering from inadequate levels of service, an increasing demand-supply
gap, poor sanitary conditions and deteriorating financial and technical performance. A recent
study conducted by the Jansahoyg a urban resource centere in Bangalore revealed that 10 out of
the 14 samples collected form water source for the urban poor were unfit for consumption.
Regarding housing, It is estimated that there are about 2,60,000 houses in the slums of Bangalore
city of which only 10% of the have RCC which is built by government, NGO/CBO and the
communities themselves .
Health care services for the urban poor
The term Primary Health care is being loosely used.
India started responding to this challenge as early as 1982 by developing policy framework for
urban primary health care. A new initiative known as Urban Revamping Scheme was started in
1984 with strong focus on improving linkages of primary health and family planning services
with other urban basic services such as clean drinking water and sanitation. This was followed by
several other initiatives including the Bank supported urban primary care project in. Bombay and
Chennai during 1988 and 1995 and the current project which closed in 2002.
The Government of India s US$ 81 million Family Welfare Urban Slums project supported by
the World Bank helped to develop new partnerships between local communities, municipalities
and non-government sector to improve reproductive and child health outcomes among 11.3 urban
poor populations of India. Implemented during 1994-2002 under the stewardship of Ministry of
Health & Family Welfare, the project aimed to (a) reduce fertility by improving access and
demand for family planning services; and (b) improve maternal and child health by decreasing
maternal and infant mortality rates among slum residents of Bangalore, Delhi, Hyderabad and
Kolkata.
The project scope was subsequently extended to 94 smaller towns in the states of Andhra
Pradesh, Karnataka and West Bengal. (Improving health outcomes among urban poor- The
challenges and opportunities
Lessons from India Family Welfare Urban Slums Project
G. N. V. Ramana Sr. Public Health Specialist
Elizabeth Lule Advisor, Population and Reproductive Health)
In Karnataka there are about 87 Urban Family Welfare Centres, 124 Urban Health Centres and
24 district-level and 149 taluk-level hospitals. There are 51 other hospitals, including superspecialty hospitals, which treat often the non-communicable diseases such as heart diseases, and
cancer. The Karnataka government has been regularly borrowing crores or rupees through the
Karnataka Health System Development Project (KSHDP) during the past seven years during the
past seven years 624 crores have been borrowed to upgrade the infrastructure for 204 taluk and
district hospitals. While six of the hospital won the ISO 9002 certification still there are urban
health centers without doctors, and medicines. It is reported that some hospitals have been
privatized. The role for private sector needs to be regularly scrutinized. The government has
established 44 primary trauma care centeres in various places.
5 PROOF Network, Bangalore
Draft as 19/06/2006
Page 7 of 9
There are around 22,000 practicing doctors in the State. With regard to the availability of
doctors, doctor available with the private sectors are three times more than the public sector.
While 4197 doctors are working with the public health care institutions, about 15,000 are with
the private sector this includes qualified practitioners from others systems of medicine.
Regarding bed strength the government institutions have 43,479, about 2000 health care
institutions with the private sector have al most the same number of beds.67
With regards to accessing these services user fee has been introduced in many government run
health care institutions. Studies carried out elsewhere shows that user fees are barrier for many
poor people to access the services. The experience of JAA-K revealed the same while
implementing the right to health care campaign. Urban areas are witnessing arrival ofmore poor
people from the rural areas. Obtaining the BPL card is found to be a difficult process for these
people, more over the way the BPL cards were issues also raises concern among the poor, as it
was distributed randomly rather rationally according to the poverty status. While 50 000 rupees
is available for accessing specialized care from the chief ministers relieffun, the procedure for
availing and information is pivotal. The government has been sectioning about one lakh to every
district hospital a year as an additional budget for purchasing drugs that are not available with
the government. Information on the way this amount is used needs to be disclosed to the people. .
It is reported that the government has handed over the super specialty hospital in Raicher built
under the OPEC grant for the poor has been handed over to Apollo Hospitals due to shortage of
specialist and funds. The government pays 3-4 cores every year for the maintenance.
Information on services offered, utilization pattern, number of poor people use these services
needs to be disclosed.
Volume 21 - Issue 18, Aug. 28 - Sep. 10, 2004, Frontline
http://indiaclen.org/Annex%20F_FINAL.pdf
Conclusion
Increasing infrastructure development for providing curative care will not provide a long-term
solution for the problem of the urban poor. Firstly factors inflicting poverty needs to be addressed
on priority basis. Secondly there is a need for immediate attention from the government to
address the land issue by notifying the slums. This will help a few government bodies would
come forward to provide the basic amenities thereby paving the way for promoting preventive
and promotive health care. Thirdly the problem of alcohol has to be addressed as highest priority.
Certainly there is a need for collaborative efforts by Government, voluntary organization and
people for improving and strengthening the existing services and to identify areas needing
intervention.
The present health care ffacilities available for urban poor which is family welfare and family
planning focused should -----move------towards
(
'
--aa comprehensive
primary health care, enabling people to
take care of their own health not merely providing; some services. It is hoped that this dialogue
would help focus the discussion achieving this.
6 Volume 21 - Issue 18, Aug. 28 - Sep. 10, 2004, Frontline
Draft as 19/06/2006
Page 8 of 9
Bangalore plans preventive health for urban poor
Vijaya K - Bangalore Issue Dtd. 16th to 28th February 2003
The Bangalore Mahanagara Palike (Bangalore City Corporation) in association with the Commonwealth Association
for Mental Handicap and Development Disabilities (CAMHADD) and Sri Jayadeva Institute of Cardiology has
embarked upon a project to provide healthcare for urban poor. A pilot project will be initially conducted for a year in
Yeshwantpur, downtown Bangalore.
‘A tn-sector dialogue for a healthy community was held to identify key areas for intervention in order to develop a city
plan for preventive health with special focus on the urban poor, which constitute 30 per cent of about 65.23 lakh
population in the Bangalore city,” informed Dr Jayachandra Rao, Chief Health Officer, BCC.
With the involvement of two private hospitals R V Dental College and M S Ramaiah Medical College the project will
initially cover 6 wards i.e. around 3 lakhs population. The pilot project is expected to flag off next month will be
extended to other parts of the city later making use of the existing infrastructure.
The decision for the pilot project was taken after holding a series of workshops with stakeholders, workshops with key
health professionals like health administrators, medical officers, health inspectors, lady health visitors and also
auxiliary nurse midwives” said Dr Jayachandra while speaking to Express Healthcare Management.
The BCC runs 68 urban family welfare centres or health centres, 6 referral hospitals and 24 maternity homes. “This is
one of our efforts to get ourselves attached to major health institutions both government and private to provide better
healthcare to urban poor. BCC just completed a five year India Population Project VIII which was initiated in the year
1994 with the financial aid of World Bank to the tune of about Rs 390 million. The project with support from NGOs
aimed at urban slums of Bangalore metropolitan area focussed on mother and child care.
It had also undertaken the task of constructing new health centres, renovation of existing maternity homes and health
centres. Accidents and trauma care, cardiovascular diseases, coronary artery disease, hypertension, rheumatic heart
diseases, HIV/Aids and primary health care are some of the issues that BCC has been working on in addition to
providing public health services like biomedical waste management, control of communicable diseases, overall
management of mother and child healthcare, control of rabies, malaria and dengue.
.http://www.expresshealthcaremgmt.com/20030228/hospi 1 .shtml
HEALTH CARE IN KARNATAKA
Frontline, Volume 21 - Issue 18, Aug. 28 - Sep. 10, 2004
The State's Health and Family Welfare Services has 8,143 sub-centres (that is, one for 5,000 people), 581 Primary
Health Units (PHUs), 1,679 Primary Health Centres (PHCs), 19 mobile units, 7,304 maternity annexes, 17 urban PHCs
and 110 Community Health Centres. While the doctor-population ratio is 1:10,260, the bed to population ratio is
1:1,220. In a novel scheme to improve services, the government has allowed 14 PHCs to be managed by medical
colleges and trusts. At these PHCs, 75 per cent of the staff salary is paid by the government and 25 per cent by the
private entrepreneur.
There are 87 Urban Family Welfare Centres, 124 Urban Health Centres and 24 district-level and 149 taluk-level
hospitals. There are 51 other hospitals, including super-speciality hospitals, which treat illnesses like cancer, heart
ailments and tuberculosis. As part of the World Bank-funded Karnataka Health Systems Project, the State government
has over the past seven years strengthened and upgraded at a cost of Rs.624 crores the infrastructure in 204 of its taluk
and district hospitals. As a consequence, six government hospitals have won ISO-9002 certification. Under the project,
user charges are levied in taluk and district hospitals, non-clinical services in some hospitals have been privatised and
44 primary trauma care centres established to provide emergency services to accident victims.
http://www.hinduonnet.com/fline/fl2118/stories/20040910002909100.htm
Draft as 19/06/2006
Page 9 of 9
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Composition:
• Medical Officer - selected because he/she
has knowledge of community and major
health and non-health initiatives.
• Is a BMP employee and has influence over
the area around health centre.
• Can provide leadership to the HULC.
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BMP - HULC
• Local NGO representative who is
familiar with the area and the exposed
populations.
• Post-Graduate student (preferably from
Social Work or the social sciences)
who is able and willing to do action
research. (Maybe as part of thesis
work).
BMP-HULC
• Suchimithras - (stakeholders). Selected
because they are familiar with BMP
and work voluntarily in the
community.
• They have influence within the
community.
Other HULCS
• BMP will manage 2 HULCS.
• Others will be managed byNIMHANS, M.S.Ramaiah Medical
College.
• Community Health Centre, VOICES.
• St.John’s Hospital or Freedom
Foundation
2
HULC Mandate
• Following intensive training (5 days
between 22nd & 31st January).
• HULCS will develop an action research
proposal according to the seven themes
selected by BMP.
• The research will be based on social
determinants of health and needs of exposed
populations.
Action research
• Proposals will be sent by BHUP office to
WHO & WKC for review.
• HULCS will be given a small grant to carry
out action research.
• These will NOT be interventions but
recommendations for policy formulation
and ideas for better governance.
Practice to policy
• Action research will find evidence to
support practice and identify policy
development pathways
• Research will inform existing draft health
policy.
• HULCS will report to Central Nodal Team
& Implementation team via the BHUP.
3
Practice to policy
• This reporting will be done through a series
of short reports which will be presented to
the two committees for inclusion in the
policy.
• The Central Nodal team will meet quarterly.
• The Implementation Team will meet
monthly.
HULC - OUTCOMES
• Identification of key social determinants
within the 7 areas identified by BMPBHUP.
• Use action research methodologies to
identify what can be changed.
• Areas where policy decisions are needed.
• Report and document these for inclusion in
the policy framework.
BHUP Responsibilities
• Coordinate HULC training with SHine.
• Monitor progress of action research.
• Hold monthly review meetings with
HULCs.
• Convene meetings of the Central Nodal
Team and implementation team.
• Facilitate reporting by HULCS
4
HULC Responsibility
• All 4 HULC team members will have to
undergo 9 days training (3+3+3) over a 9month period, starting end-January 2007.
• They will collaboratively develop an action
research proposal.
• Conduct research and report periodically to
Central Nodal Team & Implementation
Team.
KNUS
• Create local knowledge networks
(where appropriate).
• Generate documentation that will feed
into the Local Steering Committee.
• And via the Local Steering Committee
to WKC and KNUS.
5
BMP operational aspects for BHUP
1. BMP has constituted a CENTRAL NODAL TEAM with personnel at the highest
level in various sectors
CENTRAL NODAL TEAM
Chairperson
Member-Secretary
>
Commissioner/
Spl. Commissioner
>
Dy. Commissioner (Health)
Hr
u
Convenor
Chief Health Officer
Project
Coordinator
Dr. Venkatesh
Members:
1. Dr. Gururaj, Professor of Epidemiology, NIMHANS
2. Chief Engineer, Bangalore Metropolitan Transport Corporation (BMTC)
3. Chief Engineer, Bangalore Water & Sanitation Board (BWSSB)
4. Chief Engineer, Slum Clearance Board.
5. Dy. Social Welfare Officer, Social Welfare Board
6. Dy. Commissioner, Social Welfare, BMP
7. Education Officer, BMP
8. Public Relations Officer, BMP
9. Mr. P.R. Ramesh, ProLead Team
10. Dr. Shivananda, Director, Institute of Child Health
11. Mr. Sheshadri, Director, SHine.
12. Dr. Davison Munodawafa, WHO/SEARO
13. Dr. Cherian Varghese, WHO-WR
14. WKC-representative
15. Ms. Vijayluxmi Bose
2. IMPLEMNETATION TEAM FOR BHUP
Chairperson
>
Dy. Commissioner, Health
Convenor
>
Chief Health Officer
Project
Coordinator
>
Dr. Venkatesh
Core team members
1. Dr. Vijayalakshmi, CHO, BMP
2. Dr. P.S.Thandavamurthy
3. Ms. Kameshwari
4. Ms. Vijayluxmi Bose
5. Mr. P.R.Ramesh
6. Dr. Shivananda, ICH
7. Representatives from HULCS (7)
Field team members:
1. Health Officers, Public Health (E,W,S)
2. Health Officers, Clinical (W, S, E)
3. Superintendents of Referral Hospitals - 6
4. ProLead Team members - Dr. Sriniwas, Dr. Harikiran
Training needs and suggested formats for training
NOTES FROM A VISIT TO SHANTINAGAR MATERNITY HOME (SMH)
AND NEARBY SLUMS BY S. J. CHANDER AND NAVEEN - 19 DEC 2006
> Visited Shantinagar Maternity Home (SMH). Met the Medical Officer, Dr. Sandhya.
Explained about purpose of visit, and gave brief introduction to CHC and its activities.
> Dr. Sandhya is a medical graduate from Bangalore Medical College (BMC), originally from
Kolar. She was earlier working on contract basis and now has been regularized. She has a
private practice (one hour per day, Rs.50 consultation) in Hebbal where she stays. She started
the practice 16 years ago. Her husband is also in Government service. She v/as trained by Dr.
C.M. Francis on health administration during the IPP-VIII trainings.
> In SMH, she is in charge of Preventive Cardiology programme for pourctkarmikas of
Bengaluru Mahanagara Palike (BMP), which was started in association with Commonwealth
Association for Mental Handicap and Developmental Disabilities (CAMHADD), United
Kingdom. Now, she is also in charge of the Bengaluru Healthy Urbanisation Project (BHUP)
in SMH. On 20th Dec, another programme on school health is being started in the centre,
where dental and ENT check-up will be done for children from BMP schools.
> She said that they have already completed collecting information from nearby slums in
preparation for the BHUP. The slums were chosen for BHUP on the basis of this information
> The slums they covered were Vinayakanagar, Sathyavelunagar, Jalakanteshwara Pura (J.K.
Pura) and a settlement of migrant workers from Gulbarga (about 150 households). The first
three are in a cluster.
> Later, over coffee, discussed about corruption in the maternity home, the corruption faced by
doctors from clerical staff (second division clerks) in BMP, the unwillingness/ inability of the
higher-ups to take notice, the attitude of MH staff when hauled up for corruption, etc. Also
discussed about supply of drugs, attitude of patient’s to drugs and treatment, their perceptions
about drugs given from the health centres, etc.
> She said that organisations/ groups working in the slum include Shanta Jeeva Jyothi, REDS
and MICO. A senior citizens’ home is also run in the area, with support and collaboration of
BMP.
> Visited the J.K. Pura slum, where Shanta Jeeva Jyothi (SJJ) is located (in a BMP building).
Met Rajesh, who gave information about the area. SJJ works on leprosy and disability issues.
A photo of Dr. Benjamin treating people afflicted with leprosy was put up on their walls.
> Information given by Rajesh, SJJ: The whole of Vinayakanagar has over 3000 houses, of
which small pockets are slum-like. J.K.Pura has 348 houses (BMP has numbered the houses
and 348 numbers have been allotted). Satyavelunagar is a slum which is located on a private
land and is under dispute. It has about 180 households. BMP does not provide any facilities
there.
> These areas are flanked by the cemetery on one side and Bengaluru Metropolitan Transport
Corporation (B.M.T.C.), Shantinagar offices and yards on the other.
> J.K.Pura is an over-crowded mixed dwelling area with somepucca houses (some newly built
multi-floored buildings) and mostly small houses, with no ventilation, narrow roads and poor
sanitation.
> Satyavelunagar is a very congested area with sewer flowing and stray animals and children
all around. Sanitation facilities is almost non-existent. Some shelters (looking like toilets) are
not being used. They are in constant fear of eviction. Women’s Voice and Kolageri
Nivasigala Samyukta Sanghatane (KKNS) work there. We spoke to an old lady, who told us,
“Two people came some time back and told us that they had evicted people from the
Poornima Theatre slum and demolished the houses. So, evicting the Sathyavelunagar people
would be no big deal. But as long as KKNS is there, nobody can touch us Ruth Manorama
is slated to visit the slum and have a meeting next month. Posters of Women’s Voice with
Ruth’s photo were pasted all around the area.
D:\Naveen\Urban health\BHUP\Field Visit SMH 19 Dec 06.doc
- 1 -
General Observations
>
>
>
>
>
SMH and the slums are in a radius of about 7-8 kms from CHC. The medical officer incharge Dr. Sandhya, seemed very co-operative and interested in working together.
Though adjacent to each other, the slums are spread across a large area. Also the nature
of people and communities varies from street to street and cluster to cluster.
Though organisations have worked there and provided lot of services, community
mobilisation around health is still a long way away. KKNS and Women’s Voice seems to
be the main groups who have done community mobilisation, but that also seems to be
around evictions only (THESE NEED TO BE VERIFIED).
Community mobilisation for an action research would require constant full-time work in
the area, building rapport, identifying groups, understanding the group dynamics in the
area and anchoring the mobilisation efforts around a tangible service/ work.
Forming an alliance with other organisations/ groups working in the area, may be useful
to draw on their experience, familiarity with the area, and understanding of communities.
In addition, groups like SJJ already have a base in the slum itself. The alliance could help
in continuation of the efforts even after the project is completed.
- Report by Naveen Thomas
Some thoughts for BHUP meeting on 21st Dec 2006 (discussion with SJC)
>
>
>
>
>
>
>
>
>
>
Need to clarify about partner’s (our) role
Budget (under what heads)
Research plan, design and methodology
Role of the learning circle and mode of functioning
BMP draft health policy?
What after pilot project?
Time-line or calendar of events
Involving other organizations
Involve groups experienced in addressing housing, land rights, water/sanitation, etc.
Training? Research/ Working with urban poor/ etc.
D:\Naveen\Urban health\BHUP\Field Visit SMH 19 Dec 06.doc
-2-
Notes on meeting on the Bangalore Healthy Urbanisation Project (BHUP) held at
Pobbathy Health Centre, V.V.Puram, Bangalore
X
(T
"XL
'.X
V1"
it
♦ The meeting was called for by the Local Co-ordinators Dr. P.S.Thandava Murthy (PST)
and Ms. Kameshwari.
♦ The agenda was welcome remarks by CHO, BMP (who did not turn up until the end of
the meeting) and detailed discussion on the BHUP by PST (who retd. From BMP last
year after 30 years of service).
♦ The meeting slated to start at 2,00 p.m., started at 3.00.
♦ PST said that the aim of the project was to study the impact of urbanization in Bangalore.
♦ It was NOT a curative health project, NOT a BMP project, but a 1 year (of which 3
months has already passed) WHO/ WTCC research-oriented project on the social
determinants of health.
♦ Process so far
o Scoping paper done by Dr. Gururaj, NIMHANS. (got a set photocopied for us)
o Baseline data for 14 slums done (some places, still ongoing) by BMP. (will get
data when we require)
Q
Health Pr omotion Policy of BMP (have asked Dr. Vijayalaksmi, CHO, BMP who
promised to email it to me).
Training modules sent by WKC (Its being adapted by SHINE to meet our
O
standards. We can get a copy.)
♦ The next two trainings by SHINE (I and II Module) will be basically about the survey what to do. how to do, etc. The dates for the trainings are Jan 17 49,2007 and Jan 29 30,2007.
♦ The aim of the survey is to identify what social determinants exist in that particular
selected slum and to see if any policy’ exists to address it If it does, then to bring it before
the implementation committee; if not, to suggest policy measures to address it.
♦ Hie partners would meet every month and submit a report of the work and grogress,
which would be compiled and reported to WHO/ WKC by the Local Coordinators.
♦ Hie Implementation Committee wliich is composed of heads of various departments (like
water and sanitation, health, traffic, etc.) will meet once a month, and take up
implementation of policies (if it exists) to address the identified social determinants.
♦ The Central Nodal Committee, which comprises of decision makers and others, will meet
quarterly to oversee issues of implementation and to take up issues where new policies
need to be formulated.
♦
There is no funding directly available for organisations, but only for conducting
programmes, meetings, etc.
Points raised by NT at the meeting
♦ NT: If it is not a BMP project (this is factually wrong, because the brochure clearly says
a partnerddp project of BMP, with WKC Japan, WHO (SEARO and India)), then
what is BMP’s role?
PST: after a lot of denial, he finally said that BMP was the ’nodal agency’.
♦ NT: What is binding on other departments to implement what the BHUP suggests?
(need to clarify and get copies) that they
PST: They have signed an MoU with
would implement the suggestions.
♦ NT: Clarify partners (NGO) role. Arc we doing research (leg work) for a project/
research being done by WI0/WKC» since BMP has washed its hands off, saying that it
is not responsible for the project?
D:\Nsvcm\Urban heafth\BHTJF\BHUPMeding_21 Dec 06.doc
1
*
♦
♦
♦
♦
PST: The partners are not just doing the leg work. They are also representing the case to
flie implementation committee and central nodal committee. As junior officers, the BMP
staff or the project staff cannot question the senior officers, but the partner NGOs can do
that. And in the Implementation Committee and the Central Nodal Committee, the case
would not be presented by the Local co-ordinators but by the various Health Urbanisation
Learning Circles (HULCs) at the community level.
NT: what is the volume of data to be collected? Does it have to be collected door=to=door
in the selected slums. Is there any money’ to pay surveyors? (also raised by Shanmuga
Sundaram of Shanta Jeeva Jyotlri (SJJ)).
PST: The questionnaire could be quite long, since it covers the social determinants. All
households in the selected slums will have to be interviewed. But partners can choose the
slums to be taken up. There is no money to pay as honorariums or salaries.
NT: Can we involve other organisations who work in the area?
PST: The HULC is supposed to consist of 4 members. The doctor of the health centre,
NGO, PG student and suchimitra or local volunteer or anybody which the team leader
(TL) finds suitable. In areas where NGOs take the lead, the NGO would be the TL. The
TL could choose to substitute tlie place of PG student and sucliimitr a or local volunteer
with anybody7 else they choose to, including other organisations. So, in regard to working
with SJJ in Shantinagar, we could choose to have SJJ as one of the 4 members in addition
to Dr. Sandhya, the health centre doctor and CHC.
NT: Can the modules be changed/ adapted to the local situation? (In a related question,
somebody else asked, if there was a process of standardization of research protocols)
PST: SHINE has been given all the WHO/ WKC modules and asked to develop adapted
and standardized protocols. They will do it and
NT: Any research has ethical dimensions. So, if we collect information from a
community, what would be our responsibility/ accountability to them, if the project ends
after one-yeas? Similarly, social determinants by its very nature takes longer than one
year to change. So, what would be our role at the end of one year.
PST: Though the project is only for one year. WHO/ WKC has said that they would
continue the process for the next five year at least.
NT: What would be the nature of partnership between the NGOs and the project? Unless
there is respect for the partners, it would not be possible to wok together. Respect
translates into consulting us in the different processes and while fixing meetings, sending
early invitations with agenda, sharing information and so on,
PST: This won't be like working with BMP. We will be very open with everybody. We
are also a NGO like you all.
General impressions about the meeting
♦ The meeting was held to solicit NGO partnerships, because other than CHC, nobody had
''committed”, according to PST. The other NGOs were wary, because the project wanted
to outsource the most critical (and time-consuming) component of the project to NGOs
at absolutely no costs to them. [QUESTION: While providing an opportunity (and rather
insisting that NGOs be a part of the project) this totally takes them for granted and seeks
to get them to do the work, or “extract work from them’7 as PST put it in some other
context. Do we want to be a part of it in this form, or do we want to negotiate a different
deal, probably with some communication to WKC too,]
♦ PST was at pains to emphasis that it was NOT a BMP project. [QUESTION: If it is not a
BMP project (as they arc trying to project), do we want to get involved until they clarify
this and project the true picture?]
D;\Naveen\Urbsn health\BHOT\BHUP Mrrf.ing_21 Dec Ofcdoc
2
♦ The WHO/ VTCC Modules are being adapted by SHINE, and they are being appointed as
consultants to do this, as well as the trainings. PST and Kameshwari said that Hthe
modules were very difficult and we could not understand it. So, SHINE was working on
it, so that it could be understood." I explained that many in the group had done
researches using different international protocols. Also, some of us were involved in
training on health. So, there was no need to undermine the intelligence of the group.
PST, immediately said that he knew that and he didn’t mean it that way. [QUESTION:
Do we want to get involved in this process of adapting the modules. If so, how much? I
have taken Dr. Shcshadri’s numbers. We can do this by asking for a consultation.]
♦ I have called Shanmuga Sundaram of SJJ for a meeting. We could also meet the others
working in the slums around Shantinagar Maternity Home (SMH) for a consultation.
Suggestions (we need to discuss this as a team):
♦ Wc write a letter agreeing to take up the project subject to certain clarifications and
conditions
o BMP’s role is clarified.
0 We get copies of the various MoUs.
We sign agreement with BMP.
Q
o Some basic costs are covered.
0 As partners, we have access to all information and data.
o We are consulted while fixing meeting dates and get prior information (and
invitations, with agenda) for all meetings, including those of the Implementation
Committee and die Central Nodal Committee.
Important Phone Numbers / Emails
Dr. M. Vijayalakshmi, CHO, BMP: 9844051125, drvijijngyahooxom
Dr. P.S. Tliandava Murthy: 9886740954
Dr. Sandhya. Shantinagar Maternity Home: 9845244350
BHUP office: 41692754
Kameshwari, BHUP: 9449157590,
Shanta Jecva Jyothi (Shanmuga Sundaram/ Rajcsh): 22234093, 9449130499,
su@sanchametin
> SHINE (Sheshadri): 9845036123
>
>
>
>
>
>
- Report prepared by Naveen Thomas
D:\Naveen\Urban health\BHUP\BHITP Meeting_21 Dec 06.doc
3
Notes on meeting on the Bangalore Healthy Urbanisation Project (BHUP) held at
Pobbathy Health Centre, V.V.Puram, Bangalore
The meeting was called for by the Local Co-ordinators Dr. P.S.Thandava Murthy (PST)
and Ms. Kameshwari.
♦ The agenda was welcome remarks by CHO, BMP (who did not turn up until the end of
the meeting) and detailed discussion on the BHUP by PST (who retd. From BMP last
year after 30 years of service).
♦ The meeting slated to start at 2.00 p.m., started at 3.00.
♦ PST said that the aim of the project was to study the i /npact of urbanization in Bangalore. '
♦ It was NOT a curative health project, NOT a BMP project, but a 1 year (of which 3
months has already passed) WHO/ WKC research-oriented project on the social
determinants of health.
♦ Process so far:
o Scoping paper done by Dr. Gururaj, NIMH ANS. (got a set photocopied for us)
o Baseline data for 14 slums done (some places, still ongoing) by BMP. (will get
data when we require)
o Health Promotion Policy of BMP (have asked Dr. Vijayalaksmi, CHO, BMP who
promised to email it to me).
o Training modules sent by WKC (Its being adapted by SHINE to meet our
standards. We can get a copy.)
----- ♦ 1 he next two trainings by SHINE (I and II Module) will be basically about the survey —
what to do, how to do, etc. The dates for the trainings are Jan 17 -19, 2007 and Jan 29 30, 2007.
♦ The aim of the survey is to identify what social determ:nants exist in that particular
selected slum and to see if any policy exists to address it. If it does, then to bring it before
thejuiTplementation committee; if not, to suggest policy measures to address it.
♦ The partners would meet every month and submit a report of the work and progress,
which would be compiled and reported to WHO/ WKC by the Local Co-ordinators.
♦ The Implementation Committee which is composed of heads of various departments (like
water and sanitation, health, traffic, etc.) will meet once a month, and take up
implementation of policies (if it exists) to address the identified social determinants.
<-1Central Nodal^oniDlittee, which comprises of decision makers and others, will meet
quarterly to oversee issues of implementation and to take up issues where new policies
need to be formulated.
♦ There is no funding directly available for organisations, but only for conducting
programmes, meetings, etc.
♦
Points raised by NT at the meeting
♦
♦
♦
NT: If it is not a BMP project (this is factually wrong, because the brochure clearly says
“a partnership project of BMP, with WKC Japan, WHO (SEARO and India)), then
what is BMP’s role?
PST: after a lot of denial, he finally said that BMP was the ‘nodal agency’.
NT: What is binding on other departments to implement what the BHUP suggests?
PST: They have signed an MoU with
(need to clarify and get copies) that they
would implement the suggestions.
NT: Clarify partners (NGO) role. Are we doing research (leg work) for a project/
research being done by WHO/WKC, since BMP has washed its hands off, saying that it
is not responsible for the project?
D:\Naveen\Urban health\BHUP\BHUP Meeting_21 Dec 06.doc
1
PST: The partners are not just doing the leg work. They are also representing the case to
the implementation committee and central nodal committee. As junior officers, the BMP
staff or the project staff cannot question the senior officers, but the partner NGOs can do
that. And in the Implementation Committee and the Central Nodal Committee, the case
would not be presented by the Local co-ordinators but by the various Health Urbanisation
Learning Circles (HULCs) at the community level.
♦ NT: What is the volume of data to be collected? Does it have to be collected door-to-door
in the selected slums. Is there any money to pay surveyors? (also raised by Shanmuga
Sundaram of Shanta Jeeva Jyothi (SJJ)).
PST: The questionnaire could be quite long, since it cover, the social determinants. All
households in the selected slums will have to be interviewed. But partners can choose the
slums to be taken up. There is no money to pay as honorariums or salaries.
♦ NT: Can we involve other organisations who work in the area?
PST: The HULC is supposed to consist of 4 members. The doctor of the health centre,
NGO, PG student and suchimitra or local volunteer or anybody which the team leader
(TL) finds suitable. In areas where NGOs take the lead, the NGO would be the TL. The
TL could choose to substitute the place of PG student and suchimitra or local volunteer
with anybody else they choose to, including other organisations. So, in regard to working
with SJJ in Shantinagar, we could choose to have SJJ as one of the 4 members in addition
to Dr. Sandhya, the health centre doctor and CHC.
♦ NT: Can the modules be changed/ adapted to the local situation? (In a related question,
somebody else asked, if there was a process of standardization of research protocols)
PST: SHINE has been given all the WHO/ WKC modules and asked to develop adapted
and standardized protocols. They will do it and
♦ NT: Any research has ethical dimensions. So, if we collect information from a
community, what would be our responsibility/ accountability to them, if the project ends
after one-year? Similarly, social determinants by its very nature takes longer than one
year to change. So, what would be our role at the end of one year.
PST: Though the project is only for one year. WHO/ WKC has said that they would
continue the process for the next five year at least.
♦ NT: What would be the nature of partnership between the NGOs and the project? Unless
there is respect for the partners, it would not be possible to wok together. Respect
translates into consulting us in the different processes and while fixing meetings, sending
early invitations with agenda, sharing information and so on.
PST: This won’t be like working with BMP. We will be very onen with everybody. We
are also a NGO like you all.
General impressions about the meeting
♦ The meeting was held to solicit NGO partnerships, because other than CHC, nobody had
“committed”, according to PST. The other NGOs were wary, because the project wanted
to outsource the most critical (and time-consuming) component of the project to NGOs
at absolutely no costs to them. [QUESTION: While providing an opportunity (and rather
insisting that NGOs be a part of the project) this totally takes them for granted and seeks
to get them to do the work, or “extract work from them” as PST put it in some other
context. Do we want to be a part of it in this form, or do we want to negotiate a different
deal, probably with some communication to WKC too.]
♦ PST was at pains to emphasis that it was NOT a BMP project. [QUESTION: If it is not a
BMP project (as they are trying to project), do we want to get involved until they clarify
this and project the true picture?]
D:\Naveen\Urban health\BHUP\BHUP Meeting_21 Dec 06.doc
2
♦
♦
The WHO/ WK.C Modules are being adapted by SHINE, and they are being appointed as
consultants to do this, as well as the trainings. PST and Kameshwari said that “the
modules were very difficult and we could not understand it. So, SHINE was working on
it, so that it could be understood.” I explained that many in the group had done
researches using different international protocols. Also, some of us were involved in
training on health. So, there was no need to undermine the intelligence of the group.
PST, immediately said that he knew that, and he didn’t mem it +hat way. [QUESTION:
Do we want to get involved in this process of adapting the modules. If so, how much? I
have taken Dr. Sheshadri’s numbers. We can do this by asking for a consultation.]
I have called Shanmuga Sundaram of SJJ for a meeting. We could also meet the others
working in the slums around Shantinagar Maternity Home (SMH) for a consultation.
Suggestions (we need to discuss this as a team):
♦
We write a letter agreeing to take up the project subject to certain clarifications and
conditions
o BMP’s role is clarified.
o We get copies of the various MoUs.
o We sign agreement with BMP.
o Some basic costs are covered.
o As partners, we have access to all information and data.
o We are consulted while fixing meeting dates and get prior information (and
invitations, with agenda) for all meetings, including those of the Implementation
Committee and the Central Nodal Committee.
Important Phone Numbers / Emails
>
>
>
>
>
>
>
Dr. M. Vijayalakshmi, CHO, BMP: 9844051125, drviji in@yahoo.com
Dr. P.S. Thandava Murthy: 9886740954
Dr. Sandhya, Shantinagar Maternity Home: 9845244350
BHUP office: 41692754
Kameshwari, BHUP: 9449157590, chintala.devi@gmail.com
Shanta Jeeva Jyothi (Shanmuga Sundaram/ Rajesh): 22234093,
sjj@sancharnet.in
SHINE (Sheshadri): 9845036123
S © iLqJ)
-
9449130499,
- Report prepared by Naveen Thomas
3
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NOTES FROM A VISIT TO SHANTINAGAR MATERNITY HOME (SMH)
AND NEARBY SLUMS BY S. J. GRANDER AND NAVEEN - 19 DEC 2006
>
Visited Shantinagar Maternity Home (SMH). Met the Medical Officer, Dr. Sandhya.
Explained about purpose of visit, and gave brief introduction to CHC and its activities.
> Dr. Sandhya is a medical graduate from Bangalore Medical College (BMC), originally from
Kolar. She was earlier working on contract basis and now has been regularized. She has a
private practice (one hour per day, Rs.50 consultation) in Hebbal wl 're she stays. She started
the practice 16 years ago. Her husband is also in Government service. She was trained by Dr.
C.M. Francis on health administration during the IPP-VIII trainings.
> In SMH, she is in charge of Preventive Cardiology programme for pourakarmikas of
Bengaluru Mahanagara Palike (BMP), which was started in association with Commonwealth
Association for Mental Handicap and Developmental Disabilities (CAMHADD), United
Kingdom. Now, she is also in charge of the Bengaluru Healthy Urbanisation Project (BHUP)
in SMH. On 20'1 Dec, another programme on school health is being started in the centre,
where dental and ENT check-up will be done for children from BMP schools.
> She said that they have already completed collecting information from nearby slums in
preparation for the BHUP. The slums were chosen for BHUP on the basis of this information
> The slums they covered were Vinayakanagar, Sathyavelunagar, Jalakanteshwara Pura (J.K.
Pura) and a settlement of migrant workersjrom Gulbarga (about 150 households). The first
three are in a cluster.
> Later, over coffee, discussed about corruption in the maternity home, the corruption faced by
doctors from clerical staff (second division clerks) in BMP, the unwillingness/ inability of the
higher-ups to take notice, the attitude of MH staff when hauled up for corruption, etc. Also
discussed about supply of drugs, attitude of patient’s to drugs and treatment, their perceptions
about drugs given from the health centres, etc.
> She said that organisations/ groups working in the slum include Shanta Jeeva Jyothi, REDS
and MiCO. A senior citizens’ home is also run in the area, with support and collaboration of
BMP.
> Visited the J.K. Pura slum, where Shanta Jeeva Jyothi (SJJ) is located (in a BMP building).
Met Rajesh, who gave information about the area. SJJ works on leprosy and disability issues.
A photo of Dr. Benjamin treating people afflicted with leprosy was put up on their walls.
Information given by Rajesh, SJJ. The whole of VinayJ.iias over 3000 houses, of
which small pockets are slum-like. J.K.Pura has 34B houses (BMP nas numbered the houses
and 348 numbers have been allotted). Satyavelunagar is a slum which is located on a private
land and is under dispute. It has about 180 households. BMP does not provide any facilities
there.
> These areas are flanked by the cemetery on one side and Bengaluru Metropolitan Transport
Corporation (B.M.T.C.), Shantinagar offices and yards on the other.
> J.K.Pura is an over-crowded mixed dwelling area with somepucca houses (some newly built
multi-floored buildings) and mostly small houses, with no ventilation, narrow roads and poor
sanitation.
> Satyavelunagar is a very congested area with sewer flowing and stray animals and children
all around. Sanitation facilities is almost non-existent. Some shelters (looking like toilets) are
not being used. They are in constant fear of eviction. Women’s Voice and Kolageri
Nivasigala Samyukta Sanghatane (KKNS) work there. We rpoH to ^n old lady, who told us,
“7wo people came some lime back arid told us that they had evicted people from the
Pool nima Theatre slum and demolished the houses. So, evicting the Sathyavelunagar people
would be no big deal. But as long as KKNS is there, nobody can touch us ”. Ruth Manorama
is slated to visit the slum and have a meeting next month. Posters of Women’s Voice with
Ruth’s photo were pasted all around the area.
D:\Naveen\Urban health\BHUP\Field Visit SMHJ9 Dec 06.doc
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General Observations
> SMH and the slums are in a radius of about 7-8 kms from CHC. The medical officer incharge Dr. Sandhya, seemed very co-operative and interested in working together.
> Though adjacent to each other, the slums are spread across a k. ge area. Also the nature
of people and communities varies from street to street and cluster to cluster.
> Though organisations have worked there and provided lot of services, community
mobilisation around health is still a long way away. KKNS and Women’s Voice seems to
be the main groups who have done community mobilisation, but that also seems to be
around evictions only (THESE NEED TO BE VERIFIED).
> Community mobilisation for an action research would require constant full-time work in
the area, building rapport, identifying groups, understanding the group dynamics in the
area and anchoring the mobilisation efforts around a tangible service/ work.
> Forming an alliance with other organisations/ groups working in the area, may be useful
to draw on their experience, familiarity with the area, and understanding of communities.
In addition, groups like SJJ already have a base in the slum itself. The alliance could help
in continuation of the efforts even after the project is completed.
- Report by Naveen Thomas
Some thoughts for BHLP meeting on 21st Dec 2006 (discussion with SJC)
>
>
Need to clarify about partner’s (our) role
Budget (under what heads)
Research plan, design and methodology
Role of the learning circle and mode of functioning
BMP draft health policy?
What after pilot project?
Time-line or calendar of events
Involving other organizations
Involve groups experienced in addressing housing, land rights, water/sanitation, etc.
Training? Research/ Working with urban poor/ etc.
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Bangalore Healthy Urbanization Project
an urban health research site
A partnership project of
BMP, WKC Japan, WHO India and SEARO
Meeting of Medical Officers of Health
Dear Sir,
You are cordially invited for the detailed discussion of
Bangalore Healthy Urbanization Project on 21.12.2006.
Time : 2.00pm.
Date : Thursday, 21st December 2006.
Venue : Pobbathi Maternity Home, 1st floor,
Sajjan Rao Circle.
Year’s sincerely,
D r. P.S.Th a n da va m u rthy,
Local Coordinators.
To,
Mr.S.J.Chander
Community Health Cell
#359, Srinivasa Niiaya
Jakkasandra
1st Main, 1st Block
Koramangala
Bangalore-34
Mo-9448034152
Ph-25531518
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Notes of BHUP Meeting on January 16th, 2007 at 3.00 p.m., Dassappa Maternity Home
1) Agenda: Further clarification about the project with Jostacio Memo Lapitan of the
Urbanisation and Emergency Preparedness Programme, WHO Centre for Health
Development (WFIO Kobe Centre).
2) 2) The meeting started one hour late at 4.00 p.m. as Dr. Lapitan (a Filipino, working with
WKC) had just arrived. Dr. Thandava Murthy (TM) introduced the project, by again saying
that it was not a BMP project and repeated the same details as in the earlier meetings. After
the introduction, the floor was thrown open for questions.
3) We raised the following issues:
a. If it is not a BMP project, why is there so much BMP involvement? Also the
brochure says that it is a “partnership project of BMP with WKC, Japan WHO
(SEARO & India). TM accepted that it was a BMP project.
b. Methodology used for selection of seven areas for the project. TM replied that the
BMP Commissioner chose one area from different directions.
c. The logic behind composition of HULC members (NGO, BMP Dr., Suchimitra and
PG student). Dr. Lapitan said that it was based on previous projects’ experience in
developing countries.
d. The ethicality of burdening link workers and other community workers (who
themselves are from “low-resource settings”) to do additional work without
compensation. (Earlier a BMP doctor had confided in us that link workers had not
been paid their honorariums from last August). Dr. Lapitan said that BMP informed
them that voluntary agencies were already working in the area and would provide
voluntary service for the project. But regarding payment to field workers, he said
that it could be reconsidered. USD 1500 was kept aside for each HULC and some
of that money could be used for it.
e. HULC members have been requesting for communication stating the nature of
partnership, scope of work and the terms of joining the project. Dr. Lapitan asked
the BHUP coordinators to make a note of the points and send a letter to the HULC
partners.
f. What are the policy components of the “research and action project”?
g. The selection method and competence of SHINE to do the training on this issue.
4) TM suggested that we along with Dr. Anuradha of Samata Project, IIM, Dr. Nadakumar of
Ramiah Meedical College and others draft a letter stating the scope of project, nature of
partnership, etc. after the meeting concluded. We met a small group after the meeting, and
gave them points on what should be included in the letter. The BHUP team were given a
copy of the suggested points, which included details of project, budget, expected outcomes,
responsibilities, inputs required (human resources, time, materials) and so on.
5) After the meeting, we met with Dr. Lapitan, introduced ourselves and discussed with him
about the project. We also met Dr. TM and thanked him for the open dialogue. He told us
that he was very happy that we had raised the issues. Fie also said that he was expecting
that we would raise questions on why only USD 1500 was kept for each HULC. Many
BMP doctors while leaving the hall came and thanked us for raising these issues and said
“somebody needs to raise these issues, as they are always ignored”.
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Notes of BHUP Training on January 22, 2007 at 9.30 a.m.
Urban Health Training Centre
1) The first module training sessions; were scheduled to be held from 23-2511’ Jan. It was later
rescheduled to 22-23rd,’ and 25th Jan. SJC called up one of the local co-ordinators,
Kameshwari on the previous evening (21st) to confirm whether the meeting was still
happening on the same dates, she said that there had been some change and that we had to
speak to Dr. Thandava Murthy, the senior local coordinator to discuss it. She refused to
give further information. Dr. Thandava Murthy did not answer his phone in spite of both
NT and SJC calling repeatedly. SJC later spoke to Dr. Vijayalakshmi, the Chief Health
Officer of BMP who also did not give any information. He later called up Ms.
Vijayalaksmi Bose, the WHO consultant for the project, who said that BHUP had sent our
letter to WHO for clearance, since we had raised many questions.
2) SJC and NT went to Urban Health Training Centre on January 22, 2007. They met Dr.
Thandava Murthy who said that we could not participate in the programme as our name
was not cleared by WHO, and that our communication to them had been forwarded to
WHO, since we had raised many questions.
3) NT spoke to Dr. Lapitan and told him that our names were not among the list of
participants, and that we were being kept out for raising questions. NT asked him whether
they were informed of it, and if so, whether as a WKC representative, he would appiove of
groups being kept out for raising queries in a research project. He just said that SHINE had
sent the list of participants and that they were not involved in it.
4) Later SJC and NT met Ms. Vijayalaksmi Bose, who said that we had been very
confrontational in our approach. She said that she knew Dr. Thelma who was not
confrontational at all, and she did not know whether the rest of CHC was “rabid”. (She
later said that she withdrew her comment about CHC being rabid, but she stood by the fact
that we were confrontational). She said that she had observed us at other meetings and
found that we raised these issues too frequently, in a manner which would make BMP wary
of us. (Note: The only meetings where she was present were the BHUP launch meeting on
December 4, 2006 and January 6, 2007, in which SJC participated. But he did not even
speak once at the first meeting as there was no opportunity for dialogue. In the other
meeting, all the participants raised several queries about the project, including SJC. The
only other meeting she was present was during the introductory meeting on 7 Dec in
which TN and SJC participated. So, there is no basis for her observation).
5) We told her that we had only raised questions about the methodology and implementation
of the project, as it was a research project. And there was no other opportunity where we
could be confrontational. She said that she could not comment on this issue, since she was
not there, nor had we sent a copy of the letter to her.
6) We raised the point that the least “professionalism’' that could have been showni was to
have informed us that we were not to attend the training, after giving us a letter inviting us
for the same. She said that she was sorry regarding that.
7) The participants at the meeting including a doctor of BMP, Mr. Sundaram of SJJ and Dr.
Anuradha said that they were very upset with us being kept out. Sundaram and Anuradha
said that they would raise it in the meeting.
(Prepared by Naveen and Chander, 22 Jan, 2007)
Th
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The third i'ny-trng of the Bngalore Healthy urbanization was held on January 61(I)
Saturday, at Pobathi ------health1 center horn 12 to 2.30 pm. The following partners were
present for the meeting.
Dr. Nandakumar
Dr. A nu rad ha
Dr. Sunitha Krishna
Ms. Radhamani
Mr. Rajeev
Mr. Ganesan
Ms. A mud ha
Mr. S.J.€ hander
Ms. Vijayalakshi Bise
Dr. 1 handavamurthy
Ms. Kameshwari
Dr. Venkatcsh
M S Ramiah Medical College
Samatha I IM Bangalore
Samatha IIM Bangalore
MICO Bosch
Shantha Jeevajyothi
SPAD
Community Health Cell
WHO India Country office
coordinator BI IUP
coordinator BI IUP
Nodal officer BMP
Though I informed Ms. U
Kameshwari to send the agenda of the meeting, she did not.
When all the partners met at Pobathi Health Center
------- on 5J 1 Ms. Vijayalakshmi Bose said
the agenda of the meeting was to get
j
to know more about the partner organization and the
puison icpreseniing each of the partner organization.
Ms. Vijayalkshi hose said this is her first project with the Indian agency; she has health
piomotion, communication and advocacy background.
Ms. Radahmani is a professional social worker of MICO BOSCH. Dr. Nadakumar is an
assistant professor from the Community Medicine Department of M S Ramiah medical
College. He has been working with the pulse polio programme of BMP.
Dr. AnHradhu is a Gynecologist earlier worked with Samaraksha has joined Samatha of
IM since last one year. Dr.Suneeta is also from Samath IIM. They focus on sender and
health with specific focus on reproductive and child health.
Ms. \ ijayalkshi hose said the BHUP project aims al carrying out an action research for
producing evidences on social determinants of health. The evidence would be used for
policy formulation by Banaglroe Mahanagara Palike (BMP). Regarding producing
evidence, she said she doesn't need any complaints but evidences. She said BMP has
!° socialidelerniinants and il would be ltseful if each HULC takes two social
determinants (o work on as l'nie W‘H
constrain and the project will be over in a year.
Role of NGOs
NGO representatives are one of the four partners of the HULC. When asked about the
loieol NGOs she said. NGOs will just guide the research team. She said MSW student
would play the role of field investigators. About
thee research design and methodologies
-----the Bl IUP team were not sure. ""
1 hey said each H( I.C could independently carry out
based on their interest and skills. She said ----after• the module I training which will happen
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from 23-23 January 2007 the HULC partners will put a proposal to WHO fora small seed
money SHINE will the conducting the training and will impart skills related to
leadership, interpersonal communication and motivation.
Regarding MOU, Dr. fhandavamurthy has circulated a letter to ah the partners thanking
them for agreeing to work with BHUP. The letter also communicated the dates of
managers meeting which will take place on I 71" January. 2007 and the welcome reception
un
•,£'I1uary-20(>7 m which the director in charge of the healthy urbanization project of
WHO will participate.
Partners comment
Repiesentative of Ms. Ramiah Mediccal College. Sammath. 1IM and CHC met after the
meeting and discussed. A common consensus was (hat since no formal letter to
collaborate with BHUP was sent, not to agree to collaborate unless a letter is sent A
reply would be sent to the letter circulated by Dr. Thandavamurthy that we would agree
to paiticipate in the meetings mentioned. All the three agencies found out The BHUP
team neither has clarity not has skill to carry out the action research, therefore we should
not allow BHUP to just use us but to work out with BHUP the MOU if we offer our skills
in designing the action research.
r' /
177
1991 / January
for
cities
Editorial
"Yet another newsletter?" you might
ask. Yes. Yet another one. But a useful
newsletter.
The WHO Healthy Cities Project has
become a global movement. According
to our most recent counts, over 400
cities worldwide are involved in
innovation of the public health realm
into a 'new public health'. All of these
cities have one or more links to
academic institutions, or undertake
research endeavours themselves.
At a series of Healthy Cities conferences
it has become clear that traditional
research methods are not fully
applicable to new public health
questions any more.
The academic resources for research for
healthy cities are little efficient; in a
scholarly world that has been dominated
by high specialization and
professionalism it turns out that
academics who'd want to transcend the
boundaries of their discipline are limited
in choice of fora and platforms to
exchange interdisciplinary experiences.
This newsletter is therefore timely. It
gives new local public health researchers
an opportunity to exchange ideas and
experiences without having to go
through the treadmiilof academic
journal assessment and referee
procedures. Especially young
researchers, at the outset of a possibly
promising interdisciplinary career, often
find these procedures tiring and
frustrating, even to the extent that they
eventually retreat to the comforts of
monodisciplinary work.
You receive this Newsletter because over
the past couple of years you participated
in a Healthy Cities meeting. Therefore,
you know what the problems are which
the movement is facing. Thus, we don’t
have to argue that this publication is
suited to your needs. We invite you to
make this Research for Healthy Cities
Newsletter a success; you are free to
submit material for each of the sections
in this publication:
* Research notes - short descriptions
of recent projects, methodology and
outcomes. You may want to invite
colleagues from around the world to
comment or request your
publications (this Newsletter is mailed
to 500 researchers from at least 20
different disciplines in over 50
countries);
* Research plans - short descriptions of
intended projects, research policies,
>
methodological problems, or
requests for information on specific
topics;
* Meetings;
* Miscellaneous.
Another point - subscription to this
Newsletter is free of charge. The first
volume (4 issues in 1991) is already
financed/and more monies are
becoming available for following years.
However, ninety percent of .the people
on our present mailing list are from the
Westem/North-European hemisphere.
We would appreciate it very much if you
would be able to fill
the
,
'Subscriptions free!' box on the last
page with names and addresses of.
colleagues possibly interested in tW? • ,||| |
k
4
re^ ea hX
publication - especially from other
regions. You may even want to xerox
the last page, and distribute it to
colleagues at meetings or through mail.
Publications
Evelyne de Leeuw MA MPH PhD
Editor-in-chief
178
'Streetwise' is a magazine of urban
studies providing a forum for radical
thinking on urban issues, policy
development and education.
Subscription for National Association for
Urban Studies members £10, institutions
£20, individuals £14.50. International
subscribers add £4 for postage.
Apply at: Streetwise, Lewis Cohen,
Urban Studies Centre at Brighton
Polytechnic, 68 Grand Parade, Brighton
BN2 2JY, England.
'Research for Healthy Cities' is the 140page book containing keynote speeches
from last year's Research for Healthy
Cities Conference in The Hague
(Netherlands). Copies may be ordered
through TSG, c/o TNO-NIPG, PO Box
124, 2300 AC Leiden, The Netherlands.
The city of Maastricht
The Healthy Cities Project has boomed
like a successful multinational enterprise.
Agis Tsouros reports in 'World Health
Organization Healthy Cities Project: A
Project Becomes A Movement. Review
of Progress 1987-1990. FADI,
Copenhagen' Only $10!
Also, an evaluation from the Quebec
Healthy Cities Project: 'L'Equipe de
recherche de I'Universite Laval (1990)
Resultats de la Premiere 6tape
d'evaluation du reseau Quebecois de
"Villes et Villages en Sant4*
Contact Michel O'Neill, Ecole des
Sciences infirmieres, Cit£ Urifoersitaire,
Quabec, QC, Canada.
SUBSCRIPTIONS
Subscriptions to this Newsletter are free of charge. In order to keep our mailing tidy and up-toxiate
please inform us of any changes or corrections in your address label:
Present subscribers
Name :
__ __________________
Institution:_____________________________
Position:____________________________ __
Street/box no.:
Provi nee/reg ion:
Country:
enter postal or ZIP codes in the appropriate place!)
Attach old address label where applicable!
Return to.
Evelyne de Leeuw
Department of Health Ethics & Philosophy
PO Box 616
6200 MD Maastricht
The Netherlands
4
re^ ea
Healthy Cities now also in Flemish
Belgium
Research notes
Apart from some isolated efforts, the
Flemish part of Belgium has never been
successful in jumping on the racing
Healthy City train. This might change
now. The province of Limburg
investigated the capacities of
municipalities, aidermen and local civil
servants to work in the frame of the
new public health. Their findings were
that new monies were badly needed;
funding is now under way to appoint
public health policy makers in each city
and municipality.
Information: Provinciebestuur, Dienst
Public Relations. Dr. Willemsstraat 23,
3500 Hasselt, Belgium (fax (11)
22.71.92)
Indicators for Healthy Cities:
Canadian developments
The federal ministry of Health and
Welfare in Canada is pursuing its
'Knowledge development program in
health promotion'. One of its priorities
for the 1989-90 period is to stimulate
exchanges across Canada to foster the
development of indicators to evaluate
the healthy cities ventures. Indicators
development in health promotion was
179
singled out as one of the top priorities
for research at the end of a three years
long consultation process involving over
a thousand academic and non-academic
researchers across the country, as well
as users of research results. In december
1989, it was decided after a national
seminar on indicators where Prof. Horst
Noack of Berne University in Switzerland
was a distinguished lecturer, that the
very complex issue of indicators
construction should be approached on a
specific topic if any concrete result were
to be expected in a one year time span.
It was thus agreed that indicators for
Healthy Cities was to be the focus, due
to the pressing needs of the fast
growing netweroks of Healthy
communities in English Canada and
Villes et villages en Sante in Quebec. For
general information on the Knowledge
development strategy in Health
Promotion, contact Dr. Michael Nelson,
Health and Welfare Canada, health
Promotion Directorate, Jeanne Mance
Building (room 420), Tunney's Pasture,
Ottawa, Ontario, Canada K1A IB 4; tel.
(613J-957-7797.
The strategy to advance and disseminate
knowledge on Healthy Cities indicators is
to hold a series of six seminars in various
parts of the country as to build bridges
between various academic disciplines as
SUBSCRIPTIONS
Newsubscribers:
Name :
I
Institution:
Position:
Street/box no.:
Province/region:
Country:
(ptease enter postal or ZIP codes in the appropriate placet)
3
I
Return to:
Evelyne de Leeuw
Department of Health Ethics & Philosophy
University of Limburg
PO Box 616
6200 MD Maastricht
The Netherlands
...... ?T.
4
re?;
well as bridges between academics and
decision makers at the municipal or
other levels. The first of these seminars
has been held in the Prairie Region
(Manitoba and Sasketchewan provinces)
on February 19, 1990 and wass a unique
occasion both to discuss Healthy
Communities indicators and to further
develop the network of health
promotion researchers in this part of the
country. Details on this workshop as well
as the proceedings ar available from Dr.
Joan Feahter, Health Status Research
Unit, Department of Community Health
and Epidemiology, University of
Sasketchewan, Saskatoon, Canada S7N
0W0, tel: (306)-966-7939.
Two other workshops have been
formally scheduled. The first will be held
in Vancouver on October 19 for the
Western part of the country (Territory of
Yukon as well as province of British
Columbia) and the second in Montreal,
on November 1, for Quebec. The
contact persons are: Sharon MansonWillms, Center for Human Settlements,
University of British Columbia; 2206 East
Mall, Vancouver, B.C., Canada, tel.
(604)-228-6081;fax: (604)-228-6164 and
Michel O'Neill, Ecole des Sciences
infoirmieres, Unviersite Laval, Quebec,
Qc, Canada, G1K 7P4, tel: (418>-6563356, fax: (418^656-3174.
The three other workshops will held be
shortly. These regional workshops will
culminate in a special meeting during a
national conference on research
methods in health promotion to be held
in Toronto from November 30 to
December 2, 1990, where the progress
made in the different regions will be put
together, people interested by this
conference can write to: 'Health
promotion research methods: expanding
the repertoire', Continuing Education,
Faculty of Medicine, University of
Toronto, Toronto, Ontario, Canada, M5S
1A8, tel: (416)-978-2781.
ea kh
180
Academic infrastructures for Health
Promotion research are developing in
Canada
At least three universities have begun to
formalize such structures. In Ontario, the
University of Toronto has created a
Center for Health promotion whose
director is Dr. Irving Rootman, formerly
from the Health Promotion Directorate
of Health and Welfare Canada. He can
be reached at: Center for Health
Promotion, University of Toronto, Me
Murrich Building, 12 Queen's Park
Crescent, Toronto, Ontario, M5S 1A8,
tel:(416)-978-1809.
Published under auspices
of:
______
UNIVERSITE
LAVAL
Ecole des Sciences Infirmidres,
Groupe de Recherche et
d'Intervention en Promotion de la
Sant6
Cit& Universitaire,
Quebec, Canada G1K 7P4
The University of British Columbia has
started an Institute for Health
Promotion, Faculty of Graduate Studies,
Mather Building, 5804 Fairview Avenue,
Vancouver, B.C., Canada, V6T 1W5, tel:
(604)-228-2258, fax: (604)-22S4994.
Laval University, in Quebec City is also
starting a 'Groupe de recherche et
d'intervention en promotion de la
sante', under the joint leadership of Dr.
Gaston Godin and Dr. Michel O'Neill.
They can both be reached at: Ecole des
Sciences infirmieres. Universite Laval,
Quebec, Qc, Canada, G1K 7P4, tel:
(418)^56-3356, fax: (418^56-3174.
The research program of these
organizations has yet to be finalized but,
given the importance of both Healthy
Communities and Villes et Villages en
Sante, it is very likely that research
endeavors related to Healthy Cities will
be undertaken by one or the other of
these centers or by many of them as a
joint venture.
MGAJ-TH FOR
THE WHO HEALTHY CITIES
PROJECT
WHO/EURO
8, Scherfigsvej,
2100 - Copenhagen,
Denmark
DEPARTMENT OF SOCIAL
POLICY AND SOCIAL WORK
Research Unit in Health and
Behavioural Change
17 Teviot Place,
Edinburgh EH1 2QZ,
Scotland
University of Limburg
School of Health Sciences
PO Box616,
6200 MD Maastricht,
The Netherlands
:; 'j
181
h
1991 / September
for
healthy
cities
Editorial
Guest editorial
We're getting off the ground with Research
for Healthy Cities! In the months that
elapsed since the first issue of this
Newsletter, we
* increased the number of subsriptions from
250 to nearly 600;
* witnessed the creation of numerous Health
Promotion Research groups;
* received over 120 publications related to
the Healthy Cities movement; and
* started preparations for a meeting aimed
at Healthy Cities researchers in the
summer of 1992, either in Quebec (Canada)
or Maastricht (Netherlands).
Please fill out the form on the next pages to
indicate your interests and availability for
such a meeting.
Lots of news, you'll understand. In this issue
a short description of a Healthy Cities
Network analysis, several reports from
meetings, new publications, and
miscellaneous news.
Evaluating Healthy
Cities: the most urgent
research task.
Evelyne de Leeuw MA MPH PhD
Editor-in-chief
Michel O'Neill, Ph.D.(l)
There are several research areas that could
be developed in relation to the Healthy Cities
movement. What I would like to argue
however is that the most urgent task to
which academic and non-academic
researchers should devote their time is the
evaluation of the ongoing tidal wave of
municipalities running to join the healthy
cities movement all over the world. I am
aware that pushing for the evaluation of
something new and innovative can be the
best way to hinder it or, for interests made
uneasy by it -especially if powerful- to get rid
of the thing. I am also much aware that
under the heading 'evaluation' a whole sore
of totally different research endeavors can
be undertaken as well as totally different
types of questions to be asked. I nevertheless
think it is the research priority for at least
two reasons.
The first one is very pragmatic. Once the
original commitment made by cities has
elapsed for some time, and when the hard
reality of implementing the stimulating but
hazy concepts of healthy cities has been
arodnd fara while, questions are
automaticallyraised about what this
initiative is producing, and if it is worth
continuing it. Thise questions can be asked
by city politiciansfor
electoral or financial reasons, by the people
running the project to have a sense of
direction and accomplishment, by academics
interested at theorizing on a fascinating
innovation, etc. However, if there is to be a
long term commitment to the project
(V Pmfesseuc titulaice, Groupe de recherche et
cTintwventiiDn en promotion de la santeet tcole
des Sciences infirmi^fes, University Laval, Quebec,
Qc, Canada
1
21
wherever, there is no way to avoid a kind of
assessment of what Healthy Cities produce.
The second reason is that it is one of the
research areas where interaction between
users and producers of knowledge, as
suggested in the ideological rhetoric of
health promotion, is unescapable. As I have
been able to witness over the last year, in
several workshops devoted to information or
indicators to assess Healthy Cities on both
sides of the Atlantic, who evaluates what, for
which purpose, with which kinds of
information and in which delays has
tremendous consequences and poses more
than one delemna that are in my opinion
essential to confront for the very survival of
the movement.
It forces academics from a wide array of
fields and disciplines, who usually think of
themselves as the knowledgeable
researchers, to interact with the politicians,
the bureaucrats and the community groups
as well as to negotiate -or to be told ...- what
evaluation should be done. It shows that in
many a place, the development of healthy
cities networks is very uneven and that
evaluation concerns are very diversified
indeed. Moreover, it raises all kinds of
difficult issues about the link between
evaluation and control. Should localities
performing 'poorl/ (however this is defined)
be exdude< of the network? Should
relabelled old things be considered
legitimate healthy cities endeavors or should
just new things started after the healthy
cities ideology like equity, intersectoriality or
participation, move out? For how long? Who
decidesj^’p-'.
Despite
dilemmas, I would thus argue
that having rigorous and relevant evaluative
looks at the development of Healthy Cities,
be it wtthih a city, within a national network
or even internationally, is very necessary.
Otherwise, the movement might quickly
become very vulnerable and dissolve at the
same pace it has grown!
4
— re? ea
1
Publications
From different corners of the world we
received reports with Healthy Cities
Evaluations:
Baum, Fran et al. (1990) Healthy Cities
Noarlunga Evaluation. Southern Community
Health Research Unit do Flinders Medical
Centre, Bedford Park, South Australia 5042.
ISBN 0 7243 0477 7
Also available from this address: a needs
assessment manual.
Cardinal, Lise & Michel O'Neill (1990)
Resultats de la premiere ttape d'evaluation
du reseau Quebecois de 'Villes et Villages en
Sante. University Laval, Quebec, Canada
Blackstaff Community Health Project (1991)
The Blackstaff Community Health Profile.
Olympia community Centre, 14 Boucher
Road, Belfast BT12 6HR, Northern-Ireland
Other publications received include:
Bracht, Neil, editor (1990) Health Promotion
at the Community Level. Sage, Newbury
Park, USA
Evers, Silvia (1990) Health for All indicators in
health interview surveys. WHO//EURO,
Copenhagen
Scott-Samuel, Alex (1990) Total participation,
total health. Reinventing the Peckham
Health Centre for the 1990s. Scottish
Academic Press, 139 Leith Walk, Edinburgi.
EH6 BNS, Scotland. ISBN 0 7073 0630 2
Leeuw, Evelyne de, editor (1991) Gezonde
Steden. Lokale gezondheidsbevordering in
theorie, politick en praktijk. Van Gorcum,
Assen, Netherlands. ISBN 90 232 2632 1. 320page Dutch handbook. Shouldn't pose a lot
of reading problems to Germans and
Scandinavians, but Spanish and English
translations are nevertheless underway.
Cappon, Daniel; 'Indicators for a healthy
city'. Environmental Management and
Health, an International Journal, 1(1)9-18,
1990.
Fortin, Jean-Paul; O'Neill, Michel; Groleau,
Gisele; Lemieux, Vincent; Cardinao, L; Racine,
Pierre; Les conditions de ryussite du
mouvement quebe^ois de 'Villes et villages
en santy'; Quebec, University Laval,
septembre 1991, 148 pages.
Milio, Nancy; 'Healthy Cities: the New Public
Health and Supportive Research', Health
Promotion International, 5(4):291-299, 1990.
O'Neill, Michel; Cardinal, Lise; Fortin, JeanPaul; Groleau, Gisele; 'La naissance reseau
quebe<;ois de villes et villages en santG',
Rbcherches Sodographiques, 31(3):405-418,
1990.
The new bible is out! Out of the most up to
date research literature, ten years after the
PRECEDE model, Green and collaborators
have devised the PROCEED model to plan
and conduct health promotion interventions,
adding policy and environmental
interventions to the more behaviorally
focused model of 1980. The authors also
make a strong plea that communities are the
central locus where health promotion should
be carried out. Green, L. W. and Krewter,
M. W.; Health Promotion Planning, an
Educational and Environmental Approach;
Mayfield; Mountain View; California: 1991;
506 pages.
Report
Network analysis as a
method.
Marleen Goumans
Summary
Because of several reasons individuals,
groups and organizations keep up
relationships with their environments, and,
by means of this, build networks. Every
network is unique in its form and
functioning, but there are some common
characteristics to be distinghuished. In a
study of networks, an analysis of the
different relationships (such as kind of
relationship, intensity or amount) will
provide useful information about structure
and functioning of the network. There are
many methods used, but in fact there are
four main approaches: a descriptive, a socio
metric, a graph-theoretical and a
blockmodeling method. To analyse structure
and functioning of national Healthy Cities
networks a method was used which
contained some elements of those four
approaches. Because they all did not exactly
fit in with the subject of Healthy Cities, and
adaptation was needed. The outcome of the
inquiry confirmed the importance of a well
defined network analysis when a mutually
connected group of actors (individuals,
groups or organizations) are under study.
Introduction
Network analysis can be regarded as a
research instrument to interpret behaviour in
a wide variety of social situations. And,
moreover, it enables one to create a better
understanding of the network (for example
functioning, structure, development,
outcome). It is mostly used in the field of
sociology, politicology, antropology and
socio-psychology.
In this article the authors' experience on this
182
subject, based on a inquiry on national
Healthy Cities networks, will be drawn upon
to illustrate the possibilities of network
analysis in the field of ’new-public-health
networks'.
This article is not a summary of the findings
and conclusions of the inquiry.
Social networks
Almost every organization is surrounded by
an environment which influences her and
which has to be taken into account when
planning, organizing or implementing
activities. This means that an organization,
but also groups or individuals, keep up
different kinds of relationships (very formal,
such as a 'interlocking directorate' on toplevel, or informal by means of a telephone
call or a drink) with organizations, groups
and individuals in their environments
because of political, social, economical or
other considerations. Common goals and
interests or (strategic) importance of the
other party for realizing the stated goal:
the most important reasons for a form of
collaboration.
According to the literature a social network
can be defined as:
"A group of actors (individuals, groups <or
corporations), which are mutually
connected by means of many social
relationships (for example kinship
relations, financial trans-actions,
organizational information channels)."
(Felling and Huttner, p. 248)
Although every network is unique in its form
and functioning, there are several common
characteristics, such as (without being
exhaustive): equity, not bureaucratic, know
the right people, informal circuit, common
character, complexity, cost a lot of energy,
patience, effort and cooperation, flexibility,
sharing of knowledge. Those characteristics
have a so called ’glue-function*. That means,
the way organizations stay together,
reasons why relationships continue ar^ .ae
network structure will last.
Network .analysis
^pant (individual, group,
In a network i
organization! linked to other participants
by means of exchanging resources. One
orgartotion ican be participating in several
organization
networks, and has the possibility of linking
networks
with each other. This does not
nd
mean that all those relationships are of the
same character. In one network it may be a
while the same organization has a highly
formalized relationship in the other network.
Often a visual picture of a situation increases
the understanding and insight in the matter.
This is the reason why in network analysis
and network research the visualisation of the
network structure is • part of the study
which receives much attention. Such;;1; =
network structure is called a ‘topolog/
--------------------- ------------------2
: •1
4
re? ea >1'
X
(Goumans 1991a, p. 25 - 31). In a simple
network which consists of two participants
(in this case cities and/or organizations), it is
obvious that they are connected and
communicate with each other. However it
will be more difficult when the number of
participants gets larger to detect who is
communicating with whom (remember the
mathematic lessons on calculation of
probabilities...).
The purpose of network analysis is, according
to Stokman (1982, p. 168):
"To define content and patterns
of social relationships (collaboration)
between participants of a network; and
in the meanwhile examine the
consequenses of these patterns on the
behaviour of the social entities and the
influence of this behaviour on the
patterns."
The focus can be on a variety of elements
(such a specific organization, environment of
the network, motivation to participate,
quality of the relation, power, organizational
charcteristics), and there are different
methods used. The problems a researcher has
to face when he or she starts with an analysis
consist among others of how to define the
borders of the research field (what should be
included, what not, and why); the absence of
an uniform theory about network analysis;
the methods used are different for many
studies (because the research fields are
different); and difficulties how to define the
relations which will be taken into account.
Approaches
Although the methods used are
fragmentated there are in fact four main
approaches. A descriptive method, in this
method the network will be analysed by
describing and examine various elements
which are connected to the network (such as
bases for relationships, specific situational
factors, resource flows, characteristics of the
environment). A socio-metric method, this
method is also descriptive but uses also
matrices and sociometrical indices (such as
status score, group cohesion). A sociometrical
matrix expresses for example who interacts
with whom, and a sociogram illustrates the
relationships established between the
different groups or organizations. A graph
theoretical method, within this method
relationships between social entities are
represented by points which are connected
by means of lines (points and lines are very
easy for mathematical purposes). In a graph
the direction of the information flow is not
visible, in a directed graph (digraph)
however this is mead visible by means of
arrows. By means of a digraph many network
characteristics can be illustrated. For example
distances (in the graph) between
participants; detection of centres; who acts
as a inter-mediating station. And the block
modeling method, this method tries to
create an algebraic structure out of social
relationships. Here the focus is not on
183
individuals but on groups of persons.
Advanced computer programmes have been
developed to 'block' the data and provide
calculations (abstracting some aspects of the
structure), and provide therefore the
information that is needed to analyse and
describe the structure content and influence
of the relations.
Analysis of national Healthy Cities
networks
The objective of the inquiry was to analyse
organization and structure of national
Healthy Cities networks. Because national
networks are an example of social networks
(participants interchange different resources
(such as information, money, people,
facilities)), the idea was to use one of the
techniques as outlined above.
Two research objectives were formulated:
1. How are the different national Healthy
Cities networks organized and how well do
they function?
2. Analyse the relationships between actors
(participants) in a national network in view
of the creation of a M.I.P..
A Management Information Plan (M.I.P.) is in
this case:
A plan which structures and provides
insight into the information flows
between participants of a national
network, and between national networks
and the WHO/Euro/ HCPO.
In every organization (in this case network)
one can discover a multitude of information
flows. The larger the organization, the
larger, and most of the time more complex,
are the resource flows which go along.
Therefore it is important to structure,
coordinate and organize those resource
flows, thus to take care of information
management. Information management and
policy is made more concrete by means of a
information plan.
Data were gathered by means of
documentation materials in the field of the
Healthy Cities project and the national
networks, consultation of team members and
a questionnaire which was sent out to
fourteen national networks in Europe. The
latter has been the most important source of
information for answering the research
questions, and as such as the most important
source for structural analysis of the national
Healthy Cities networks.
----------------
(4> W fCMMM O*
$: « C>1
o' act
Figure 1. FRAMEWORK FOR STRUCTURING DATA
The data were structured as shown in figure
1. The different kinds of activities (1) as used
in the questionnaire, can be subdivided into
nine categories (3). The participants of a
national network (2) can be subdivided into
ten groups of participants (4). Attention was
paid to:
relation (1) - (2) on country level
relation (3) - (2) on country level
relation (3) - (4) to compare countries with
each other
relation (5) - (6) to create a general picture of
a network
To make comparisons between the different
national networks possible and useful, there
has to be worked with some general
parameters. In this particular inquiry this
means dividing the different activities in
'categories of activities' and the different
participants of every single country in
'groups of participants'. Important was that
all the participants as appeared in this study,
were represented in one of the general
groups. And moreover the categories and
groups had not to be too general and still
had to yield useful information.The compa
risons as made in this inquiry are stored in
tables. For comparison (3) - (2) (see figure 1)
it was also possible to provide information
about frequencies of involvement in certain
activities and the resources which were used
by the participants (see table 1). However for
comparisons (3) - (4) and (5) - (6) it was not
possible to provide detailed information
about frequencies and resources. This
because the range of frequencies was ver
wide (0 to 365) and the amount of
respondents low (8).
2 K prelect city
5
■-CaTlmwr
* mu ii m
»_
7 lawnaM <<••■<>
t
imerwt fro^e
•:==
•:=ZZ
H==
T«bte 1. PARTOPANTS AND AOTVmES
In table 1, the activities are presented
horizontally by means of numbers (1 to 9), ;
and the participants are presented vertkaOy
by means of letters and abbreviations or the
3
4
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1
name of the particular group of participants.
The tables concerning 'participants in
relation with activities' (table 1) and
'resources and frequencies' (table 2) are
almost similar.
0»*
Table 2. RESOURCES AND FREQUENCIES
(EXAMPLE: ISRAEL NATIONAL NETWORK
The first one provides information about
who is involved in what (marked with X), and
the latter provides information about the
resources used (marked with letters) and the
frequency (times per year) with which a
participant is involved in an activity (marked
with numbers). The latter provides insight
into the intensity of the involvement. For
example, two participants can be involved in
the same activity, but one can do this once a
year and the other can do this very regularly.
To make comparisons between national
networks possible and legitimate, there were
also tables used were the participants of a
country were divided into groups. It was also
possible to study the role of a specific
participant in the several national networks.
In this case the several countries (in stead of
activities) were presented vertically. By
means of using those grids, several
comparisons were, and could be, made.
Thus, the approach used for analysing the
relational structure of national Healthy Cities
networks, was not exactly one of the four
methods. It was rather a combination of
those methods with ideas of the researcher.
For every country a general dexcription was
given about development of the network
until so far (descriptive method). After this
the most important participants of a
network, as detected by the researcher and
checked by the respondent, were introduced
(descriptive). The activities of a network and
the involvement of the different participants
were processed into tables (socio-metrical
method). Some extra attention was given to
the role of the WHO/Euro Healthy Cities
project office and national network
coordinator in every network, a digraph was
used to show the relational structure of the
national network coordinator (descriptive
and graph theoretical method). Followed by
a description of the importance of different
activities and organizations for the national
r
network (descriptive). And finally the
relation between activities and participants
were presented again, but now in a way
which makes it possible to compare the
different networks with each other (block
modeling method [when realizing that is
spoken about 'groups of participants' in
relation with 'categories of activities']).
Discussion
Networks are interesting but difficult to
study since they do not have natural
boundaries. When a network as a whole is
impracticably large, the usual procedure is to
dreate a 'subgraph' and treat is as a
representative sample of the whole network.
Therefore when collecting information about
(the existence of) relationships between
participants of the network, one has to be
aware that one is working with only a part
of the total network. It is in this case very
important to use clear definitions of terms
used, relationships which are taken into
account and meaning of those relationships
in this research.
The inquiry on national Healthy Cities
networks is on a national level, but imagine
a road-network, there are high-ways and
roads but there also streets and small
landroads which are not taken into account.
Regarding the research objectives, the first
objective has been reached partly. It was
possible to write eight reports anout the
structure, functioning and organization of
national networks, and those findings are
useful in the way that they provide insight
into a network structure; provide insight into
the relation between the participants and
the activities which are organized or take
place; provide insight into the role of the
WHO. However, it was not possible to speak
about structures of national networks in a
sense of 'who is communicating with whom
(except for the communication (relation)
between a network coordinator and other
participants); it was only possible to speak
about structures in a sense of 'what is going
on; who is doing what'.
The second objective has also been reached
partly. As mentioned before, it was not
possible to analyse the relations between the
different participants. However, the results
are useful for the development of a
Management Information Plan (M.I.P.). The
basis of a M.LP. consists among others of a
description of the participants, their activities
and the resource flows. The findings proved
information about the participants of a
network; their functions and roles in the
network; their relationships with the
national network coordinator; their activities
in and for the network; and the resources
they provide for the network.
This shows also that techniques which are
developed in other fields (and/or for other
purposes) can be used, but have to be
adapted to the specific situation and
environment in which it will be used. And
the outcome has to be interpreted in the
light of these adaptions.
184
For more information about “What about
Healthy Networks?" an analysis of structure
and organization of national Healthy Cities
networks in Europe, please contact Marleen
Goumans (+31 40 384099)
Correspondence adress:
Ms. drs. M. Goumans
Dutch national Healthy Cities project officer
c/o GGD Eindhoven
Po.box 2357
5600 Q Eindhoven
The Netherlands
References;
7. Felling, A.J.A., Huttner, HJ.M. (1981). De
analyse van sodale netwerken. In Albinski,
M. (ed.), Onderzoekstypen in de sodologie.
Assen: van Gorcum.
2. Hall, R.H. (1982). Organizations,
structures, processes and outcomes. New
Yersey: Prentice-Hall.
3. Goumans, M. (1991a). What about
Healthy Networks? An analysis of structure
and organization of national Healthy Cities
networks in Europe. (Masters thesis on HPA).
Maastricht Rijksuniversiteit Limburg.
4. Goumans, M. (1991b). Netwerken van
Gezonde Steden en hun karakteristieken. In
Leeuw de, E. (ed.), Gezonde Steden - Lokale
gezondheidsbevordering in theorie, politick
en praktijk. Assen: van Gorcum.
5. Lauman, E.O., Knoke, D. (1987). Social
Choice in National Policy Domains: The
Organizational State. Wisconsin: the
university of Wisconsin press.
6. Leeuw de, E. (1989). Policy and
Information: an unseparable couple in health
promotion. (Unpublished article).
7. Light J.M., Mullins, C.N. (1979). A Primer
on Blockmodeling Procedure. In Holland,
P.W., Leinhardt S. (eds.). Perspectives on
Social Network Research. New York:
Academic Press.
n
8. Mitchell, J.C. (1969). Social netwo,
urban situations. Manchester.
■■
4
re? ea
News
New director in
Vancouver
The Institute for Health Promotion Research,
of the University of British Columbia in
Vancouver, Canada, has recently appointed
its first director, the well known Dr.
Lawrence W. Green. British Columbia has a
very lively network of Healthy Communities,
and it is most likely that some of the research
endeavors of the Institute will be linked to it
in the near future.
Institute for Health Promotion Research,
Faculty of Graduate Studies, Mather
Building, 5804 Fairview Ave., Vancouver,
B.C., Canada V6T IV/5; tel. (604) 228 2258;
fax (604) 228 4994.
New money for health
promotion
In August 1991, two federal granting
agencies of the Canadian government, the
National Health Research and Development
Program (NHRDP) of Health and Welfare
Canada as well as the Social Sciences and
Humanities Research Council (SSHRC), have
announced a 2.5 million dollars (CAN) joint
venture to fund up to five national centers in
health promotion. This infrastructure money
is to be given in the amount of 100,000
dollars a year for five years to each center,
chosen by a peer review process, in order to
stimulate the development of top quality
academic research directly linked to the
needs of agencies and grass-roots
organizations involved in health promotion
practice. Details on this most welcome
innovative program, that could inspire other
central or regional governments, can be
obtained from:
Social Sciences and Humanities Research
Council of Canada, do Julie Dompierre,
Strategic Grants Division, 255 Albert Street
Box 1610, Ottawa, Ontar, Canada, K1P6G4;
tel. (613) 992 4227.
WHO Healthy Cities
Collaborating Center
in US
The Institute of Action Research for
Community Health, based in the School of
Nursing of Indiana University in Indianapolis,
USA, has been designated a WHO collabo
rating Center on Healthy Cities matters as of
the beginning of 1991; the activities of this
new center include research and dissemi
nation of healthy cities information.
>h
Institute of Ation Research for Community
health, School of Nursing, Indiana University,
NU 237, 111 Middle Drive, Indianapolis, IN
46202, USA; tel. (317) 274 3319.
Indicators workshop
As part of the Health Promotion Knowledge
Development initiative of the Canadian
Health Promotion Directorate of Health and
Welfare Canada, a series of five regional
(Winnipeg, Vancouver, Montreal, Calgary,
Toronto) and two national (Toronto)
workshops was held in 1990-1991, the
scheme in six cases out of seven being
related to information or indicators to assess
Healthy Communities. The proceedings of
several of these workshops are either already
or soon to be available as well as more
general analyses about what was learnt in
such a series of workshops. For information,
contact
Sylvain Paradis, Health Promotion
Directorate, Health and Welfare Canada,
Jeanne Mance Building room 420, Tunneys'
Pasture, Ottawa, Ontario, K1A 1B4, tel. (613)
954 8026.
Research for Health for
All: the Healthy City
and its evaluation.
Mike Kelly
Early in April, 1991 a conference entitled
'Research for Health for All: the Healthy City
and its Evaluation' was held in Glasgow. The
meeting was organized by the Healthy Cities
Project Glasgow, the Department of Public
Health, University of Glasgow, Greater
Glasgow Health Board, the Scottish Health
r
185
Education Group, the Strathclyde Regional
Council and the British Sociological
Association.
The purpose of the meeting was to bring
together three constituencies. The first was
as academic researchers with an interest in
applied aspects of health and social and
scientific research related to the Health for
All targets and the concept of the Healthy
City. The second was policy makers, planners
and initiators at national and local level. The
third were member of ordinary local
communities.
Some 137 people were present from these
three groups.
The theme of the conference was
communication between the three
constituencies as they relate to and use socia
scientific and medical research. Some years
ago, the British Sociological Association had
recognised that much sociological and other
social scientific research has a direct bearing
on the Health for All targets, and on its
translation into the Healthy Cities
programme. However many sociologists and
others working In the field seem unable to
share their results with others and sometime
show little understanding of, or interest in,
the mechanisms whereby such research may
be disseminated to a broader community
(Kelly 1988). Ordinary members of
communities on whom research is done hav
little control over the way findings are
generated, commented upon and used eith
by academic, of by policy makers and
planners. It was this concern which led to tf
establishment of the meeting.
The aim of the conference, therefore, was t
bring the three constituencies together
within a structured framework in order to
encourage discussion and exchange of idea
The mechanism used was to invite a numbe
INFORMATION FORM
RESEARCH FOR HEALTHY CITIES SEMIN
SUMMER 1992 QUEBEC/MAASTRICHT
i
Seminar population:
A maximum number of 35 participants from as diverse fields as possible
i
Seminar purpose:
To develop an International Healthy Cities Research agenda
I
Name:
Address:
I
Phone:
Fav
E-mail:
; i
I
Return to:
_
Ev^yrw cto Lmuw, lUswch for Healthy Gtias Newsletter. Dept GEW, University of Limburg,
PO Box 616, 6200 MD Maastricht The Netherlands. Fax: ♦SI 43 254838
p.
4
re? ea
4
of distinguished authors prepare papers in
advance of the conference, which were to
act as a focus for discussion. The invited
authors were: Sonja Hunt; Lee Adams;
Jan Smithies; Agis Tsouros; Trevor Hancock
and Margaret Whitehead.
The lessons which we learned from the
conference were as follows:
From an organizational point of view, the
idea of pre-prepared papers acting as a focus
for structured discussion works quite well.
However the workshops really required
better focus with specific aims and objectives
to achieve. The recommendations from the
meeting would probably have had a less
diffuse quality had we thought to structure
the process in this way.
At a more general level it is clearly possible
to bring together the three constituencies,
although each is discrete and the
assumptions of each are different.
Communication between the three
constituencies can be problematic and
quarrelsome but that does not detract from
either the importance of attempting to open
up links nor from the benefits that may be
derived from so doing. We believe that the
meeting in Glasgow was an important first
step in this facilitation process and the hope
is that other groups, locally, nationally and
internationally will pick up the idea and
develop it further.
The proceedings of the conference along
with recommendations for further action
and in conjunction with other invited
authors from North America (Michel O'Neill)
and Australasia (Fran Baum) will be
published during 1992, by Routledge and
Kegan Paul in London.
Reference:
Kelly, M.; Workshop and Information
Exchange on Health for All, Social Research
Association News No. 6, July/August, 1988,
pp 10-11.
r
186
Austrian course
The Rotterdam Local
Health Information
System
The Interuniversitares Forschungsinstitut fur
Fernstudien (inter-university institute for
advanced research) is going to organize, in
collaboration with WHO, courses with
duration of several weeks spread over
different periods. The courses will focus on
increasing strategic capabilities of local
health promotors.
The first period is between 11-15 November
in Vienna. Total costs: dS 8400.
Information:
IFF, Siebensterngasse 42/10, A-1070 Vienna,
Austria. Telefax (0222) 93433118
In Rotterdam a local health information
system has been set up by the Municipal
Health Service, referring to target 35 of the
Healthy Cities Project. The information
system aims to (1) monitor the health
situation and related factors in Rotterdam at
neighbourhoud level and (2) contribute to
the development of a local health policy for
reducing the differences in health.
Information is collected on health (e.g.
mortality, morbidity), lifestyle (e.g. smoking,
alcoholconsumption, drugabuse), social
environment (e.g. educational level,
unemployment, marital status), physical
environment (e.g. housing, traffic, noise) and
the health care system. The system is a
collection of quantitative data linked with
qualitative information. Quantitative data
are collected from various institutions and
municipal services, and from the population
itself by means of health surveys.
The resources for qualitative information
include opinions and ideas of key informants
living or working in specific neighbourhoods,
and articles on health and health related
factors published in local newspapers.
The data are collected at neighbourhood
level and are updated annually. All data are
stored in a central database and can be
accessed in various ways with the help of a
range of software. First results show a
number of differences between
neighbourhoods. On the basic of this
information, recommendations can be made
to improve the health in a systematic way.
Information: J.A.M. van Oers, Municipal
Health Service for Rotterdam area,
Schiedamsedijk 95, 3011 EN Rotterdam, the
Netherlands.
Research Clearing
house in Maastricht
The School of Health Sciences at the
University of Limburg has established a
clearinghouse for healthy cities research.
Research reports will be collected and made
available upon request. The institution thus
needs: - research reports
- requests
Contact:
Evelyne de Leeuw
Dept. GEW
University of Limburg
PO Box 616
6200 MD Maastricht
The Netherlands
phone (43) 888767 or 888780
fax (43) 254838
Published under auspices
ot
O| UNIVERSITE
o LAVAL
Ecoia das Sciancas mtirmMras.
Groupa <ta Racharcha at
cTintarvanWon an Promohoo da la
Santt
Cite Unr.-e'Sitaue
Quebec Canada G i K 7P4
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Job description:
Involved in research:
> 50% of time
< 50% of time
□
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□
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Policy
Social epidemiology
Clinical epidemiology
Other
I
THE WHO HEALTHY CfDES
”WJCCT
.
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EURO
8. Sch«d>g«wi.
2100 • Ccp^Ywgen
Denmark
Relevant publications
(empirical research only):
(or enclose list)
Research area (max. 2):
Lifestyles
Community health
Environmental health
Participation
Management
□
□
□
□
□
Focus of research:
Cities
Neighborhoods
Communities
Settings (e.g. schools, workplace)
Vulnerable groups (e.g. children,elderly)
Determinants (e.g. AIDS, food & nutrition)
Other:
□
□
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Yes, I am interested in attendingthe seminar
No, I'm not, but keep me informed
No, I'm not interested
DEPARTMENT OF SOCIAL
POLICY AND SOCIAL WORK
Rmwrcb UnM in Hrntth and
Banaviounl Change
17 Tevioi Race,
EOnburghEHI 2OZ.
Scoiland
Untwarty of L*sW1
Itanfae Hearth Sciences
POBo««l8.
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Dsa Matnadandc
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6
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187
;h
1992/April
Editorial
Healthy cities begin to be flourishing all
around the world. The World Health
Assembly's attention to urban health last
year has clearly stimulated numerous
cities around the world to adopt health
promotion principles in urban planning.
This means good news as well as bad
news. The good news is undoubtedly that
health increasingly is put on political
agendas. The bad news is that as yet
research endeavours still seem to be
carried out in an isolated way.
The Clearing House for Research for
Healthy Cities in Maastricht (Netherlands)
is currently establishing an annotated
bibliography. Inventory of present data
shows that over a period of only four
years (1988-1992) the number of
publications increased from about 10 to
100 annually. However, most of the
publications are little empirical and
restrict themselves to rethoric. The total
number of published empirical inquiries
(be they qualitative or quantitative,
outcome evaluations or process analyses,
clinical or social epidemiological) is
around twenty.
Reason for anxiety?
Probably not, for two reasons. On the one
hand, we know that a lot of research is
currently being carried out, and hope to
see reports in the near future. On the
other hand, a tradition in healthy cities
research has yet to be established.
However, there is a lot of confusion and
uncertainty, among researchers as well
as healthy cities officers, about where to
go from here.
Healthy Gties Research Agenda
In order to establish consensus in the
academic community about a 1990s
research agenda for healthy cities, the
University of Limburg is hosting a
Research for Healthy Cities Expert
Seminar from 15 through 19 November
1992 (previously announced for Summer
1992). In cooperation with Universite
Laval (Quebec) and the University of
Glasgow/Glasgow Healthy Cities Project
a select group of researchers will be
invited to participate in problem-based
and community-driven debates. The stage
for the discussion will be set through a
'Position Paper'.
Invitees may expect information on the
meeting soonest. Of course, the
proceedings will be available to ail our
readers, together with the bibliography
mentioned above
Evelyne de Leeuw
Editor-in-chief
Guest Editorial
Is the project making a difference?
My conviction that it does is always at a peak
when I visit cities and see and feel the extent
of the impact of the project, on people,
decision-makers and structures that are
concerned with health. It is important at this
stage to ask ourselves wether we are
sustaining a myth or missing the wood for
the trees, eager to evaluate and look for
significant city health gains, but missing the
point of what this is all about? Are we just a
sophisticated campaign that timely managed
to catch the imagination and the attention
of hundreds of cities or is it that its full scale
effect can only be seen with a birds eye
view? I don't want to repeat the calls for a
new paradigm of research and I don't want
to bring up the issue of appropriate
indicators for healthy cities again. We have
heard all this ad nauseam.
My point is that the project as it has grown
and developed out there, is much more than
the sum of its stated methods and activities.
The project is a source of inspiration and
meaning which each dty is weaving into its
1
fabric in a different way -to give cities and
organizations a new reason for existing.
How do we evaluate this.
It was a fascinating exercise at our
recent business meeting in Mechelen to
hear what's in it for every city. Anxious
to live up to traditional epidemiological
expectations we become defensive and
shy about its full potential. This potential
has reached new meanings in cities with
special needs. Take St. Petersburg or
Zagreb for example. For Mr. Sonchal this
project is clearly a major vehicle to
reform health care and international
resource mobilisation to address the
health implications of major social
problems in this city. For the thousands of
refugees in Zagreb, the help from one
project city alone (Horsens) was worth
seven million dollars.
The WHO project phase 1987-1992 is
now ending and a new action orientated
phase will start in 1993 to 1997 with old
and new cities. Furthermore national
networks in Europe are now in the
process of creating an association
together with WHO. This means a better
structured EURONET and a stronger
political base for public health advocacy
at European level. No doubt now more than
ever we need to mobilise resources,
imagination and incentives for research
that can thrpw light and appreciation of
the multiple facets and effects of this
project Social scientist need to be more
involved. We need more research that is
directed towards evaluating innovation
and chlftges in social and political
proce«|^5|ut in reality although we may
sense^itiOWi or intuitively appreciate
the impect of the project it will always be
difficult tdi put a finger on the projects
overall :^»ct. I think that the project is
not onlijfi|:!ldcans for change but it has
created |ii junique medium conducive for
innovation and international cooperation.
Ag/s TiocmtMt Mp,
WHCKEURO
>h—
4
re? ea
Sheffield Information
and Research Forum
Only a few Healthy Cities initiatives have
ready access to research capacities
(universities, institutes, etc.).
Nonetheless, most of those cities and
communities recognize the need for
research. The Healthy Sheffield 2000
Initiative has found a clever way of
dealing with this problem. They established an Information and Research Forum.
The terms of reference of this IRF were
defined as follows: "The IRF will promote the
coordination of public health ^formation
-^d research in Sheffield in support o
althy Sheffield Initiative. It aims to
facilitate collaboration between statutory
and voluntary service providers, academic
researchers and community initiative^in the
field of public health. It will liaise wrth the
Sheffield Information 2000 Project.
IRf has published its first annual review
recently and takes the local Our City Our
Health' document as a starting point for
further activities.
Information and requests.
18(9
Canadian provinces on
right track (again)
Sy crt7eTmov°ement. During a series of
Communities' were further strengthened.
Quebec has always had a lively network
which is now being evaluated extensively by
Michel O'Neill c.s. (Universite Laval, Groupe
de Recherche et d'Intervention en Promotion
de la Sante, Ecole des Sciences lnflr™'6res'
Cite universitaire, Quebec. Canada G1K 7P4,
fax 09-1-418-656-7747).
Provinces of Manitoba and Saskatchewan
have started numerous community vision
workshops; Joan Feather (Dept, of
Community Health and Epidemiology,
University of Saskatoon, Saskatoon S7N 0W0.
Canada phone 09-1-306-966-7932. fax 09-1306-966-7920) edited proceedings of a
related conference.
The British Columbia Public Healt
Association organized a conference on the
issue of ‘Healthy Public Policy - Everybody s
Business' centering around Hea^y
Communities (Jane Hoffmeyer #300-30 East
6th Ave., Vancouver BC VST 4P4).
Liz Caere
Health Promotion Research Officer
Sheffield Health Authority
West Royd, 119 Manchester Road
Sheffield S10 SDN
fax ^44 742 660498
German Healthy Cities
Evaluated
researchers interested in Healthy Cities. The
Center also will issue reports about the
worldwide Healthy Cities movement; provide
research and training opportunities for
visiting scholars and WHO visiting scientists
and research trainees; organize and host
national and international conferences and
congresses on issues relevant to the Healthy
Cities movement; and, promote information
exchange about Healthy Cities programs,
research, and resources.
The official inauguration of the Center was
held October 31 - November 1, 1991 at he
University Place Hotel and Conference Center
on the Indiana University - Purdue University,
Indianapolis campus. The theme of the
conference was "public Policies for healthy
Cities: Involving the Policy Makers." Keynote
speakers included Dr. Angela McBride,
Interim Dean of the School of Nursing; Dr.
Greg Goldstein, WHO, Geneva; Dr. Agis
Tsouros, WHO - European Region,
Copenhagen; Dr. Robert Knouss, Pan
American Health Organization; Dr. Trevor
Hancock, Public Health Consultant, Canada;
Dr. Sheila Smythe, New York Medical
College, New York; and Mr. Richard Louv,
Columnist San Diego Times, California. Most
of the participants came from North America
to welcome the new WHO Center to Indiana
WHO Collaborating
Center in Healthy
Cities at Indiana
University
The European Centre for Social Welfare
wXltt fQrTesund^THamLrg) are
limits of an interaction between an
international organization like
local groups and actors. The project is
financed by the German Ministry of Health.
Information:
Adalbert Evers
Social Welfare Policy
European Centre for
and Research
Berggasse 17
1090 Vienna
Austria
fax +43 1 31 45 05 19
for Community Health as a WHO
Collaborating Center in Healthy Cifes.
This is the first WHO Collaborating Center
designation for Indiana University (IU),
and it is a recognition of 'U's
commitment to international
development, dissemination, and utilization.
This status also is a result of the work of
Healthy Cities Indiana, a eollaborat
X^^^eaKitiesintndiana.and
ssasss,-.
designation for four years.
As a WHO Collaborating Center the
Institute is identifying research needs,
and is conducting and collaborating in
research relevant to the Healthy Cibes
movement. One of the first research efforts
involves developing a global Healthy Cities
information system. This system will be
accessible to community leaders and
University.
Further information about the WHO
Collaborating Center In Healthy Cities may
be obtained through:
Dr. Beverly C. Flynn, Professor and
Director
Institute of Action Research for
Community Health
WHO Collaborating Center in Healthy
Cities
Indiana University School of Nursing
1111 Middle Drive
Indianapolis, IN 46202
U.S.A,
telephone; (317) 274-0026 or 274-3319
FAX: (317) 274-2285
Analysis of the
implantation of
three "Healthy City"
initiatives in the
Montreal area
In September 1991, a research team began
tot evaluate some "Healthy City" initiatives
in the Montreal area. Concerned at the
outset with looking for indicators, the team
chose a method which was perhaps less
ambitious than analysing the results, but
which is nevertheless just as promising: 1^.,
study of the implementation of the proit^,-'
>h-------------4
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1
Three initiatives are under study: PointeClaire, a small Montreal suburb whose
population can generally be described as
being of a high level socio-economica I ly, and
two of Montreal's working class
communities, Mercier-Est and Saint-Michel.
The evaluation will make it possible to focus
on the context in which these initiatives take
place and to identify elements likely to
affect their success.
The three initiatives are being analysed
individually and comparatively according to
a series of variables, the analysis is first
looking at the initiatives' external
environment (laws, by-laws...) and internal
environment (characteristics of the local
community). It will then study the way in
which the three predominant elements in
the Healthy City concept are put into
practice (sharing of common objectives,
citizen participation, intersectorial action) by
those involved, to keep the project moving
in the right direction. Lastly, it will focus its
attention on the concertation structure and
activities generated by the initiatives.
The Evaluation method used is based on the
same approach used by the Healthy Cities
movement, i.e. the participation of the
principals involved. Data collection, which
occurs throughout the study via interviews,
field observation and the perusal of written
documents, includes periods of analysis
closely involving those responsible for the
initiatives, by means of a steering
committee.
The committee, consisting of representatives
of the initiatives under study and
researchers, meets on a monthly basis. The
former are asked to comment on the data
collected by the latter. The results of these
analyses are then conveyed to the three
communities by means of a means of a
monthly liaison bulletin.
In the spring of 1992, mid-way through the
evaluation process, a committee of health
promotion experts will submit its opinion on
the congruence of the principal elements in
the Health Cities concept and the
orientations of the three initiatives under
study, based on summaries of cases in each
location.
Gilles Forget Francine Quellet and Danielle
Durand
Community Health Department hdpital
Sacre-Coeur
5400 Gouin Rlvd, West
Montreat Quebec, Canada
H4J ICS
(Cet article a
traduit par Helena Scheffer,
Hopital G^n^cal du Lakeshore)
Intersectoral
collaboration: Theory
and Practice
Central to the Healthy Cities project is the
notion of intersectoral collaboration to
achieve the development and
implementation of Healthy public policy and
health promotion at the city level. It is both
about fostering interdependence between
agencies in order to launch new programmes
which require the resources of more than one
agency and its about reorientation of existing
public policy to include and acknowledge the
health dimension. What intersectoral
collaboration means is getting organisations
and people within those organisations and
people within those organisations to work
together. Understanding interorganisations
to work together. Understanding
interorganisational behaviour is therefore
crucial to any evaluation of the likely
effectiveness of intersectoral activity.
Interorganisational theory and the growing
empirical literature on collaborative activity
in a variety of contexts from the relationship
between health and personal social services
to inner city policy and environmental
planning, can provide a framework for
analysis. Such a frame work was used to
analyse the early experience of the Healthy
City project in Liverpool1 and is currently
being developed to provide a model
framework for training and education on
intersectoral collaboration2. The original
study contains a review of interorganisational
theory and of empirical studies done in three
areas, WHO intersectoral projects in
developing countries, joint car planning in
the UK and inner city policy in the UK. This
provided the framework of analysis of the
process taking place at the time in Liverpool
using qualitative methods including
interviews with key personnel and participant
observation. The research was used to help
and identify prospects for interagency
working offering insights for those working
in the Project of possible sources of conflict
and change.
Both the theoretical and empirical literature
demonstrates that interorganisational
interaction is a complex, multilevel and fluid
process which can only develop over time and
only when it is perceived by organisations
and individuals as advantageous to the
pursuit of internal and common goals. The
slow developmental process takes place via
many short bursts of exchanges around
individual problems and through small scale
transactions with little risk involved. Over
time trust develops but large scale
commitments rarely occur early.
Research further indicates that
interorganisational relations operate in a
cyclical manner, early ad hoc activities leading
over time to more formalised relations which
create Inner tensions followed by a phase of
reduced interaction. Indeed the whole
process is one of constant flux between
189
interdependence and conflict. Benson3
suggests however there are a number of
strategies that can be adopted to manage
the process and bring about change in
organisational relationship. The study
referred to here covered the first phase of
development with intersectoral activity
consisting of small projects with only verbal
commitment from the large agencies to the
Project as a whole and generally a low level
of awareness amongst members of the
contributing organisations of the Project.
In many ways the Healthy Cities Project is the
renegotiation and recognition by agencies of
their respective responsibilities for the
domain of public health. It is also about
reorienting the flow of resources within and
between organisations. Thus, a number of
key elements were identified by the study as
relevant to effective intersectoral
collaboration. The study examined the
environmental context of the Project, the
degree of organisational connectedness,
domain consensus and territorial tension the
distribution of power in terms of access to
and control over strategic resources, the flow
of resources in existing interorganisational
relations, and the degree of actual and
perceived centrality of key organisations, the
role of informal structures were also
examined, in the particular networking,
interpersonal relationships and the degree of
belief in a common philosophy and ideology
amongst potential key actors. This informal
level holds crucial ingredients in determining
the likelihood of successful collaboration. A
recurrent theme highlighted in research
studies is the role of key personnel with
specific personal and social skills called
networking skills.
Like all those cities chosen by WHO,
participation in the original project for
Liverpool meant the adoption of a specific
planning framework which reflected the
assumptions of a rational planning model.
Research on intersectoral collaboration
demonstrates, however, that in practice
interagency cooperation rarely takes place in
a programmed manner and often varies in its
degree of intensity over time. Both empirical
and theoretical studies indicate that the
existence gf a formal framework does not
guarantee collaboration and indeed effective
and real collaboration is rare. While formal
structures may provide a symbolic signal to
the individuals working within the
organisations concerned of the general
commitment to intersectoral working, those
formal structures merely pay lip service to
the process or even may hinder it. The
interplay of inward looking organisational
goals and objectives and structures,
professional Jealousy and a lack of
understanding of the possible linkages
between agencies which all research studi^,|i]||j
reveal were all manifest In the experience df(,ji||
Liverpool.
The task that the Heathy Gti«$ project in
------------------------------3
4
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1
Liverpool had and has been given was an
impossible task and totally unrealistic. It was
expected that within five years, the goals of
the major agencies would be reorientated,
agencies that were unclear of what their
goals were anyway and who were under
constant threat of change in a different
direction from external forces. It required an
internal restructuring of those agencies and
the development of skills amongst managers
for the management of change in a city
where change is slow. At the same time the
Project was expected to maintain a high level
of visibility and enhance community
involvement from a base in an agency that
historically was perceived as having low
credibility and a poor record of intersectoral
working. It is not surprising therefore that
activity has largely been at an informal level.
Yet given past research, this is the level at
hich successful collaboration is possible if
.e right skills amongst managers and key
personnel are encouraged4. It is networking
that lies at the heart of collaboration. Such
networks provide the cement that any
structure set up requires and the channels
through which information and resources
can flow reducing the level of uncertainty
and fostering trust. Wether The Liverpool
project develops will depend in effective
networking. The process of intersectoral
networking can bring about the cultural
change necessary through the diffusion of
beliefs and attitudes that will change the
behaviour and assumptive worlds of key
decision-makers that influence public policy
and health promotion action. Cultural
change takes along time to emerge and
often involves conflict not consensus.
Dr. Jane Springett
Reader in Health Studies
and Health Promotion,
Liverpool Polytechnic
School of Health Science
Trueman Street Building
15-21 Webster Street Liverpool L3
tel: 051 207 3581, fax: 051 2072630
190
References
1. J. Springett (1991)
The Healthy City Project in Liverpool:
Intersectoral Action: theory, prospect and
experience
Liverpool Healthy Cities Research Consortium
Occasional paper 4/91
2. J. Springett (1992)
Training for Health for All, a discussion paper
Institute for the Advancement of Health
Promotion,
Liverpool Polytechnic Working Paper 1.
3. J.K. Benson (1975)
The interorganisational Network as a
political economy
Administrative Science Quarterly vol 20 June
4. J.K. Friend, J.M. Power, CJ Yellett (1974)
Public Planning The InterCorporate
Dimension
Published under auspices
of:
ng UNIVERSITE
all LAVAL
Ecole des Sciences Infirmi&res,
Groupe de Recherche et
d'Intervention en Promotion de la
Sant6
Cit6 Universitaire,
Quebec, Canada G1K 7P4
DEPARTMENT OF SOCIAL
POLICY AND SOCIAL WORK
Research Unit in Health and
Behavioural Change
17 Teviot Place.
Edinburgh EH1 2QZ,
mexmjx for all
THE WHO HEALTHY CITIES
PROJECT
WHO/EURO
8, Scherfigsvej,
2100 - Copenhagen,
Denmark
Scotland
University of Limburg
School of Health Sciences
PO Box 616,
6200 MD Maastricht,
The Netherlands
4
—
191
1993 / April
41
if the research parameters, let alone the
Editorial
Guest editorial
The fourth issue of this Newsletter
has taken some time to produce.
The Clearing House has been
extremely busy in organizing an
expert meeting on Healthy Cities
Research in November, 1992.
This meeting has been extremely
successful. Thirty academic and
practice researchers have been
meeting in Maastricht where they
discussed various issues pertaining
to a research agenda for healthy
cities. The proceedings book of the
meeting is available from our
centre (see Publications).
Issues 4 and 5 of the Newsletter will
be devoted largely to the
presentations given at the seminar.
They were generally innovative,
interdisciplinary and challenging
orthodox research practices. You
are invited to contact authors in
order to strengthen our
international network.
Also, please send us any material
you want to have published as
news in this circular. Longer
manuscripts may also be published
in our Research for Healthy Cities
Monograph Series. You are invited
to submit such contributions.
Understanding through information
academics and practitioners eager to
exchange
develop their work in city health. Our
research results have yet to be agreed, the
production of a newsletter can only benefit
Evelyne de Leeuw
editor
experience in publishing "Positive Health"
Our world has become a global health
for over eight years now, has demonstrated
village, generating an urgent need for
the need for the dissemination of informed
mutual learning and understanding. We live
opinion and information through an
at a time of increasing health
international newsletter. The critical point is
interdependence both within and between
that the newsletter should be accessible and
nation states. Health has no political
"user friendly" Academic journals and
allegiances, but we have to recognise that it
periodicals can afford to be less concerned
does align itself with economies. The wealth
with these issues since they reach, in
gap between countries and between socio
general, a different more dedicated
economic classes within countries is
readership "Health Promotion
widening. This economic schism is mirrored
International" does try to bridge this
with an ever widening health "gap" There
difference by combining all the traits of
are tragic inequalities in health worldwide
academic publishing with an applied and
which need to be addressed urgently.
practical approach to health promotion by
One way of drawing attention to this
international injustice is to sponsor applied
supporting the development of action as
research into the causes and solutions of ill
has encouraged submissions from Health
health and health inequalities and to make
City researchers and practitioners and over
that research evident and familiar. In the
the last five years has a good record in
developed world we are very good at
collecting data by employing a variety of
publishing papers in this area.
instruments but less successful at publicising
the research findings and the implications of
industry of the twentieth century, and I
suspect will'continue to be beyond the year
the data analyses. Thankfully there is now
2000. We need to feed of this growth by
growing support and evidence that this is
developing our own communication media.
changing.
Cardiovascular intervention studies, such as
Whilst we might need to exercise some
North Kerelia, Standford and Hearbeat
broadsheets, newsletters and bulletins we
Wales have been diligent in publishing the
must recognise that they do provide an
excellent forum for information exchange
results of the interventions. Indeed
Heartbeat Wales has not only published over
outlined in the Ottawa Charter. Indeed HPI
Communication has been the growth
caution in promoting the proliferation of
especially when they supplement other
100 of its own technical and briefing reports
communication means such as symposia and
it has also ensured a wide coverage for its
conferences. Research for Healthy Cities is a
findings in many academic and professional
classic example of this relationship and
journals.
Similarly the Health Cities project has
consequently will, I am sure, grow from
strength to strength.
generated a wealth of interest. Over the last
couple of years it has spawned a number of
publications including this one dedicated to
informing readers and practitioners on the
latest developments in the programme. Even
Gordon Macdonald. .■.•JX,.
,,
. ?!!i'<:ii{ii:ii}i|l
Associate Editor. He^.ei^tion^j
internal
. ...................... .... ........... li|! .
Editor-in-Chief, Positive Health. ■
!
■•1
192
4
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Publications
Maastricht, 15-18 November 1992
Abstracts from the Research for
The Research for Healthy Cities Clearing
Healthy Cities Expert Panel
House is publishing a Monograph Series
The first three volumes are now available
Polman, L , M. Goumans & E de Leeuw
(1992) Healthy Cities Research Bibliography
RHC Monograph Senes No. 1 Maastricht
(250 pages)
ISBN 90-74590-01 2
important to have a project like "Healthy
The Development,
implementation and
evaluation of local
health projects
Leeuw. E. de. M O'Neill. M. Goumans & F
Education of the University of Limburg is
de Bruijn (1992) Healthy Cities Research
Agenda. Proceedings of an expert panel.
involved in the development,
implementation and evaluation of local
RHC Monograph Series No. 2 Maastricht
health projects. The most important project,
the "Healthy Bergeyk" project, started in
1990. Bergeyk is a Dutch municipality with
10.000 inhabitants. The development of the
Goumans, M. (1992) What about healthy
Bergeyk project was based on community
networks? An analysis of structure and
organization principles (intersectoral co
organization of national healthy cities
operation, participation, social network
networks in Europe RHC Monograph Senes
approach, structural changes, etc.), as well as
No 3 Maastricht (100 pages)
health education behavioral change models.
ISBN 90 74590-03 9
The major goal of the project was a
reduction in cancer-related and coronary
Orders:
These publications may be ordered through
heart disease-related risk behavior
prevalence. During the experimental phase
your regular bookseller (quote our address)
of this project, a project group with
or directly from
Research for Healthy Cities Clearing House
representatives from eleven different sectors
organised several health activities for their
University of Limburg
community, such as stop smoking courses,
nutrition education meetings, self-help
PO Box 616
6200 MD Maastricht
The Netherlands
fax +31 43 67 09 32
materials on smoking and nutrition, an
information centre, mass, media messages, a
sandwich "Healthy Bergeyk" which was sold
The price for each volume is DEL 25.
in local cafeteria's, etc. The project group
was supported by a parttime local
Payment should involve no charges on our
co-ordinator and used a workbook that was
part, and should be made out to:
developed by the university. In this
workbook about 30 possible health activities
University of Limburg
Netherlands Postbank Account No. 2103100
were described. To assess the results of the
Quote Budget number 235 915. 'Research
project, Bergeyk was copared to a control
for Healthy Cities'. RHC Mono No
community. Telephone interviews were
conducted at three times with about 600
inhabitants from both the experimental and
the control community. The pretest was in
I
(
As far as behavioral effects were concerned,
the results suggested that the project
successfully reduced fat intake in the
experimental community, compared to the
were found on smoking behavior, alcohol
consumption or exposure to artificial
sunlight. On the whole, the projectgroup
members were satisfied with their
participation in the projectgroup and the
function of the group. Especially the
intersectoral co-operation was judged
positively. The time presure on the project at
a results of the fact that there was a
research connected to the project, was a
negativ side of the project. Also, the
projectgroup had the opinion that the
University had been to steering at some
occasions. After the research was finished,
the project has been taken over and
continued by the projectgroup, though the
university is still in de advisory committee o
the Health Bereyk project.Currently. the
Department is conducting the process
evaluation of the local fat reduction
program "Let op Vet" (Watch fat) in
Alkmaar. This project is an experir
initialized by the Dutch Steering C
't
mitte
on Good Nutrition. In the next few years,
this committee aims to start several local
nutrition projects as a continuation of the
National "Let op Vet" Campaign. In Alkma
an analysis will be made of local policy
development and intersectoral co-operatic
Besides the projects described, the
Department of Health Education conducts
several worksite projects and projects on
smoking prevention in schools. Also, the
Department advises the Regional Health
Center, that is starting neighbourhood
February 1990 (T1), project implementation
health projects in Maastricht. Finally, the
Department aims to start a research on tl
took place from March 1990 to February
1991, while two follow-ups were conducted
possibilities and willingness of national
in February 1991 (T2) and September 1991
i
thought the project should be continued.
control community. No significant effects
Since 1988 the Department of Health
(70 pages)
ISBN 90-74590-02-0
Bergeyk" in their community. Almost 80%
(T3). Process-evaluation was assessed during
organisations to support local nutrition
projects.
the whole implementation period. At T2
more than 80% of the respondents in the
experimental group wwas familiar with the
project. Additionally, almost 40% said that
they had talked with someone else about
the project. Of those familiar with the
!
protect, more than 80% thought it to be
Patricia van Assema
Department of Health Education
University of Limburg. PO Box 616.
6200 MD Maastricht The Netherlands
phone:+31 43 88 33 04
fax: +31 43 67 10 32
4
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1
Maastricht, 15-18 November 1992
Planning healthy
Communities
Abstracts from the Research for Healthy Cities Expert Panel
Bedford Park\South Australia 5042
the evaluation, implying that the
interviews have had a motivation' effect
Australia
on the politicians and an improvement in
Research Unit Flinders Medical Centre
Phone +61 8374 1177
Video “Best Laid Plans"
(VHS format)
20 minutes
department s attempt at needs assessment
the goes wrong. It raises questions about the
use of research by bureaucracies, ways in
which communities can be involved in
research and the most appropriate
methodologies for community health needs
assessment The video was made to
accompany a manual on how to do
community health needs assessment
he video would be a good discussion starter
about these issues which are central to
Healthy Cities research agendas
Research for Healthy
cities: experiences from
down-under
the relationship between them and us
2 We can now say that
Most of the municipalities have had good
fax +61 8 3 74 0230
outcomes measures (in terms of Health
(produced by S A C H R U )
This video is a wry look at a health
193
Diagnosis and Plan Fulfillment).
The Healthy Cities
Movement in the
Valencian Network
But less than half of them have developed
The Valencian Community occupies the strip
and cultural proximity, technical support
of Mediterranean coast between Catalonia
and attendance of the annual meetings as
intersectoral and have practiced
participative ways of working. Looking at
the healthier factors, we show geographical
and Murcia and has a population of almost 4
favourable factors for the development of
million inhabitants In 1987 the idea if
the project. And we detect the important
Healthy cities m our Region began to
role that the network plays in giving
develop The University of Alicante and the
information, encouraging motivation,
Valencian Institute for Studies in Public
facilitating cooperation, coordination and
Health (IVESP) took on the committment of
better use of resources
giving research and training support to the
H.C. Project in the Region, some months
What are we going to do with these results?
later the regional Network was established
1 We gave some feed-back to the
From 1987 until February 1992, 59 cities
(which house 62Ozo of the total population)
made up the Valencian Healthy Cities
Network. The interest of the cities to join
the Network altered over the years, but it
participants in the Regional Healthy Cities
annual meeting last April
2 We will have workshops with them to
discuss the difficulties they have and to
plan future activities.
3 We want to establish evaluation as a
Healthy cities was adopted as a national
was related to municipal elections
pilot project in Australia in 1987 Four
Among the tacit committments of the
process and to repeat the interviews with a
"cities" were involved in the three year pilot
Network one can highlight
visit to them every year
Noarlunga (South Australia), lllawarra (new
1 Approval by a council majority of the
South Wales), Canberra (Australian Capital
Territory) and Nganampa Health Council
(central Australia). The national project co
willingness to join the network and
obligation to carry out a Health Diagnosis
2 Setting up of a Health Plan that corrects
ordinated research and evaluation
the existing deficiencies and inequalities in
endeavours for the three year period
health.
This resulted in detailed evaluations of the
evelopment of a Healthy Cities evaluation
framework These and subsequent
Conclusions
Concerning the evaluation methodology
1 It's very difficult to evaluate this kind of
projects or movement. We need a dynamic,
partipative, flexible, motivating and in
3 The above should be carries out an
intersectorial approach including
community participation.
some way 'political evaluation It's
necessary to involve and respect the
politicians and their needs, and at the
same time to assess what's happening and
developments will be described in the paper
to simulate the process.
1 EVALUATION
Healthy Cities research in Australia has been
After 4 years working in the Network we
of two types: evaluation of Healthy Cities
decided to start a process of evaluation or
A Political evaluation, from
initiatives and the development of ways of
assessment of the project. We interviewed
B Public Policies analysis
measuring the health and assessing needs of
those responsible for the project in each city
cities and other communities. Both of these
(mayor, health councillor and technical
categories of research have raised
coordinator), asking them about two kinds
substantive methodological concerns about
of variables.
issues such as competing and
1 Outcome variables: those related to the
complementary research paradigms, the
committments taken (health Diagnosis and
2 It is necessary to separate
Concerning the results in our network:
1 Quantity doesn’t mean quality, in other
words:
* We have many cities in the network but
not all of them are really working in the
Planification)
2 Other variables that could explain the
H.C. Movement ' Some of them are
interested just in the beautiful flap of H C
will review these issues drawing on
success or failure of the idea, such as
Australian experiences, and consider ways in
political parties supporting it, the person
but not in the health of the citizens.
* On the other hand, the bigger the city, the
which research can be made more
to start the project, budget, size,
participative and contribute to encouraging
participation in the network activities,
policy agendas to shift towards health
->romotion goals
external support, etc.
And ... what happened?
Fran Baum
2 EVALUATION RESULTS
and individual leadership. Which means
Southern Australian Community Health
1 We have had some 'good side effects' of
that the possibilities of continuity are very
value of research to planning and the values
and interest underlying research. The paper
worse the results. All three cities with more
than 100.000 inhabitants have important
problems in developing the H.C. ideas
2 The movement, at least in our reality,
depends too much on personal involment,
3
4
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X
Maastricht 15-18 November 1992
194
Abstracts from the Research for Healthy Cities Expert Panel
weak in fact we have some cities that have
contemporary health promotion goals and
experienced good development until the
values m order to address questions
politician or the political components
.-hanged Then, the movement came to a
st aridstill
Challenges
1 To develop methods to assess health',
public policies
2 To move from politics to policies
Obtaining
Continuity To overcome politician and
personal changes
Mechanisms of social accountabilitv
Favourable social climate
Rosana Peiro
Institut Valencia d'Estudis en Saint Publica
including to what extent is Healthy Cities
practice distinctive, what practical lessons
Constructing
Involvement in Healthy
Cities
have been learned in the project about
initiating and sustaining change at city
level, what do participants consider to be
The goals of the research project
Constructing Involvement in Healthy Cities
the processes which contribute to
are manyfold One is the design of a
S'irces/failure and what are their
assessments of the policy context in which
typology on the topic of participation
the projects operates in their city?
of characteristic Dutch Healthy City projects
Another is the classification and description
with the help of criteria and a questionnaire
3 To produce a critical view of the
information aprocess entailed in the
research in order to identify obstacles to be
better description and dissemination of
reports of Healthy Cities practice
derived from the typology A comparison is
made with US and Canadian projects studied
on location The third goal is a field
experiment in the North part of Amsterdam
Here in a collaboration between the
Amsterdam local authorities, the health and
(IVESP) Juan de Garay 21
Methods
The mam data collection instrument was an
46017 Valencia. Spam
phone +34 6 386 9369/386 9383
extensive written questionnaire which was
Immigrants and Health is established
negotiated with WHO and sent out by them
The method used is an integrated and non
to all cities participating in the Healthy Cities
individual modification of the Delphi
fax
+34 6 386 9370
Sharing evidence of
good practice in the
Healthy Cities
movement.
Introduction
A movement such as Healthy Cities is
vulnerable to the charge that it is stronger
on rhetoric than achievements unless it can
demonstrate examples of practice which are
welfare services, the immigrant comn
‘ies
and the Utrecht University a project ca..ed
project in 1991 The questionnaire was semi
method While developing a health project
structured with a large number of open
questions Project respondents were asked
with and for immigrants an underlying
to select up to three Healthy City activities in
dichotomies of top-down versus bottom up.
their city which they considered to be their
objective versus perceived health and
greatest achievements Questions covered
research versus action Meanwhile, in a
aims, processes and resources, outcomes and
fourth project, a more solid theoretical base
self-perceived reasons for success
Supplementary informal material in the
for Healthy Cities in social sciences is
attempted to build Used are among other
form of reports etc was also solicited
purpose is finding a way out from the
theories from the tradition of Urban
Studies
Results
To date information has been obtained on
36 activities in 14 cities and is being analysed
Joop ten Dam
innovative, distinctive, applicable elsewhere
and compatible with the goals and values of
by qualitative methods. Preliminary analyses
Urban Studies
Department of General Social Sciences
the movement as a whole Yet identifying
suggest that intersectoral collaboration is
University of Utrecht, PO Box 8014P
"models of good practice" can be a
problematic research task. We may ask who
identified by many participants as an
important process in obtaining resourses for
3508 TC Utrecht, The Netherlands
a project Outcomes identified by
fax +31 30 531 619
is defining good practice; at what stage can
initiatives be identified as successful; and
how are local experimences to be made
useful and disseminated to others,
particularly given the great diversity of
settings for Healthy City projects? The
research I shall be presenting was an
attempt to negotiate a method for
participants as useful include increased or
denser activity within networks associated
with project activities The analysis will be
completed by October 1992 and in the
presentation I hope to suggest how
subjective material of this type could be
incorporated into pluralist evaluation
describing local Healthy Cities practice as a
preliminary to developing frameworks which
strategies for Healthy City projects
could be used for evaluation
Lisa Curtice
Research Unit in Health and Behavioural
Aims
1 To pilot a research approach to enable
Change
The University of Edinburgh
project participants to identify and
24 Buccl^uch Place
Edinburgh EH8 9LN, Scotland
describe project and programme
development work which they considered
worth disseminating and to elicit their
criteria for success.
2 To describe and analyse a range of local
Healthy Cities activity within the context of
phone: +31 30 534 7001534 9171531 408
Thoughts on Research
The need for a multi-disciplinary systems
oriented study of health and cities.
The problem of synthesis of ideas from
diverse orientations. How can we pull
together ideas from medicine, to politics,
phone: +44 31 650 1000
fax: +44 31 662 1552
sociology economics, etcetera.
How can we study values that are
important to a Healthy City program? Wh.
is the relationship of Healthy City to other
values in the community? The importance
culture, religious practices and local custo
An awareness of the base line data
needed, that is obtainable from existing
studies and reports
What are the new kinds of data needed
4
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Maastricht, 15-18 November 1992
Abstracts from the Research for Healthy Cities Expert Panel
The importance of studying process
way m which the three predominant
inc often .-.e look at input and output, and
elements in the Healthy City concept are put
into practice by those involved, to keep the
qr.orn the way business gets done
Th-s Aould include research on issues of
project moving in the right direction
iai entrepreneurship", or how to get
shannq of common objectives, citizen
business done, creativity developing
participation and intersectorial action
vueptsand ideas, planning, programs, and
Finally, the analysis will focus on the
■•■anagement Some prelimmiry material on
concertation structure and activities
•np topit is in my book.
generated by the initiatives
Ine Social Entrepreneurship of Change.
Pate University Press. New York, 1990
Tools for research, which include
195
Interactive method
The evaluation method used is based on the
for healthier cities, m the areas of epidemies
prevention (AIDS, cholera, etc ) and the
rationalisation of human, economic and
technological ressources
The research is developpmg the following
steps
a) identification of current experiences on
the use of ICT m the management of public
and private health services, b) Evaluation of
the impacts of ICT use regarding benefits for
users, health providers', the health system
and urban life quality, impacts on connected
areas, such as training and research,
anthropological research and other
same approach used by the Healthy Cities
qualitative techniques, library research
including "browsing" through information
movement, i e on the participation of the
prevention and public information
parties involved Data collection occurs
from diverse fields, quantitative inquirv. and
throughout the study via interviews, field
campaigns, etc . c) Evaluation of the impact
of ICT application considering the level of
more
observation, perusal of written documents
One area that interests me is ‘be processes
of getting to know a city, using some other
It is interspersed of periods of analysis
closely involving those responsible for the
techniques outlined in "Guide to Assessing
initiatives, by means of a steering
Healthy Cities", which Hancock and I wrote
committee
The committee, consisting of representatives
Leonard Duhl
of the studied initiatives and researchers,
School of Public Health
meets on a monthly basis
University of California
The representatives are asked to comment
Berkeley CA 94708
USA
on the data collected by the researchers
phone +1 510 641 1715
then conveyed to the three communities by
fax
510 643 6981
Analysis of the
implementation of
three "Healthy City"
initiatives in the
Montreal area
In September 1991. a research team began
to evaluate some "Healthy City" initiatives in
the Montreal area At first concerned about
the research of indicators, the team chose a
method which was perhaps less ambitious
than analysing the results, but which is
nevertheless just as promissing the study of
the implementation of the projects.
Three Case studies
Three initiatives ware under study Pomte-
Claire, a small Montreal suburb whose
population can generally be described as
being of a high socio-economic status and
two of Montreal's working class
The outcome of these monthly meetings are
means of a monthly liaison bulletin
Significant results
The analysis showed the attractiveness of
policies for ICT application for healthier
cities
The program also partipates in a network
including teams from Venezuela (CENDES).
USA (university of Hawaii) and Mexico
Susana Finquehevich
Centro de Estudios Urbanos v Regionales
Av. Cortlentes 2835
efficient functionning methods to mobilize
Cuerso "B" 70 Piso
citizens and organisations from different
(1193) Buenos Aires
backgrounds around common and diverse
Argentina
phohe -i-SA 19612268
projects
fax +54 19611854
Danielle Durand
DSC Lakeshore
175. chemin Stillwew #310
Pointe Claire
Quebec. Canada H9R 4S3
phone. +1 514 694 2055
The Rotterdam Health
information system
In Rotterdam a local health information
system had been developed which supports
Information
Technologies as Tools
for Healthier Cities.
Policies for the 1990's
in Latin America
This research program, started by CEUR and
individually and comparatively according to
Fundacion RED in 1992, intends to study the
a series of variables. The analysis is first
use of information and communication
technologies (ICT) in the field of public and
the local community). It will then study the
conservation, services for lower income
groups, etc , d) Comparison between the
cases of Buenos Aires and Rio. f) Proposals of
the "Healthy City” project. Such
attractiveness lies upon its flexible and
The three initiatives are being analysed
tne internal environment (characteristics of
the interaction with urban areas such as
water and sanitation, environment,
(Cologie de Mexiro)
communities, Mercier Est and Saint-Michel
looking at the initiatives' external
environment (laws, by-laws...) and those of
efficiency achieved, the degree of
operativity. the coverage of the services and
the local strategies for Health for All
The WHO "healthy Cities project" makes
such a system highly desirable.
The paper pays attention to the goals and
design of the system and presents some
results.
The central aims of information systems are:
1. to record the health situation and related
factors in the city of Rotterdam at district
2
and neighbourhood level;
to contribute to the development of a
local health policy for reducing the noted
private health services' management, using
differences in the health situation of the
Buenos Aires and Rio de Janeiro as case
studies The main goal is to propose policies
population.
5
4
rec' ea
1
Maastricht, 15-18 November 1992
1 he information system contains data
Abstracts from the Research for Healthy Cities Expert Panel
autonties have been convinced to throw their
relevant to health, not only mformat.on on
weight behind healthy community projects
health itself but also on -determents of
has been generated in categorical health
health"
programs, such as heart disease prevention
information ,$ rollected from vanous sources
rtia! can be rouqhlv categorized as follows
statistical information, such as mortality
and morbidity rates, figures covering
health related areas like housing,
employment and leisure time activities and
so on and so forth.
lata collected from the population itself
among others by questionnaires (health
surveys) data related to health . lifestyles
and determants of health.
documentary information (gathered from
the local newspapers and hmftedcirculation
196
Zealand and Japan What is less well known
is the rapid development of Healthy Cities
projects m an increasing number of
developing countries
projects, and these have usually been
The objective of the Healthy Cities project is
university based rather than community
based This paper will compare some of the
differences in the implementation
to strengthen the capability and capacity of
municipal governments, and to provide
opportunities for individuals, families and
experiences between community-based
community groups, to deal with their health
projects pursuing the pre defined categorical
health model, particularly in cardiovascular
and environmental problems "Healthy
Cities" achieves this by providing a
disease prevention, and healthy community
framework which combines several key
projects sponsored by the same Ministry of
Health m British Columbia, but starting from
elements
a carte blanche with respect to the definition
of health or health-related problems Our
methodology will be to compare the actual
experience of two groups of projects in the
Increased awareness of health and
environment issues in urban development
efforts by all municipal and national
authorities.
A network of cities which provides
same province of Canada, matching
information exchange and technology
ideas and views of key members of the
comparable communities and examining at
least the early stages of their development.
transfer,
community as expressed in personal
interviews, group discussions or in
Neither group of projects will have reached a
leaflets),
questionnaires
rhe system is a collection of quantitave data
(numerical material from vanous statistics
and health surveys) linked with qualitative
data (with emphasis on content, underlying
information derived from documentation,
key informants, etcetera) The data are
collected and presented at district and
neighbourhood level
Fh? paper will discuss some results and the
meaning of the system for health policy
Henk Garretsen
Head Department of Epidemiology
Municipal Public Health Service
O Box 70032
3000 LP Rotterdam
phone +31 10 4339 620
fax +31 10 4339 493
A Comparison of Pre
defined Categorical
Health Projects and
Open-ended
Community-defined
"Healthy City" Projects:
A Tale of Two Cities
One of the guiding principles of the
Healthy Cities" process has been that the
community ideally begins with a clean slate
which to define its own priorities for its
community development effort. Much of the
research base, however, on which health
point of having concrete outcomes that can
be compared at the time of the conference,
but we should be able to compare the
barriers and challenges they encountered in
the planning and mobilization process, how
they overcame these problems, and how the
respective program plans meet various
technical criteria of planning such as dear
A linkage of technical programmes for
health and the environment with political
mobilization and community participation
New partnerships are developed between
municipal government agencies (health,
water, sanitation, housing, social welfare,
etc ), universities, NGOs, private companies
and community organizations and groups,
to make the urban environment supportive
of health rather than damaging to it
objectives, timetables, allocation of resources,
and assignment of responsibility The
community projects will be compared also on
how they meet criteria of health promotion
as promulgated by various provincial,
national and international organizations such
as the Health and Welfare Canada (Achieving
Health for All), the B.C Ministry of Health.
the American Public Health Association, and
the World Health Organisation Finally, we
will include a discussion of how different
"models" or assumptions drive the
implementation process.
Major developments in Healthy Cities in the
fast six months include
* In the Eastern Mediterranean region:
Many countries are planning national
networks of Healthy Cities There was a
remarkable meeting in Teheran in December
1991, attended by 19 out of 23 major citic*'
in Iran, the provincial capitals, with 19
mayors in attendance and many key political
figures A Healthy Cities office has been set
up in Teheran, and projects have been
Lawrence W Green, James Frankish & Joan
started to upgrade a number of low-income
Higgins, Institute of Health Promotion
housing areas in the city
Research, Faculty of Graduate Studies
6248 Biological Sciences Road
In Pakistan, in February 1992, there was a
Vancouver BC V6T 1Z4
meeting in Lahore to set up a national
phone: + 7 604 822 2258
network of Healthy Cities which attracted
fax. +7 604 822 3210
many mayors and national officials, and it is
planned to commence the project in 12
major cities including all provincial capitals
Rapid development of
WHO Healthy Cities
Project outside of
Europe
and the national capital.
A number of other countries in the region
are setting up, or have plans to set up,
similar networks including Saudi Arabia,
Egypt, Yemen, Tunisia and Morocco. Many
of the above cities intend to participate in
The WHO Healthy Cities Project is best known
the 7th International WHO Healthy Cities
for its work in cities throughout Europe, as
Symposium. Copenhagen, 9-12 June 1992,
well as the US, Canada, Australia, New
with a particular interest in developing
6
4
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Maastricht, 15-18 November 1992
197
Abstracts from the Research for Healthy Cities Expert Panel
twinning arrangements with European
Consortium for Public Health to take place in
(n = 4) and (categories of) activities (n = 9)
cities
San Francisco in December 1993, which is
which were examined The analysis provided
* In the African region:
expected to attract many cities from South
information about the development of the
and Central America that wish to participate
network, among other things it looked at
A major meeting in Ghana of the Accra
m Healthy Cities. The meeting will be
why they started, who took the initiative,
Healthy Cities Project took place in March
bilingual, in English and Spanish.
what changes occurred during the period of
development, who were the participants at
1992, with a focus on a review of health
problems in Accra, and on developing broad
* In the Western Pacific region:
strategy directions, which covered the
There have been discussions on a city
undertaken, and the relationship between
following areas: environmental sanitation,
networking project involving participants
activities and participant As expected, the
food hygiene, development of urban health
from China, Malaysia, Philippines, Republic
findings did not provide a uniform picture of
services, school health, public education and
of Korea, Singapore, Japan, Australia and
'what a national Healthy Cities network
communication, community involvement in
New Zealand. Only the latter 3 countries
should look like' nor did the give the recipe
health and sanitation, and land-use
have an established Healthy Cities project,
of 'how to become a Healthy Cities
planning. A subsequent workshop in
but all are discussing and planning a project
network'. However, the strength of national
action plans. There was an excellent
Greg Goldstein
continue the Healthy Cities project aims and
attendance by senior politicians and good
Responsible Officer
objectives, even if the WHO project ever
Environmental Health in Rural and Urban
ceases
networks is that the have the potential to
Sogakope undertook to develop specific
>edia coverage. The Ghanaian city of
a national level, what activities were
Kumasi was also represented at this
Development and Housing
meeting. A series of further activities were
Division of Environmental Health
WHO/HQ
Dept. Health Ethics & Philosophy
Via Appia, 1211 Geneva 27, Switzerland
Section Health Promotion
identified with a particular focus on the role
of sub-district health management teams.
An African French-speaking network of
Marleen Goumans
phone: +41 22 791 21 11/791 35 59
University of Limburg
fax: +41 22 791 07 46
PO Box 616, 6200 MD Maastricht
Healthy Cities is progressing well, and with
The Netherlands
Canadian Government support,
phone +31 43 88 11 49
a preliminary meeting of this network is
planned to take place in Dakar, Senegal,
2 5 June 1992. It includes Cameroon, Chad,
Congo, Zaire and Senegal. Ghana and
Nigeria may also attend the meeting
The Third Global French-speaking Healthy
What about healthy
networks?
An analysis of national
healthy cities networks
in Europe.
Cities Congres is scheduled to take place in
Montreal and Sherbrooke (Canada, Province
of Quebec) from 27 September to 2 October
The World Health Organization (WHO/Euro
1992, and cities located in all WHO regions
Healthy Cities Project has received much
^re expected to attend
attention since the first project cities were
selected in 1987. In fact many more cities
fax: +31 43 67 09 32
Report on a Proposal to
EC "Evaluation of the
World Health
Organization's Healthy
Cities Project and of its
Spin-off-Effects in Six
European States"
* In the South-East Asian Region:
than can participate showed (and still show)
A network is being developed in 6 cities in
their interest. This initiatives have been
The BIOMED programme offered an
various countries (Bangkok, Kanpur,
taken to establish activities similar th the
opportunity for collaborative research
Hyderabad, Dkaha, Surabaya, Colombo), and
Healthy Cities Project, not only in Europe but
programmes within the EC. Together with
funding for initial activities is in the process
all over the world, 'national networks of
five other partners (Greece. Italy. Austria,
of being secured. Healthy Cities will be the
Healthy Cities' have developed. The national
Spain, Great Britain) we developed a
focus of a WHO inter-country meeting on
networks in Europe call themselves
proposal and sent it to the EC. This proposal
urban health in New Delhi planned for
EURONET, a European network of national
has been postponed to winter 92/93.
August this year.
Healthy Cities networks. EURONET is not a
In its summary we stated:
formal association; how this initiative will
* In the Americas:
develop in the near future is under
"The Healthy Cities Project is innovative in
Apart from Canada and the US, Healthy
discussion.
Cities initiatives are in progress in Brazil (Rio
A national network is an example of a social
that it introduces, on a local level,
new patterns of decision-making and
de Janeiro), Bolivia and Colombia
network, but because of its complexity and
administrative planning as well as new aims,
(collaboration with Canada/Quebec)
different levels of 'networking', is difficult to
structures and instruments of health policy.
The WHO Collaborating Centre in Indiana is
analyse. However analysis, and evaluation, is
The WHO directs a complex and much-in-
actively working to promote an
needed to review the functioning and
depth action programme at local institutions
international network of cities in this region,
impact of the healthy cities idea. To study
without spending substantial financial
and is also developing a global database on
and analyse the networks in Europe, which
?althy cities.
There is an international meeting on Healthy
are as a whole rather large, a selection has
been made to reduce the number of
funding. In this respect, too. the WHO
Project, in international discussion, is treated
as a model. This model rhay also be
' ‘
Cities planned by Western Pacific
participants )n = 14) number of resources
interesting, in accordance with the
.
'/"Mil
7
4
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Maastricht, 15-18 November 1992 Abstracts
198
from the Research for Healthy Cities Expert Panel
conclusions of Maastricht, for future EC
Programme. Six research teams from
action programmes which will improve the
consulting institutions (small enterprises) or
health systems in the Member States.
universities will join in the Concerted Action,
such teams representing six European
Evaluation of the WHO Project, however, is
countries with a focus on Southern Europe
only beginning in some countries or regions
It is hoped to work for two years."
The evaluation will critically review the
Healthy Cities project in Glasgow.
The strengths of these projects are identified
including their focus on participation,
empowerment and change Some of the
tensions and difficulties in these projects are
also described In particular, the lack of a
clear theoretical and methodological
framework, the need to statisfy very
extent to which innovations have effectively
Helmut Hildebrandt
been realized It will examine the ways of
GesundheitsConsult
disparate constituencies, highly positivistic
expectations of communities as well as local
making operational the conceptual goals
politicians, the role of local politicians
themselves in the research process, the role
communication between all parties
Falkenned 74a
2000 Hamburg 20. Germany
phone +49 40 480 2637 I 48 84 90
concerned (WHO/Cities. cities/cities within
fax. +49 40 48 89 59
and will scrutinize the problems of
the national subnetworks, municipal
it will further provide knowledge about how
a supra-national body can, and needs to,
guide the local process of action in the
respective countries. For such results to
become comparable and productive for
future European action programmes, it
appears useful to organize a coordinated
and comprehensive evaluation study under
the BIOMED 1 Programme
The proposed Concerted Action will
therefore consist in (1 ) establishing common
criteria, methods and tools for the national
evaluation studies to be carried out by the
participating research teams, (2.) jointly
comparing and analysing the national results
with a view to compiling a comprehensive
evaluation report. Such Action needs a
coordinating body, certain meetings of
embers of the researchteams,
communication facilities and scientific
support in order to achieve a "European
added value" under the BIOMED 1
the relationship to mainstream medical
public health.
admmistrations/citizines in it iat ives/loca I
□erts).
of city hall bureaucrats in the research, and
Theoretical Problems
and practical
applications:
developing an
appropriate science for
Healthy Cities
A sociological account of the tensions and
difficulties is provided in terms of the
difference between modern and post
modern theories of social formation. It is
further argued that the disjunction between
the pathogenic disease model and the
salutogenic positive health model and a
failure to integrate different analytic and
conceptual levels (individual, organisational,
This paper describes briefly a series of small
scale research projects carried out in
Glasgow between 1987 and 1991. Each of
social and environmental) helps to explain
the difficulties of applying Health for All
principles within a conventional scientific
these projects used the community
development perspective on health and
discourse
attempted to put into practice some of the
Mike Kelly
University of Greenwich
Health for All principles particularly
participation and intersectoral collaboration
The three projects are concerned with the
effects of unemployment on health,
School of social sciences
Churchillhouse
Wellingtonstreet. Woolwich.
provision of child care support in multi
London SE 18 EPF England
deprived communities and the development
phone: +44 81 316 8902
of a community health profile. Each of these
Fax: +44 81 316 8905
projects has been linked to the University
Department of Public Health and to the
Published under auspices
_______ __
of:
UNIVERSITE
LAVAL
Ecole des Sciences Infirmferes,
Groupe de Recherche et
d’Intervention en Promotion de la
Sant£
Cit6 Universitaire.
Quebec. Canada G1K 7P4
University of Limburg
School of Health Sciences
PO Box 616,
6200 MD Maastricht.
DEPARTMENT OF SOCIAL
POLICY AND SOCIAL WORK
Research Unit In Health and
Behavioural Change
17 Teviot Place.
Edinburgh EH 1 2QZ,
Scotland
MEXUJX FOA ALL
THE WHO HEALTHY CITIES
PROJECT
WHO/EURO
8. Scherfigsvej.
2100 - Copenhagen,
Denmark
199
1994 / Januari
re
CZ..
.
51
(Hites
Editorial
Healthy City Conferences
booming industry?
Following the explosive growth of the
healthy cities movement academics now
witness a booming conference industry
around the theme. If you'd really want, you
could be m Hilton Hotels and on JumboJets year round. The last quarter of 1993
witnessed two healthy city confe-rences
which both claimed to be 'global'. Between
25 and 30 October 1993, the 1993 Cultural
Capital of Europe, Antwerp, was host to a
twin-conference 'City 93; urban environ
ment, social issues and health in cities' 'EPH 93; environment and public health in
modern society'. Although many, many
interesting presentations were proposed,
the infrastructure and logistics of the
onference did not facilitate the type of
exchange healthy cities initiatives require.
Too many lengthy plenary lectures and too
little workshops in weird environments
(imagine conducting four parallel work
sessions with around 300 people seated
aside long tables in one and the same
hall...). Colleagues who did not attend the
Antwerp meeting may consider themselves
fortunate: they didn't waste any money.
Those who stayed at home between
7 and 12 December missed out on a great
International Healthy Cities and
Communities Conference in San Francisco.
Although dominated by US participants,
the conference bore a truly global healthy
city attitude. The conference was organized
through healthy cities principles:
public participation and self-organizing
systems brought about a meeting with
^early 100 worksessions and some
ipressrve plenary presentations.
A 'Commons' area facilitated communica
tion and exchange of experience, and site
visits in the Bay Area brought to light some
of the appalling environmental and social
conditions in the US as well as the
incredibly creative solutions implemented.
It is still unclear whether there will be
proceedings of the conference (one would
expect the organizers require several
massive volumes). However, the work
session devoted to research, run by the
Maastricht WHO Collaborating Centre,
added about 50 researchers to the list of
subscribers of this Newsletter. In upcoming
issues several of the projects presented at
the conference will be described and/or
reviewed.
Stay tuned!
Evelyne de Leeuw
editor
Guest editorial
Cityhealth research
network aims to put
the cooperation back
into research.
Co-operation is a precondition for effective
healthy cities research. No one discipline,
research centre or nationality could expect to
encompass all the necessary perspectives.
Moreover, partnership between researchers
and practitioners is essential in healthy cities
research. The need for co-operative
approaches to healthy cities research derives
from the priorities in urban health practice
which the healthy cities movement have
brought to light. There is a need, not only to
create, but also to transfer knowledge about
how to undertake programmes to improve
and sustain the health and environment of
cities. This in turn calls for a new set of
research skills. We need to be able to evaluate
the effectiveness of approaches to urban
health, taking into account differences in local
settings and using criteria which are meaning
ful, not only to technical experts but also to
politicians and local residents. This requires
that we can work together to improve
communication, to integrate different kinds of
expertise and to disseminate knowledge of
good practice. In practice grant-awarding
systems and research jobs often favour
competition, specialisation and topic-based
approaches. But funding from the European
Union has provided a way for some urban
health researchers to tackle these problems.
The EU Human Capital and Mobility
programme aims to improve human resources
by enabling researchers to move within
Europe to develop their skills. Under this
programme the Commission has awarded a
grant for a research network on the theme,
CITYHEALTH. Over the next eighteen months,
seven research centres in different European
countries will be jointly developing and
comparing approaches to the evaluation of
urban health policies and practices. The grant
for the network will be used to employ at
each centre a researcher from another
European country and for a small number of
joint meetings. Within the network research
programme, each research centre has selected
a complementary research theme and has
also identified a project which can be used to
train the researcher and to give him or her the
opportunity to contact local practitioners in
the field. The network themes include
environmental health, policy development,
organisational development and impact
evaluatjph.' The advertisement for the network
research posts appears in this issue of the
newsletter. Please help us to publicise it widely.
With this recruitment the network is taking
the first step to model a process of research
co-operation which is based on sharing skills
between countries and disciplines.
Change,24
wi'lfj
4
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1
Quebec network
publishes directory
The network office of the Reseau
Quebecois de Villes et Villages en Same has
,ust published a wonderful directory with
istmgs of participating cities and villages,
some of their core indicators (demographic
information, contact addresses, responsible
coordinator and politician),and past, current,
xuture and possible projects in the cities.
Apart from a quite mobilizing book
(;t just shows how broad and powerful the
Quebecois Healthy Cities movement is)
the material presented in the document
might also be of interest to researchers
formulating healthy city research questions.
The scope of current activities turns out to
? very wide, and researchers may use the
descriptions provide to lay foundations for
community and action relevant
(and therefore 'fundable'?) inquiries.
The availability of the material on diskette
would facilitate the use of the material for
research purposes.
Contact:
Reseau Quebecois de Villes et Villages en
Sante
1050, Chemin Sainte-Foy
Quebec
Quebec CIS 4L8, Canada
fax+1 418 682 7925
Research Monographs
still avalaible
Iman, L., M. Goumans & E. de Leeuw
(1992) Healthy Cities Research
Bibliography. RHC Monograph Series No. 1.
Maastricht (250 pages)
ISBN 90-74590-01-2
Leeuw, E. de, M. O'Neill, M. Goumans &
F. de Bruijn (1992) Healthy Cities Research
Agenda. Proceedings of an expert panel.
RHC Monograph Series No. 2. Maastricht
(70 pages)
ISBN 90-74590-02-0
Goumans, M. (1992) What about healthy
networks? An analysis of structure and
organization of national healthy cities
networks in Europe. RHC Monograph
Series No. 3. Maastricht (100 pages)
ISBN 90-74590-03-9
r"rik, M. (1993) An exploratory inquiry into
e meaning and implementation of health
promotion within the health promotion
and health education departments in
England and Wales. RHC Monograph Series
No. 4. Maastricht (88 pages)
ISBN 90-74590-04-7
Orders:
These publications may be ordered through
your regular bookseller (quote our address)
or directly from:
Research for Healthy Cities Clearing House
University of Limburg, PQ Box 616
6200 MD Maastricht, The Netherlands
fax +31 43 67 09 32
ft
200
The price for each volume is DFL 25.
Payment should involve no charges on
our part, and should be made out to:
University of Limburg
Netherlands Postbank
Account No. 2103100
Quote Budget number 235 915,
'Research for Healthy Cities',
RHC Mono No. ..
/Abstracts from the Research for
Healthy Cities Expert Panel
Health and Housing Survey 1992, Belfast
The Healthy Cities Project is a World Health
Organisation initiative to create a European
network of Healthy Cities whose residents
and administrators will corporately ensure
that health in the widest sense, is explicitly
considered in policies, plans and
programmes which directly or indirectly
affect the health of the city residents.
The project seeks to stress three key
elements of health promotion within the
urban context;
1 .The promotion of healthy lifestyle of city
dwellers.
2. The promotion of health as a
fundamental consideration within public
policy, plans and programmes.
3. The creation of a healthier urban
environment.
governed by five specified objectives:
1. To broadly identify the types of urban
environments which may have an impact
on the health of residents.
2. To select case study areas within Belfast
urban areas which represent these
environments.
3. To measure the health status of the
residents using the Nottingham Health
Profile (NHP) as the core measurement
technique.
4. To explore the casual relationships
between the health status of the
residents, housing environment and
other socio economic factors.
5. To explore these relationships over time
by longitudinal analysis.
The condition and nature of dwellings have
a major influence on the lives of residents
and is widely believed to have a direct
bearing on the quality of day to day living
and health. The empirical evaluation of the
direct relationship between housing
conditions and the health of occupants has
posed significant difficulties because of the
multifactoral non-housing variables, the
inadequate indices for measuring health
and hygenic quality of housing and the lack
of specific epidemiological studies.
The Housing Executive in this role as a
statutory agency for housing in Belfast has
developed a specific research project in
conjunction with the Eastern Health and
Social Services Board.
The overall aim of the research is to
examine the extent to which self reported
health of individuals varies between
different urban environments.
The scope and direction of the research is
The project involves measuring the selfreported health status of tenants in high
rise estates, redevelopment areas, sectarian
interface locations, high density locations
and on an estate recognised as "good
quality". The total number of dwellings in
the project is approximately 700.
The questionnaire to be used is based on
the Nottingham Health Profile which is a
technique to measure comparative health
scores of different housing environments
and includes measures of stress, physical
pain, mobility problems and social isolation.
Information will also be gathered on the
housing and environmental conditions and
the social and demographic profile of the
residents. The project is being jointly
funded by the Housing Executive and the
Eastern Health and Social Services Board.
Fieldwork will be carried out during June
1992 and preliminary results will be
available in October/November 1992.
—
2
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201
Abstracts from the Research for Healthy Cities Expert Panel
Bill McGivem
Northern Ireland Housing Executive
The Housing Centre
2 Adelaide Street
Belfast BT2 8PB
Northern Ireland
phone. +44 232 240 588
fax. +44 232 248 464
Participatory Action
research: the develop
ment of a paradigm for
evaluation of Healthy
Cities
Participatory Action research is a qualitative
holistic inductive research methodology
which involves the subjects of the research
in the research process from the initial
design stage through data gathering and
analysis to the final conclusion. It is about
learning and empowerment and its
strength lies in the abillity to study major
changes through the creation of an
environment in which the participants give
and get valid information, make free and
Environment and
urbanization
The October 1993 issue of the journal
Environment and Urbanization is devoted to
health and well-being in (mostly third world)
cities. The journal contains articles on such
diverse topics as intra-urban differentials in
Accra, violence prevention in US cities,
respiratory diseases in Jakarta, the healthy
cities movement, and disaster management
in Lusaka. As always, there is a very
extensive book corner. Subscription rates for
two issues (of about 200 pages) per year are
£8 (third world) or £17 (elsewhere).
E&U
International Institute for Environment and
Development
3 Endsleigh Street, London WC1H ODD
United Kingdom
fax +44 71 388 2826
Urban Management
Programme
The UMP, a joint effort by Habitat and
World Bank is publishing reports and well
informal choices and generate their
commitment to the results of their enquiry
While any evaluation method chosen
should be the one best suited to the
questions asked. Participatory action
research is a research methodology that
carries out research according to the
principles of Health for All.
The paper discusses the methodology, its
strengths and weaknesses illustrated with
examples of three on-going Research for
Healthy Cities projects in Liverpool
Networking and intersectoral
Collaboration: theory and practice.
The purpose of this paper is to examine
network forms of organisation and assess
their significance for the study of
intersectoral collaboration and community
participation both at the heart of the
Healthy Cities project.
The emergence or reemergence of network
forms of organisation has been highlighted
by a number of authors covering a wide
range of areas. It is now recognised as
replacing older forms of organisational
interaction amongst commercial, industrial
and public sector organisations
(Powel, 1990). Research has established,
as working papers. The UMP publications
series shows by now 12 titles (interesting
ones like A Review of Environmental Health
Impacts in Developing Country Cities (no. 6)
or Elements of Urban Management (no. 11)
and ones on first sight less interesting to
healthy cities like no.1, Property Tax Reform).
The first issue in the Working Paper Series
is Environmental Innovation and
Management in Curitiba, Brazil.
Maybe unknowingly, the paper is a prime
example of an excellent healthy city project.
UMP Coordinator
Technical Cooperation Division
United Nations Centre for Human
Settlements (Habitat)
PO Box 30030, Nairobi, Kenya
fax +254 2 226 479/473
Urban Policy and
Economic Development
Perhaps the best way for healthy cities
developers to read the. World Development
Report 'Investing in health' is in combina
tion with a somewhat older World Bank
publication: Urban Policy and Economic
Development; an agenda for the nineties
for example, that networking lies at the
heart of Japanese industry’s ability to
sustain a system of continuous innovation
(Mody, 1990.) Networks provide the
channels through which information and
resources can flow reducing the level of
uncertainty and fostering trust and the
allocation of resources and encouraging the
development and dessemmation of ideas,
experiences and skills. Networks can take
different forms and have different
functions but there are certain underlying
element that are common to all networks,
the existence of which it is hypothesised
help to account for the degree of succes or
otherwise in achieving change for health
for all. Understanding the development of
networking and networking skills are
fundamental tools for those working for
health for all.
Jane Springett
School of Health Sciences
The Liverpool Polytechnic
Trueman Street Building
15-21 Webster Street
Liverpool L3 2ET United Kingdom
phone: +44 51 207 3581
fax: +44 51 207 2620
(1991, ISBN 0-821 ^-1816-0).
World Bank, 1818 H Street, NW,
Washington DC 20433, USA
fax+1 202 477 6391
Development of
Evaluation Framework
in Canada
Apparently the best way to start the
evaluation of healthy cities and
communities effort is through a research
network. Apart from the network funded
by the European Union described in our
guest editorial, the Canadians have also
formed a network that covers almost all
provinces of the country. The network will
perform an 'evaluability assessment' in
order to clarify constituent theoretical
frames is Well as stakeholder concerns,
needs and expectations.
Contact
Blake Poland
Department of Behavioural Science,
Faculty of Medicine
McMumch Building, Unhfliwtyof Toronto. ;i|
Toronto, Ontario, Canadi WSS 1A8 •i!1 h iT-ii-ij'
fax+1 416 978 2087
.
3
’
•
■ ;
J’
Illi
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J:h -
Electronic
communication
developing further
The WHO Collaborating Centre m Hea'f'v
C.?es ot i.ndiana University nas set uo a
Global Healthy CT.es. Information System
o” internet it wh: contain programme ano
tool oescnpt ons Information
WHO CC /n Healthy Cities
iARCH
: ■ 11 Middle Drive N'U 236
Indianapolis IN 46202
USA
'ax + i 317 2 74 2285
EMail CITYNET@INDYVAX.IUPUI EDU
The WHO Collaborating Centre tor
Research on Healthy Cities is also
xoanding its electronic services.
The research bibliography (500 entries
including lengthy abstracts) will go on-iine
by 1 February 1994 It will be an interactive
search system, those logging on will also be
given the opportunity to download into the
system their own publications, abstracts
and references Of course, one-to-one
communications remain possible too.
WHO CC RHC
School of Health Sciences
University of Limburg
PO Box 616
6200 MD Maastricht
The Netherlands
fax + 31 43 670 932
EMail
EVEL YNE.DELEEUW@GW RULIMBURG.NL
202
City health
★
EC Research Network for the Evaluation
of Urban Health Policy and Practice
University of Limourg
Short term research
post abroad
x ea kh
Seven recently trained researchers are reau>red immediately to take part in
research on sustainable healthy cities in Europe As pan of a collaborative,
international network, you will help to develop common evaluation
approaches m a multidisciplinary environment Posts are available :n
• Germany (4 months) at Helmut Hildebrandt Gesundheits Consult,
Hamburg,
• Greece (9 months) at the institute for Social ano Preventive Medicine
(ISPM). Athens.
• Italy (6 months) at Sistemi Orgamzzazione e Gestione Servizi Social' e
Sanitan (SOGESS). Milan.
• Netherlands (12 months) at Research for Healthy Cities Task force.
University of Limburg. Maastricht;
• Spam (12 months) at the Institut Valencia d'Estudis en Salut Pubhca
(IVESP). Valencia.
• UK (12 months) at the Institute for Health. Liverpool John Moores
University, Liverpool;
• UK (18 months) at the Research Unit in Health and Behavioural Change
(RUHBC). University of Edinburgh (Co-ordinating Centre)
ISPM
Liverpool
7 John Moores
University
He r~ . ■
H
'd eSr3rd•
G e s U n d u e ' ’ s C o r s „ 11
You will work at a centre in a European country of which you are not a
national or long-term resident You have a good command of English, are
qualified in a health, social or human science, and have research
experience and good communication skills Proficiency in the language of
the country you apply to work in is desirable
Requirements and conditions are specific to each centre. For an
information pack and application form, send a postcard giving your name
and address to "CityHealth" to any of the addresses below
SOGESS
RUHBC. 24 Bucdeuch Place. Edinburgh. EH8 9LN, UK.
ISPM. 32 Skoufa Street, 106 73 Athens. Greece
SOGESS. Via de Amicis 53. 20123 Milano, Italy
Evelyne de Leeuw. Research for Healthy Cities. University of Limburg.
PO Box 616, 6200 MD Maastricht. The Netherlands.
Sarah Whyte, IVESP, Juan de Garay 21, 46017 Valencia. Spain
Personnel Services. Liverpool John Moores University, Rodney House, 70
Mount Pleasant. Liverpool, L3 5UX, UK. Quote ref: B 5321
Closing date for applications: 31 January 1994
Published under auspices
of:
HCffl UNIVERSITE
LAVAL
Ecole des Sciences Infirmieres,
Groupe de Recherche et
d’Intervention en Promotion de la
Sante
Cit6 Universitaire.
Quebec. Canada G1K 7P4
DEPARTMENT OF SOCIAL
POLICY AND SOCIAL WORK
Research Unit in Health and
Behavioural Change
17 Teviot Place,
Edinburgh EH1 2QZ,
Scotland
University of Limburg
School of Health Sciences
PO Box 616,
6200 MD Maastricht.
The Netherlands
THE WHO HEALTHY CITIES
PROJECT
WHO/EURO
8, Scherfigsvej,
2100 - Copenhagen,
Denmark
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THE HEALTHY CITIES PROJECT OF THE
WORLD HEALTH ORGANIZATION
The Netherlands Healthy Cities Network
1992
286
The Healthy Cities Project of the World Health Organization
Background
In September 1986, eleven cities were selected to be the first participants in the
Healthy Cities project of the World Health Organization, Regional Office for Europe.
The project was introduced to demonstrate that new approaches to public health,
grounded in the Health for All principles would work at the local level.
We thought that, if the project would be successful, it would provide the foundation
for a new locally based public health movement and enhance the health and well
being of people living in European cities.
Five years later, 35 European cities are participating in the Healthy Cities project.
National and subnational Healthy Cities networks have been set up in 18 countries
and they involve of about 400 cities. Regional networks are functioning in Australia,
Canada and the United States and individual cities are working with the project model
in several other countries.
What is a Healthy City?
In the first Healthy Cities papers, Hancock and Duhl (1988) define a Healthy City,
"as one that is continually creating and improving those physical and social
environments and expanding those community resources which enable people to
mutually support each other in performing all the functions of life and in develop
ing to their maximum potential".
A Healthy City is defined by a process and not just an outcome. A Healthy City is not
one that has achieved a particular health status level, but is a city that is conscious of
health as an urban issue and that is striving to improve it. Any city can be a healthy
city if it is committed to health and has a structure and process to work for its
improvement.
The Healthy Cities is rooted in a concept of what a city is and a vision of what a
healthy city can become. A city is viewed as a complex organism that is living,
breathing, growing and constantly changing. The project strives to realize the vision o
a healthy city through a process of political commitment, visibility for health, institu
tional change and innovative action for health and the environment.
The ultimate goal of Healthy Cities is to:
"improve health and wellbeing by applying the principles and strategies of Health
for All and Health Promotion at the city level".
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There are no simple solutions or recipes for this Healthy City process. Strategies at
the local level must be compatible with the cultural, social and organizational
traditions of a city.
However, any Healthy City should strive to provide:
A clean, safe physical environment of high quality (including housing quality);
An ecosystem that is stable now and sustainable in the long term;
A strong, mutually supportive and non-exploitive community;
A high degree of participation and control by the public over the decisions
affecting their lives, health and well-being;
The meeting of basic needs (for food, water, shelter, income, safety and work) for
all the city's people;
Access to a wide variety of experiences and resources, with the chance for a
wide variety of contact, interactions and communication;
A diverse, vital and innovative city economy;
The encouragement of conectedness with the past, with the cultural and biologi
cal heritage of citydwellers and with other groups and individuals;
A form that is compatible with and enhances the preceding characteristics;
An optimum level of appropriate public health and sick care services accessible to
ail; and
High health status (high levels of positive health and low levels of disease).
Framework for action for Healthy Cities
As was previousiy mentioned, the principles of Health for All and strategic develop
ment in health promotion provide the framework for action in local Healthy Cities
projects.
Local action means political support. This implies getting political commitment from
city councils to reorient policies towards equity, health promotion and disease
prevention, in other words: new approaches for public health.
Political commitment is the first step in working towards a healthy city. Cities that
have entered the WHO Healthy Cities network over the past six years have been
requested to make such commitments. These cities have been asked to formulate
intersectoral health promotion plans with a strong environmental component and to
secure the resources for implementing them. These should amongst others include an
intersectoral political committee, mechanisms for public participation and a project
office with full time staff. Long term strategic planning, environmental analysis and
accountability mechanisms are used in these cities as tools to influence policy
formulation and implementation.
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Healthy cities initiatives imply an abitious health agenda:
Local action to reduce inequalities in health status;
Priority for health promotion and disease prevention;
Cooperative action for health among departments of city government and other
public and private organizations;
Greater participation by community groups in decisionmaking and action to
improve health and the city environment;
Health care reform to place greater emphasis on primary health care and on
disease prevention and reform of environmental services;
Adoption of healthy public policy throughout city government and in other sectors;
Cooperation among cities in developing new approaches to public health.
The project becomes a movement
The diversity of the 35 cities in the WHO project network show that there are
different ways to create this policital commitment to improve the health of the city
residents. Project cities are located in 18 countries with different political systems,
economies and social conditions. They vary in size from Horsens in Denmark with a
population of 55.000 to St. Petersburg, the Russian Federation, with more than 4
million residents. Some enjoy a high standard of living and health, while others suffer
widespread unemployment, poverty, lack of resources and the health problems
commonly associated with severe deprivation. There are wide differences in ilifestyles,
environmental conditions and access to primary health care within cities. The city
administrations have varying degrees of jurisdiction over matters that affect health and
different organizational structures through which to address health problems. But
regardless of these differences, they all strive to become a healthy city.
Within the WHO project network multi-city action plans have been set up recently to
bring groups of cities together to address key issues, such as nutrition, tobacco use,
women's health issues, traffic control and AIDS. Under these plans groups of cities
compare experience as a basis for agreeing on better methods to follow the future.
Each action plan is linked to the relevant programme within WHO/EURO.
Dissemination of Healthy Cities strategies has been greatly accelerated by the growth
of national and subnational Healthy Cities networks, now existing in 18 countries.
Both national networks and the number of cities participating in the movement have
grown much more rapidly than expected. The scope and intensity of network
activities varies. The activities currently include advocating for Healthy Cities, through
dissemination of information by means of translated background documents, newslet
ters, information packages, and organizing business meetings, workshops and training
courses.
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The future
WHO/EURO has renewed its commitment to Healthy Cities by deciding to continue the
project for another five years. In this second phase the project will retain its commit
ment to the principles of health for all and to health promotion strategies. This will
mean continued concern for equity, sustainable development, creation of settings for
healthy living and health care reform.
Major initiatives in this second phase of the project should reflect the achievements of
the first period of five years and the challenges of the future. While work accomplished
in phase one will continue,
1‘
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------------- >in
n the
second phase new approaches and priorities
will be needed. Committed effort will be
required at the international, national and
local level.
In so far <as the WHO project is concerned, the methods developed over the past five
years will continue to be applicable
the future, Some adjustments in approach will
-------- in
--------------------be made to reflect inew priorities, the current state of development and the support
networks that now exist.
WHO will work with its national and local partners to create a network of Healthy
Cities reaching accross the European Region. It will be their challenge to protect and
improve public health in a period of unprecedented political, enonomic and social
transition.
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The National Healthy Cities Network in the Netherlands
History
Nether,ands at the ^ond Healthy Cities Conference in
Dusseldorf
for™
m
Were S° ,nSPired by What thev heard- that theV ^eed with the
formation of a Nat.onal Network of Healthy Cities in our country.
DuSSe,d°rf Conference a follow-up meeting took place in
Ddhoven for all th
Hea'thy CitieS project' Durin9 thia meeting it
enthousiasm m various Dutch cities for establis-
became clear that th56
hing 7 NaXna Health6
fo?med tDs Com r V
S
At th,S meetin9 a s°-ca"ed "C°r* Group" was
tim? knowledoe
C°nSIStS °f Pe0P'e Wh° Were and sti" are wiilin9 t0 invest
Core Groups tn f
t ^9"
Healthy CitieS movement. The main task of this
Core Group ,s to funct.on as an initiator and promoter of ideas for the Network
t^NeZrlandV^T
their nroiert f 0
published its first5’
tion
^h
'
f°r the Hea,thV Cities movement in
t0
anuary' the Clty of Eindhoven was designated by WHO as one of
T JanUary 1988 the C°re Group of the National Netw°rk
'
601 f°r the NetWOrk’ This ^cument included a proposi-
need for a pro ec off ° t
'
Strate9ies for the "^o* activities and the
M• .
ice t0 suPPort these network activities. In September 1988, the
Cenue'and staffT' b63'^ 306 CultUral affairs decided to subsidize this Support
an ?mLr?ant t
, 7
35
W3S felt that 3 National Hea,thV Cities Network is
thP NPth < H
the Netherlands.
S
development of the new public health at local level in
The Support Centre for the National
Network started in January 1989 in Eindhoven
with three part time staff members:
a network coordinator, a project officer and a
secretary.
In 1990, when the initial period of two years ended,
the Core Group felt that we had
to continue the Network and its Support Centre. Due to the enthusiasm for Healthy
Cities and the Network, the workload of the staff members at the Support Centre
increased and we felt that we needed two full time officers for carrying out all the
necessary work. The Ministry of Health reacted positively to this request of the Core
Group and they decided to continue to support the Healthy Cities Network for four
more years with an increased budget for network activities and for two full time staff
members with secretarial support. It was also decided that the Support Centre would
stay m Emdhoven until the end of 1992 and than move to Rotterdam. The City of
Rotterdam was appointed by WHO as second project city for the Netherlands in July
i y 91.
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Organization of the Network
The Healthy Cities Network is an open platform where all those who are interested or
involved in Healthy Cities in the Netherlands and in Flanders (Belgium) can meet to
exchange ideas and practical information. The Network has no other participation
criteria than a clear commitment to the Health for All and Health Promotion principles.
This commitment can range from a personal to an organizational and a political
commitment. In order to involve as many people and organizations as possible, no
membership fees are asked. The aim was to create a large, open, interactive commu
nication network for Healthy Cities in the Netherlands.
Within such an open interactive system, the Network concentrates its activities on
two main target groups:
The first and main target group consists of those persons and organizations that
are active in the health system, for instance: workers at public health services,
health policy makers at national and local level as well as at the administrative
and executive level, health promotion officers, epidemiologists, politicians,
academics and students at universities and other research institutes and many
persons working in other governmental and non-governmental organizations.
The second target group is formed by the potential partners with whom intersec
toral action for health can be developed, such as community development and
environmental organizations, city planners and architects.
Next to these target groups, we also distinguish two different kind of involvement
with the Network. First, there is for instance the personal and/or organizational
involvement from professionals working at the previous mentioned organizations and
institutes. This group consists of approximately 500 persons. The second group is
formed by municipalities that are implementing the Healthy Cities philosophy as a
result of their local health policy as established by their City Councils. In approximate
ly fifteen Dutch municipalities, including the large cities as Amsterdam, Rotterdam,
The Hague and Utrecht, but also in smaller cities like Almelo, Lelystad, Almere,
Eindhoven, Tilburg, Groningen and Maastricht, activities within the "spirit of Healthy
Cities" have been started.
Network activities
The main task of the Network and its participants, of the Core Group and of the
Support Centre is to enable, mediate and advocate for Healthy Cities in the Nether
lands.
The Core Group of the Network has as main task to function as an initiator and
promotor of ideas for the Network and to contribute to the development of new
strategies for new public health at the local level in the Netherlands.
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Dissemination of information on Healthy Cities initiatives in the Netherlands and in
other countries is a major activity for the Support Centre.
A newsletter "Nieuwsbrief Gezonde Steden" with national as well as international
information has been published on a regular basis since 1989. This newsletter is
distributed free of charge to anyone who applies for a subscription.
This year we started with publishing of the so-called "Dutch Health Cities papers
series of booklets on relevant Healthy Cities topics. The first booklet was on the
Healthy Cities project in general and described its concepts and principes an
the project grew into a movement at national as well as international level.
e
second booklet was issued last week and gives a general descript.on of the devel°P
ment of healthy public policy and health policies at the local level and contains a la g
variety of Dutch models of good practice. We have planned to issue three more
this year: on research for Healthy Cities, on intersectoral action and on environmenta
activities.
different Healthy Cities topics are
Information packages containing various articles on
also available.
Healthy Cities which contains
The Support Centre has a well documented library on
national as well as international (i.e. english) informationi on relevant subjects. This
all books and reports are lend out
documentation centre is open for everybody and l..-----
free of charge.
plenary Network Meetings each year. The
The Support Centre organizes one or two
health topics in the Netherlands or important
subject of these meetings are actual I----Network issues.
Each year a National Network Symposium, based on the annual theme of the "^®rnatl
onal Healthy Cities project is organized in order to give feedback from the annua
Healthy Cities symposium.
Many smaller technical workshops are organized during the year. These meet g
always organized in close collaboration with other organizations.
This year we also started with -Healthy City visits’. For a start, the two WHO^prraect
cities Eindhoven and Rotterdam are organizing a one day meeting w er
and Show on location what is being don. in their city within the framework of the
Healthy Cities project.
3 and the University of
In collaboration with the Dutch Health Education Centre
introduction to Healthy Cities.
Maastricht we developed a training course as an i--------Centre. We also give
•
■
; on location in cities or at the Support
We give consultations
organizations on request.
lectures in cities, at polytechnics, universities and other <
! Healthy Cities related
We also attend many national conferences and symposia on
topics in order to promote the Healthy Cities ideas in these areas.
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Achievements
Since the start of the Network, we have seen that the concepts and principles of
Healthy Cities have been picked up by many municipalities in the Netherlands. In the
beginning we started with a small group of enthousiastic people, but in the course of
the past five years the Healthy Cities principles were adopted as guidelines for many
local health policies. Healthy Cities was explicitely mentioned not only in the policy
documents of Eindhoven and Rotterdam, but also in those of Almelo, Almere,
Dronten, The Hague, Groningen, Lelystad, Tilburg, Utrecht and Groningen.
In many other cities, "Healthy Cities" activities are carried out. Although these
activities -often initiated by the public health services or by community development
workers- are not always labeled as "Healthy Cities", they have similair aims, such as a
bottom up and multidisciplinary approach. The Dutch Institute for Care and Welfare
played an important role in this development. This Institute started the Healthy
Communities" project, in which they developed a video programme, a handbook of
models of good practice and a training course with regard to the practial aspects of
health promotion at the local level.
Summarized, we can say that the Healty Cities movement in the Netherlands is well
on its way.
The future
There will be a National Healthy Cities Network with a Support Centre in Rotterdam at
least until 1 January 1995. For the next two years the Network activities will be
subsidized by the Dutch Ministry of Health.
The Support Centre shall continue its activities with regard to the dissemination of
and other meetings
information by means of the newsletter, reports from
t----- workshops
-------Healthy Cities booklets. We also will continue to organize training
and the series of I
and other workshops and provide consultation.
. For instance, the structure of our Network
We do expect, however, some changes
convinced that the threshold for becoming
will problably be transformed. We still are
interested in Healthy Cities and for joining the Network should be as; low as possible.
have also witnessed that after some years the very open platform structure
But, we
also means a rather low commitment to the Network and its activities. The Core
Group of the Network started a discussion to find a solution for this problem. We
expect to have another Network structure in the course of 1993.
Regardless of the formal structure of the Network, our principal aim is and will be in
the future: to enable, mediate and advocate for Healthy Cities and new public health
at the local level.
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The Netherlands Healthy Cities Network
The Netherlands enjoys a high standard of health
care: health services are accesible to
all, both financially and otherwise. The national government as well as the local
authorities are responsible for taking statutory measures and creating the right
conditions for the prevention of disease and accidents and the improvement of
treatment and care. It is worth noting that average life expectancy in the Netherlands
has nsen from arount 50 in 1900 to 73 for men and 79 for women. This is due in
large part to advances m medical science, while improved hygiene, better housing and
a safer working environment have also contributed.
The National Healthy Cities Network was establised in 1987 as a result of the
Dusseldorf Healthy Cities Conference. In 1 989 a Support Centre in Eindhoven, WHO
project city, with two part time professionals was subsidized by the Ministry of
Welfare, Health and Cultural Affairs for a period of two years. In 1991 it was decided
to continue this financial support for another period of four years for two full time
professionals. As from January 1st 1993, the Support Centre for the Network will be
located in Rotterdam, the second WHO project city in the Netherlands
The
of the Network and its Support Centre is to enable, mediate and advocate for
ealthy Cities in the Netherlands, through organizing training, symposia, workshops
and other meetings, by distributing a Healthy Cities Newsletter, by publishing the
socalled Dutch "Healthy Cities" papers and by giving lectures and consultation.
The Network is an open platform where all those interested in Healthy Cities can meet
to exchange ideas and practical information. The Network has no other participation
criteria than a clear commitment to the Health for All principles. No membership fees
are asked. The Network can be described as an communication network.
After five years, the ideas and principles of Healthy Cities have been picked up by
many cities and other organizations in the Netherlands. In approximately fifteen local
hea th policy documents Healthy Cities are mentioned as guiding principle and many
public health services and community development workers consider Healthy Cities as
a challenge for their activities.
256
Healthy Cities are well on their way in the Netherlands.
the activities of the Dutch national network
by Janine Cosijn, National Network Coordinator
In the previous number of this newsletter two fellow countrymen expressed their somewhat critical- views on Healthy Cities initiatives in the Netherlands. As this was
the first time that Dutch activities were described in this newsletter, I felt it was
necessary to give more background information on the Dutch National Healthy Cities
Network.
The first initiatives to create a Healthy Cities Network in the Netherlands were taken
almost immediately after the second Healthy Cities conference in Dusseldorf in 1987.
The Dutch participants at this conference were so inspired by what they heard, that
at a follow up meeting of this conference, they agreed that there was enough
enthousiasm in various Dutch cities for creating a national network.
A steering group, the so-called ’’Core Group" was established to function as an
initiator and promotor of ideas for the Network and to define the terms of reference
for the network. The group consists of people who were and still are willing to invest
time, knowledge and energy in the Healthy Cities movement in the Netherlands.
This Core Group published a first policy document for the Network in 1988. This
document included a proposition for the working structure of the network, the
strategy for its activities and the need for a project office to support these activities.
In September 1988, the national Ministry of Welfare, Health and Cultural Affairs
decided to subsidize a support centre and staff for an initial period for two years, as it
was felt that a national Healthy Cities network is an important stimulus for the
development of the new public health at the local level in the Netherlands. The
Support Centre started in Eindhoven (WHO project city) in 1989 with part time staff
members. When the first period ended, the Core Group felt that the Network and the
Support Centre had to be continued with full time staff members this time. The
Ministry of Health reacted positively to the request of the Core Group and they
decided to continue the support for the Dutch network for four more years with an
increased budget for network activities and for two full time staff members with
secretarial support. It was also decided that the Support Centre would stay in
Eindhoven until the end of 1992 and than move to Rotterdam, the second WHO
project city in the Netherlands.
Due to the financial support of the Dutch government, the Netherlands Healthy Cities
network is at this moment the only national network in Europe that is able to employ
two full time professionals.
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When the network started five years ago, the Core Group very clearly chose for the
structure follows stratey" approach. This approach is concerned with creating
possiblities for innovation. Whenever you start with something new and unexpected,
there is alway little room for it. Only few people are willing to experiment with new
things and these people are always watched closely and critically by more conservati
ve colleagues. A first positive reaction to introducing something new is creating
tolerance until succes becomes visible. Then you reach the second phase, where you
are given the benefit of the doubt. Innovative trendsetters go beyond this phase and
they dare to speak out loud what they believe in and stand for. Gradually, the group
that promotes innovation grows and the new trend manifestates itself. After a certain
period of time, a period which can vary according to the groups involved, the new
thing becomes an everyday phenomenon and becomes then institutionalized.
The strategy of the Core Group was first to concentrate on the innovators and to
involve as many people in the network as possible, before creating any official
structure such as a legal organisation. The main objective of this network was to
advocate for the Healthy Cities principles and the main tasks of the support centre
were to fulfill the advocacy function and to disseminate information in various ways.
The network is therefore also described as an open communication platform, with no
other participation criteria than a clear commitment to the health for all and health
promotion principles as stated by WHO. A network, which can be joined by everyone
interested in Healthy Cities, where no membership fees are asked.
In 1990 two major developments in the Netherlands influenced the Healthy Cities
movement.
The first was that in June 1990 the Dutch legislation put the responsibility for health
protection and health promotion in the hands of the local authorities. The Collective
Prevention Act instructed the Dutch municipalities to develop a local health policy.
This implies that health is, or at least is supposed to be, on the political agenda of the
city. The problem, however, is how to make the policy makers aware of the Healthy
Cities approach in preparing and implementing a local health policy. This is one of the
main tasks of the Network.
The second important development for Healthy Cities in the Netherlands is the socalled Social Innovation movement, which aims to improve social relationships at the
local level. Social Innovation is initiated by the national government, which also
finances social innovation-projects. Many of the key principles of this Social Innova
tion movement are similar those of Healthy Cities, such as: strengthen community
participation, bottom-up, intersectoral and multidisciplinary approaches at the local
level. In Rotterdam, the Healthy Cities project and its activities is one of the many
projects initiated within the overall municipal Social Innovation programme. And in
Eindhoven, Healthy Cities and Social Innovation initatiatives are also linked together.
When I have to explain in the Netherlands in one sentence what the Healthy Cities
project is about, I often use the expression that "the Healthy Cities project deals with
the health aspects within Social Innovation". Social Innovation started with four main
topics: housing, education, employment and social security. Healthy Cities adds the
health dimension to these issues. This development implies that there are many
initiatives developed in the Netherlands which could be labelled Healthy City, but
which have been initiated within a Social Innovation programme. But is this labelling
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258
or desire to claim the ownership of the ideas so important? I don't think so, as long
as we are all aiming at creating together a better world to live in. And there is an
important task for the Healthy Cities network: to increase the awareness for the
health dimension in those Social Innovation programmes which are mainly focussed on
the four initial topics.
As the Healthy Cities project is initially about finding ways to implement the new
public health, it was obvious that the first group of people interested in this project
would be found in those institutions dealing with public health matters in the Nether
lands. This are the Municipal Public Health Departments. These Public Health Services
have a long tradition in social medecine. With the introduction of the Collective
Prevention Act, they now also have a responsibility to support the local authorities in
developing a health policy. Some Dutch cities have discovered that the Healthy Cities
project can be used as a framework for this. In approximately fifteen Dutch municipa
lities, including the large cities as Amsterdam, Rotterdam, the Hague and Utrecht, but
also in smaller cities like Almelo, Lelystad, Almere, Eindhoven, Tilburg, Groningen and
Maastricht, activities within the "spirit of Healthy Cities" have been started.
The main task of the Network and its participants is to enable, mediate and advocate
for Healthy Cities. Dissemination of information on Healthy Cities is one of the major
activities of the Support Centre. A newsletter " Nieuwsbrief Gezonde Steden" is
distributed free of charge on a regular basis since 1989. This year we started to
publish the so-called "Dutch Healthy Cities papers", a series of booklets on relevant
Healthy Cities topics. Plenary meetings are organized twice a year, one always giving
feedback on the annual international Healthy Cities symposium and many other
network meetings and training workshops are organised to exchange information and
experciences.
As mentioned before, the Network is set up as an open communication platform.
Within this platform, three target groups can be distinguised. Representatives from
these target groups are the participants in the Dutch Network. The first target group
consists of those persons that are reponsible for the development and implementation
of local health policies: the politicians and the policy makers. The second group
consist of those professionals involved in public health, such as workers at the
municipal public health services, other governmental and non-governmental institutions
and scientific and other research institutions. The third target group is formed by the
potential partners with whom intersectoral action for health can be developed such as
community development and environmental organizations.
The future for the national Healthy Cities network in the Netherlands looks good. The
national Ministry of Health will finance the Support Centre and its activities until
1995. That implies that the work of enabling, mediating and advocating for Healthy
Cities and new public health at the local level will be continued for at least two more
years. But it is up to the cities themselves to develop and implement healthy policies
to improve their citizens health and well-being.
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259
COPENHAGEN
HEALTHY CITIES
CONFERENCE
1992
"Heaithy Cities are well on their way in the Netherlands"
A summary of the Dutch national network
Illi!
by Janine Cosijn, National Network Coordinator
In a previous edition of this newsletter
two fellow countrymen expressed their
- somewhat critical - views on Healthy
initiatives in the Netherlands. As this
was the first time that Dutch activities
where described in this newsletter. I
felt it was necessary to give more
background information on the Dutch
National Healthy Cities Network.
The first initiatives to create a Healthy
Cities Network in the Netherlands were
taken almost immediately after the
second Healthy Cities conference in
Dusseldorf in 1987. The Dutch
participants at that conference were so
inspired by what they heard, that at a
follow up meeting, they agreed that
there was enough enthusiasm in
various Dutch cities for creating a
national network.
A steering group, the so-called "Core
Group" was established to function as
an initiator and promoter of ideas for
the Network and to define the terms of
reference. The group consists of
people who were and still are willing to
invest time, knowledge and energy in
the Healthy Cities movement in the
Netherlands.
Policy
This Core Group published a first
olicy document for the Network in
.988. This document included a
oroposition for the working structure
of the network, the strategy for its
activities and the need for a project
office to support these activities. In
September 1988, the national Ministry
of Welfare, Health and Cultural Affairs
decided Jo subsidise a support centre
and
staff for
—
L. an
.... .initial
’...‘JJ period for two
years, as it was felt that a national
Healthy Cities network would be an
important
stimulus
for
the
development of the new public health
at the local level in the Netherlands.
The Support Centre started in
Eindhoven (a WHO project city) in
1989 with part time staff members.
The Core Group felt that the Network
and the Support Centre should be
continued with full time staff. The
Ministry of Health continued
ipporting the Dutch network for four
more years with an increased budget
for network activities and for two full
time staff members with secretarial
support.
Due to the financial support of the
Dutch government, the Netherlands
Healthy Cities network is the only
national network in Europe able to
employ two full time professionals.
When the network started five years
ago, the Core Group very clearly chose
the "structure follows strategy
approach concerned with creating
possibilities for innovation. Whenever
you start with something new and
unexpected, there is always little room
for it: few people are willing to
experiment with new things and tnese
people are always watched closely and
critically by more conservative
colleagues. A'first positive action when
introducing something new is to create
tolerance until success becomes
visible. Then you reach the second
phase, where you are given the benefit
of the doubt. Innovative trendsetters
go beyond this phase and have the
courage to speak out loud about what
they believe in and stand for. Gradually,
the group that promotes innovation
grows and the new trend manifests
itself. After a certain period of time, a
period which can vary according to the
groups involved, the new idea
becomes an everyday phenomenon
and then becomes institutionalized.
Strategy
The strategy of the Core Group was
first to concentrate on the innovators
and to involve as many people in the
network as possible, before creating
2000
any official structure such as a legal
organisation. The mam tasks of the
support centre were to fulfil the
advocacy function and to disseminate
information in various ways. The
network can be seen as an open
communication platform, with no
other participation criteria than a clear
commitment to the health for all and
health promotion principles as stated
by WHO. Within this platform, three
target groups can be distinguished.
Representatives from these target
groups are the participants in the
Dutch Network
Target Groups
The first target group consists of those
persons who are responsible for the
development and implementation of
local health policies: the politicians
and the policy makers. The second
group consists of those professionals
involved in public health, such as
workers at the municipal public health
services, other governmental and non
governmental institutions and scientific
and other research institutions. The
third target group is formed by the
potential partners with whom
intersectoral action for health can be
developed such as community
development and environmental
organisations. The network can be
joined by everyone interested in
Healthy Cities, and no membership
Amsterdam ere of about 15 municioalties in the Netherlands which have found that healthy cities provides a usetui
framework for new public health policy sucn as the Collective Prevention Act.
COPENHAGEN
HEALTHY CITIES
260
CONFERENCE 1992
Netherlands
Continued irom Page 7
the Support Centre. A newsletter is
ownersmo of the ideas so important? 1 distributed. We puolish
Duolish the so-caiiec
so-cailec
In 1990 two major Developments in the don't think so. as long as we are all "Dutch Healthv Cities papers
—3 .. aa series
series
Netherlands influenced the Healthy aiming at creating together a better of booklets on relevant Healthy Cities
uitie.
Cities movement. In June 1990 the world'to live in. And there is an topics. Network meetings and traininc
Dutch legislation put responsibility for important task for the Healthy Cities Tifefuture foMhe^anonal Healthy Citiet
Healthy Cities
health
protection
and health network: to increase the awareness for The^futurnm
promotion in the nands of local the health dimension in those Social network in the Netherlands looks gooa
authorities. The Collective Prevention Innovation programmes which are
Act instructed the Dutch municipalities mainly focussed on the four initial finance the
the' SSupport
u p p o rf CCentre
e n tre_ and
and* it.
it
to develop a local nealth policy. This topics.
activities until 1995. That
Resposibiiity
implies that health is. or at least is
the work of enabling, mediating ant
supposed to be. on tne political agenoa As the Healthy Cities project is initially advocating for Healthy Cities and ne\
nev
of tne city. The proolem. however, is about finding ways to implement the public health at the local level will bhow to make the policy makers aware new puolic health . it was obvious that continued for at least two^more^years
two more years
of the Healthy Cities approach in the first group of people interested in But it is up to the Cities themselves t
• • —■■ healthy- policie
preparing and implementing a local this project would be found in those uu
develop
IGIUU and implement
nealth poiicv. This is one of the main institutions dealing with public health to ilHMIWU
Iiiv.i -citizens
----------------improve their
hea th an
matters in the Netherlands. These are well-being. In Rotterdam, the Health
asks of the Network.
Municipal
Public
Health Cities^profect ana its activities is one :
The second is the so-called Social the
veiiicm. which
wn.u.. aims
auHo to
lu
Departments, wnose services have a the manv projects ininateo
Innovation movement,
initiated wir
wit
tt
improve social relationsmos
i--------------- at the local long tradition in social medicine, wun overall municipal Social inoo--'1^
level. Social Innovation is initiated oy the introduction of the Collective programme .^And
;..,J m Eindhoven. Health
the national government, which also Prevention Act. they now also have a Cities <...d
and Social
Zzz.' Innovation initiative
nether. When I! have t
............
finances the projects. Many of the key responsibility to support the local are also linked
together.
authorities in uevciupiiiy
developing a nua.u.
health policy. - - -.lain in the
DrmciD'les
.
’; in on
principles of
of this
this SociaTlnnovation
Social Innovation autnoruies
Netherlands
movement are simitar those of Healthy Some Dutch Cities have d,scovere
Ortr
,+anro VA/hq
t ttthe Healthy 2^5.Proper
sentence
what
Cities, such as: strengthen community the Healthy Cities project cani be^used as
I often use the expresssionjhj
— a framework for this. In approximately ‘thebHeaithy Citi'es'proiect deals with th
participation.
bottom-up
and
intersectoral and multidisciplinary fifteen Dutch municipalities, activities iicaii.ii
aspects with'."
within S oc i«
health asp.ects
within the “spirit of Healthy Cities have Innovations". Social Innovation starte
approaches at the local level.
,
. ..
There are many initiatives developed in been started.
’ , .T.a:r.
housmc
wiih”four
main to_pics:
Network and its education, e m p ioy ni e rit a nd s o c i:
the Netherlands which could be The
mu mam
main task of the -------included under the Healthy Cities label, participants is to enable, mediate^and security.
securFty.^Heaithy"Cities
Healthy Cities adds the heal
for
Healthy
but which have been initiated within a advocate
dimension
to these issues.
Social Innovation programme. But is Dissemination of information on Heaitny
this labelling or aesire to claim the Cities is one of the major activities of
fppc orp pckpfi
uiiu
Gi
The structure of the Netherlands Healthy Cities Network
presentation for the workshop on National Healthy Cities Networks
1992 Copenhagen Healthy Cities Conference
Janine Cosijn, coordinator
When compared to other National Healthy Cities Networks in Europe, the Healthy
Cities Network in the Netherlands has a very open structure. The Network is meant to
be a platform where all those who are interested or involved in Healthy Cities can
meet to exchange information and ideas. The Network has, therefore no other
participation criteria than a clear commitment to the Health for All and Health
Promotion principles. Our Network can be decribed as a communication network in
stead of an association of cities.
That was the way the Network started in 1987. It was decided at that time to
concentrate first on developing of a strategy for Healthy Cities in the Netherlands,
before setting up a firm structure. We chose for a ’’structure follows strategy”
approach. We decided to involve as many people and organizations in the Network as
possible in order to create an open interactive network. In the beginning, those people
who had become immediately enthousiastic for the ideas of Healthy Cities were the
main target group for the Network. Through this group of 'innovators for Healthy
Cities' in the Netherlands we tried to spread the message and to involve more persons
and organizations. Therefore no membershipcriteria were established, no fees were
asked. We also distributed the newsletter free of charge, everybody could attend the
meetings and workshops.
This strategy worked. Many people and organizations became interested and involved
in Healthy Cities initiatives. Healthy Cities is mentioned as guiding principles for many
local health policy documents.
Although the content of Healthy Cities and dissemination of information are and will
remain the most important issue for the Network and its activities, it is also felt that
after five years, another structure than the open platform would be more appropriate.
This in order to increase the political and other commitment to Healthy Cities. We feel
that cities, especially City Councils and other institutions do want to belong to a more
structured organization that the open platform. A kind of membership will probably
also increase the commitment.
At present we are discussing possible options for a new structure. This is not an easy
discussion, because there is a danger that for example the question whether or not
we should become a legal association could very easily become more important than
the concepts and principles for Healthy Cities. However, as long as we are aware of
this danger, we can fight it. We expect that in the course of 1993 we will have
solved this problem.
262
HEALTH EDUCAT1CN JOURNAL
I
'. OL44
NO 3
1985
DEBATE
To educate or promote
health?
That is the question
Jeff French
CURRENTLY a small minority of nealth authorities Implications
What implications does the adoption of the phrase
have decided or been advised to change the name ot
health promotion' into a title of a worker or organisa
their health education departments to that of health tion entail? Current definitions of health promotion are
promotion department, and to rename their health many and wide-ranging Activities seen to fall within
education officers 'health promotion officers/advi- the remit of health promotion include behavioural
sers' It has also been mooted that the Health change, personal education, self-empowerment,
Education Council and other health education organi mass media information and education, administra
sations should consider a change of title. Before any tive and legislative change, community development,
such decision is taken. I feel it would be as well to preventive medicine, curative medicme. positive
address some fundamental questions regarding
services, and so on. If we accept such
health promotion. Why have some people decided health
definitions, then to adopt the title of health promotion
that this change of title is necessary? What are the officer/adviser, or health promotion organisation, is to
implications of this decision? And what significance imply that a worker or organisation has some special
does it hold?
ability or expertise which enables them to marshal ail
the above activities. This position is clearly ludicrous,
Why change?
for it would surely require a superman/woman to fulfil
In answer to the first question a»number of such a role, even if it was desirable, which it is not
explanations are possible. The phrase 'health promo Surprisingly, some even go so far as to propose the
tion' may be perceived as a more accurate description development and employment of such super-people
of the role carried out by health education officers
It is evident that health promotion, by its very
Health promotion may be viewed by some as a more nature, cannot become the preserve of any one group
’scientific' activity than health education, and more of workers, and that any attempt to professionalise
readily amenable to quantitative evaluation. Some health promoton in this way would lead to the
may favour health promotion because it sounds like an fulfillment of one of the World Health Organisation's
up-market high-profile approach to health education, fears, namely "there is a danger that health promotion
and obviously this type of approach is both much will be appropriated by one professional group and
easier to understand and also more readily seen to be made a field of specialisation to the exclusion of other
done than many current approaches to health educa professionals and lay people. To increase control over
tion. All these reasons have their base in a dissatisfac their own health, the public require a greater share in
tion with existing approaches to health education. But all resources by professionals and government
is this sufficient grounds for its rejection? I think not.
Health promotion demands widespread participa
very few district health authorities have actually tion Consequently it is necessary to involve adminis
established fully staffed and funded health education trators, opinion leaders, community networks, politi
units. In fact, such units can be counted on one hand
cians, voluntary organisations, individuals and others.
Is it not, then, a little premature to abandon a concept It is only in this way that tme health promotion will
and a way of working which has never been funded to result. One group of workers cannot encompass the
a position where it can begin to work effectively?
of skills or exert the necessary influence to bong
In addition, some workers in health education and range
about health promotion. However, those concerned
community medicine view health promotion as an with health education can and do educate this wide
attractive enough field to fight over, leading to a spectrum of influence about the need and process of
power struggle between HEOs and community physi
promotion. This is the role of health education,
cians. This, of course, is a very negative view, and health
to stimulate and facilitate health promotion, not to
statements like “we are really changing our name toi dominate it. Those of us who are lucky to live in a
lay a claim to this way of working" will only serve toi broadly democratic society and cherish the concept of
divide the very people who through co-operation
could and should be prime movers for healthi democracy, should oppose any professional group
which seeks to annex health promotion, because
promotion.
115
263
sP:ne
0:!S!0ih:yo!
'iI,anot bv a promotion? Most certainly not, 1 fully endorse the
■-•'4
-4sb-oZ 0° H Jw
0!iyCf
"•aicr^'al!
and
• -.%v
-h° “d,yd4s Education has a vital role A Hu- defii.-ition of healtn promotion', and view health
- Nav
lhe words ol Henrv Peter ■Fducanon promotion as the mc.ans through which the health of
our population can be improved. I also commend the
;easvbut dlfficu1110 diive-easv establishment at district and regional level of multi
■ govern duu impossible to enslave ;
... 4 7ouJd be weil adwsed. then, as Wilhams^ disciplinary health promotion teams Health promo
hnert n 4 S.C®ptIcai about th°se who claim to be tion is the responsibility of all those who are con
nu hea th promotion and seek to sell us a cerned to bring about the improvement of health
Health education is an aspect of health promotion
1 roduct that is not theirs to sell
and
its role is to maximise the involvement in health
nt AmCj?an9S °f tKie from bealth education to health
promotion,
as well as providing people with informa
p.omotion would appear to indicate a change of
tion,
skills
and
experiences through which they can
- .lotion, which would be immediately obvious if job
exercise a greater degree of control of their own
-'oanis'Uons0^ temS °f reference °' individuals or health I fundamentally reject the notion that health
ke hn4
6 comPared why. then, if one does
•■'±1 Zh TParLS°nS are on,y minor dlfferences to promotion is or could be an area over which one
--med
h3Ve healtn promotl°n officers not been professional group could or should dominate Health
--on! 4 P°WerS “ affect 'be health of local promotion should be seen as a banner under which a
•-’Pie. for instance the right to veto any health wide variety of people can gather to work for the
10Ca] government decision that they judge enhancement of people s nealth It is both illogical and
tmns o4rhV0Urhbiy affeCt thS heaJth of 10cal P°Pufe- counterproductive for any one group to appropriate
h rlght 10 insist 0I- [he introduction of no health promotion, and I therefore commend the HEC
and the vast majority of organisations and health
smoking areas? The answer of course is simple
5 aaenTof10" officer7advisers are viewed not as education units with the sense to refrain from
mL/ i
f chanSfe' but as marketing agents and incorporating the phrase health promotion' into their
titles, which by the very act of doing so negates the
sXsh of XT W°rkerS' P31d t0 Create a transient purpose.
splash of publicity or act as secretary to a policy™fic49adTP' Tte °nly 1631 P°Wer a health Promotion
edS ™ r 'fP0STS 15 that of Persuasion and
he4h Ih ' h ‘Sf«Why ln reallty he °r she ‘s still a
oh nS4Catlon °7er- aIbe>t using a limited range of
cause^r methodrs- These methods themselves are
J concem- 111S almost as if health promotion
re being used as a time machine to transport us
heahh;7nty.years 1° the mass media approaches of
References
Denis J et al Health promotion, in the reorganised NHS The
Health Services 26 1 82
2 WHO Health promoaon A discussion document on the
and pnnciples of practice Copenhagen. July 1984
3 concept
Heter H. Pocket Treasury of Great Quotations Reader s Digest
1 y /o
4
Williams G Health promouon - canng concern or slick
salesmanship? Journal of Medical Ethics 1984, 10: 191-195
r ^4 haVS 10n9 SlnCe Sh°wn to be
ol limited value if used m isolation
Whither health promotion?
Am I, therefore, advocating the rejection of health
• Jeff French is District Health Education Officer for
the Mid-Downs Health Authority
MENTAL HEALTH
Education in hun^an relatioi
with mental handicap
•'V-Z I
7^1^.
Nigel A Malin, BA, DipASSA, MPhil PhD
oenior Lecturer
Sheffield City Polytechnic
G CainPion, SEN, SCM^
CertHSR
'
Health Education Officer"^
Lincoln
v o are
ii
:7 -
116
are
ch-
v 4’ lan
list
workers
into schools to
develop
.
----------r -this
—J are^xHuman
relationships education is important in enabling
mentally handicapped people to survive indepen
dently within the community.
1 y
teaching within health educafor DMDte
“ the1context °f Providing services
or People with mental handicap. The paper consid-
e
health education in Europe
al outline
THE NETHERLANDS
nncipality of Monaco is a small town. Climate and health conditions are
ood, and there are sufficient well-trained doctors to serve the population
i problems in Monaco are thus less acute than in other countries, but
education is nevertheless not neglected.
noolchildren (about 5,000 chilchtn and adolescents) have a medical and
check-up at least once a year; on this occasion, doctors and dentists give
patients* any advice they think necessary.
time to time sessions are also held during whi^h short films are shown on,
ample, the harmful effects of alcohol, smoking\nd drugs.
J. HAGENDOORN
(onaco Red Cross also runs regular courses on mother and child health,
f the elderly, and care of the sick.
\
•ffice of Occupational Medicine is in charge of preventivdsoccupational
ine, and its main function is to supervise the environmentabhygiene in
ss firms and factories, and the safety of the workers; in thX regard,
lists advise employers and staff representatives on accident prevention and
itional diseases.
\
Statistic data
Capital : Amsterdam
Surface area : 41,160 km2
Population : 14,600,000
Density : 355
Annual rate of increase : 0.4
Infant mortality rate : 8.0 per 1,000 live births
Life expectancy at birth : 76
Urban population : 89%
Number of unemployed : 694,100 (11.6%)
Drs. J. Hagendoorn is director of the Dutch Health Education Centre
Address
Dutch Health Education Centre, P.O. Box 5104, 3502 JC Utrecht, The Netherlands
HEALTH EDUCATION IN EUROrt
Health education trends and objectives
Health education has a long tradition in The Netherlands. In the middle of the
19th century information was available on ante and post natal care use of
alcohol, hygiene, etc.
The term health education was introduced by a government committee in 1961
Health education encompasses all activities undertaken to influence consciously
and systematically the relationship between health and behaviour and is seen as
part of health promotion. Health promotion also includes activities in the related
fields of education, legislation, health care, taxation, welfare work, etc.
Up till 1975 there was much discussion about the organisation of health
education and policy related issues.
In 1976 a committee for National Planning in Health Education was established,
which gave a strong impetus to the further development of health education.
Many of the committee^ recommendations were put into practice, c.g.
■ i
rl
i I
I I
IJ
!■
i
- implementation of health education activities in every stratum of the Dutch
health care system;
- support for these activities by special health educators in the main health care
institutes;
- regional bureaus to support the health education activities of the several
institutes;
- introduction of health education in schools;
- a national institute to support the development of health education and
improve its quality;
- a national board for health education to advise the government and health
education practitioners.
Meanwhile, a special department for health education was incorporated within
the Ministry of Health.
Strongly supported by government policy, the broad trend in health education in
Holland shows rapid development in schools and in general health care.
The main aim is the formation of a coherent and continuous system of education
and care in which health education is an integral and undeniable part.
In addition, increased attention has to be given to the educational aspects of the
activities of voluntary organisations and specific institutions working in areas
such as nutrition, road and home safety, dental health, cardiovascular di eases,
smoking, cancer, alcohol and drugs, birth control and sex education.
Health education within health policies
I
At government level:
i
■ MB .
• During the last three years, health education has been given considerable
emphasis in Dutch legislation.
• Although government health policy is constrained bv limited resources, health
THE NETHERLANDS
They are even formulated as cornerstones of policy for future years. There is a
change from health care policy to health policy.
• In the same way high priority is given to the development of systematic patient
education.
• Health education was introduced as a compulsory subject in primary schools
in the Netherlands in 1985.
• A law was passed which made information and health education compulsory
in the work place.
• The National Health Council (an advisory council for the Minister of Health)
has a special standing committee on health education.
At organisational level:
• Many important health care organisations formally accepted the long-term
policy to introduce health education.
• The most important organisations in public health, primary health and mental
health expressed their willingness to develop health education within their
sectors. Funds have been and still are made available to provide the money
needed for this development.
• Some initiatives started about twenty years ago, others are just beginning, and
much (still) has to be done, but primary conditions for the implementatior
process have been created.
Organisation and planning of health education in the health system
The general principle of the organisation of health education in the Dutch health
care system is: every health worker (c.g. doctor, nurse, social worker) has not
only a curative, but also a preventive role, part of which is health education. But
experience shows, curative work has a tendency to dominate and expand at the
expense of preventive work.
Special attention has to be given to develop and consolidate the preventive
elements; therefore special health educators must be appointed to do this job.
They are employed in several strata of the Dutch health care system, and their
main role is to be supportive, but sometimes they are also involved in concrete
health education activity. Occasionally they are supported by their national
health care organisations, and mostly by the Dutch Health Education Centre.
It is possible to specialise in health education at several universities. However,
only at the University of Limburg there is a specialised curriculum of health
education. Most Dutch health educators have had an academic training.
The introduction of patient educators in hospitals and clinics has just started.
There is experimentation with several models, sometimes in cooperation with
patient organisations.
Health education is carried out not only in the health care system. Every region
has many organisations which are involved in health education activities: c.g. sex
wlMCitum* anti-smoking, non-drinking, healthy food etc.
a
The development of health education in the Netherlands is based on the assumn
tion that, although activities are mostly carried out by non-specialists health
education is nevertheless a specialised activity for which appropriate skills are
needed, particularly in the field of communication. These activities have to be
supported by information, training, research, special methods and careful
registration.
Health system, general lines:
Paid by:
1 Public health care (mainly preventive)
2 Primary health care
- ante and post natal care (mainly preventive)
- home care of the elderly (mainly curative)
- general practitioners (mainly curative)
3 Ambulatory mental health care
(curative/preventive)
4 Intramural somatic care hospitals/clinics
(mainly curative)
5 Intramural mental care hospitals/clinics
(mainly curative)
municipality
national insurance law
health insurance funds
national insurance law
health insurance funds
private insurance companies
national insurance law
For these reasons, the Dutch Health Education Centre was founded in 1981. This
national institute aims specifically to stimulate the development of health
education in the Netherlands and to improve the quality of related activities. The
institute carries out pioneer projects to stimulate developments in patient
education, school health education and AIDS information in secondary schools.
Projects on efficiency and occupational health education are being developed.
During the five years of its existence this institute has acquired a central place in
the development of health education in the Netherlands.
At the moment about 300 full-time health educators are working in the Dutch
health care system. Approximately 1000 health education projects are carried
out.
Health education in the school system
Health education in primary schools (including kindergarten) has been an
incidental activity until 1985. The new law on primary schools in 1985 made
health education a compulsory subject. Every teacher has to give attention to
health education subjects. Over the next few years much thought has to be given
to the systematic introduction of health education in primary schools. A general
curriculum and a manual for teachers has been developed. A three year
implementation project was started at the Dutch Health Education Centre which
aims to collect literature on health education and make it available to primary
schools; to coor ’’ 'ate the work of organisations involved in integrating u alth
education into
primary school curriculum; to develop instrument .hat
promote adequate support at national and regional levels; and to give advice and
support to teachers and health care workers.
The general trend is to incorporate health education in the curriculum. There is
no special role for doctors, nurses, dentists, volunteers, etc. in giving special
aspects of health education.
In secondary schools, depending on the type of school, health education
sometimes is integrated in the curriculum and sometimes it is a special course. In
some schools special teachers are appointed for health education.
Much has to be done to reach an adequate level of health education in secondary
schools.
Mass media and health education
The mass media - TV, radio, newspapers, journals and magazines - are used for
general campaigns. The government itself carries out promotions in a limited
way, however the majority is done by the specialised national institutes, e.g.
campaigns in road safety, anti-smoking, moderation in drinking, good nutrition,
etc. Educational television also plays an important role in this field. The mass
media, in addition, provide an important general information service to the
public on various health education topics.
The Dutch Health Education Centre does not carry out campaigns itself, it has
primarily an advisory role.
Health education training
In general, developments in training stem from the need for health educators in
the several sectors of health care or for teachers in education.
With the expanding demand for academically trained health educators, several
universities focus attention on health education. Specialisation in health
education is possible at one university.
Some teacher training programmes in Holland pay attention to health educa
tion, sometimes even as a special subject.
There is still much discussion about whether health education should be a special
subject or integrated in other subjects in secondary schools.
Research
A considerable amount of research is done on health education topics by
universities and specialised research institutes.
Each year, the Dutch Health Education Centre publishes overviews on ongoing
research and recently completed and published research. Most researchers in the
field of health education are members of a special research working group in the
- 173-
- 172 -
HEALTH EDUCATION IN EUROPE
NORWAY
If
r
Vc
a
Dutch Union for Health Education
I
n
The
x Dutch
L>ulcn Union
union for
lor Health
rieaith Education
Education was
was established
established iin 1979 to support the
development of health education in the Netherlands, and now has about 500
members. It publishes a journal, organises an academic lecture every year, has a
‘theme of the year'
year’ around which special activities are organised and has special
working groups.
o
Recent developments
e
c
e
c
5
!(
E. HEIBERG ENDRESEN
The introduction of a new law on labour conditions, which includes la rangew of
measures concerning health education, necessitates giving special attentioni to
the introduction of health education in the workplace.
An introductory programme will be devised by the Dutch Health Education
Centre in cooperation with several (business) organisations.
Another area of development is health education for the elderly. Henceforth,
special attention has to be given to enable special approaches in this field.
Conclusions
Present conclusions for the development of health education in the Netherlands:
- gradually health education has been accepted as an integral part of (health)
care, but there is still a long way to go;
- health education will only be carried out systematically if there is continuous
support from certain specialists in the field;
- a national and regional policy is under construction to support and promote
the development of health education;
- a structure for scientific support was established to encourage the introduction
and improve the quality of health education activities;
- health education is not only a part of the health care and educational systems
but is also an important subject in the industrial sector. Basically health
education has its roots in a broader system of health promotion by means of
laws, regulations, etc. which are vital for the health and well-being of the
people;
- in general in The Netherlands favourable conditions exist for the development
of health education in the future.
Statistic data
Capital/ Oslo
Surface arod : 324,219 km2
Population : 4,200,000
Density : 13
Annual rate oj^ncrease : 0.2
Infant mortality rate : 8.3 per 1,000 live births
Life expepfancy at birth : 76
U/ban population : 70%
Number of unemployed : 31,700 (1.5%)
Health Bulletin 48/4 July 1990
The World Health Organisation’s Definition of Health
Promotion: Three Problems
Michael P Kelly
Senior Lecturer in Health Promotion
Department of Public Health
University of Glasgow
2 Lilybank Gardens
Glasgow G12 8RZ
Heald) Bulletin 48/4 Julv l'N()
The three problems
While the WHO definition and its practical implications arc extremely interesting, a
number of matters should not go unchallenged. The first concerns the alleged ditlcicncc
between medical and social models of health and illness upon which it is based
Medical and social models of illness
The WHO definition, emphasising political, economic and social factors, is derived
from the view that much modern medicine tails to meet the needs of individuals ami
populations. High technology and high cost medicine are said to be of limited value in
dealing with, or preventing, the ma|or health problems which afflict both developing
and developed societies. This is true, so the argument goes, in relation to diseases
associated with poverty and malnutrition in the 1 bird World and to premature mortality
and degenerative diseases in advanced societies. High technology medicine is said to
encourage dependency on the medical profession, and to discharge individuals and
Introduction
This paper highlights three problems with the definition of Health Promotion which has
been advanced by the World Health Organisation (WHO). These are: a tendency to
oppose medical and social explanations of illness, a focus on the future rather than on
the present and a failure to take account of known processes of behavioural change. The
WHO definition is not necessarily the best, or the only definition of Health Promotion.
However it is influential through its association with major programmes such as Health
For All ^O(X) and the Healthy Cities Project. Therefore in view of us potential impact
on current planning, the internal contradictions of the definition merit attention.
The 1986 WHO Charter for Health Promotion (The Ottawa Charter)* defines Health
Promotion as ‘the process of enabling people to increase control over and improve thenhealth’ This process requires for its implementation a number of major politica . socia
and economic pre-requisites. These are identified by WHO as peace, shelter, adequate
eroups from taking responsibility from their own health The suggested solution is io
change the emphasis in service provision from a concentration upon sick individuals,
towards appropriate forms of primary care and measures to address the social conditions
and the political and economic factors which determine patterns of health ami illness
Communities should become more active as empowered and liberated participants in
matters relating to their own health.
The danger ot this approach lies not in its intent. Rather, an enthusiasm lor non-meilical
explanations of disease may lead to a false and unhelpful dichotomv between the socalled medical and social models of health and illness. A convincing case can be made
that the medical and social models are in fact not very different in so lai as both hold
that bad precursors lead to bad outcomes. The fact that, in the medical model, precursois
are largely of microscopic dimensions and in the social model they are delects in social
structure, and that the outcome is called disease in the medical model and social disinte
education, basic nutrition, sufficient income, a stable material environment, sustainable
resources, social justice and equity. It is argued that a social system without this basis
gration or deviance in the social model, should not detract from their similarities.
is a very difficult one in which to promote health. The Charter specifies five bas.c activities
The concordance of the social and medical models is an idea particularly associated with
of Health Promotion as a consequence of the definition:
the work of Antonovsky1 *. He argued that both the behavioural and medical sciences
1. building healthy public policy,
2. creating supportive environments,
3. strengthening community action,
4. developing personal skills, and
5. reorienting health services to their users.
tend to concentrate upon disorder and abnormality. The difference between them is one
of method, not of their inherent approach. Both seek to explain the originsot breakdow n
whether of bodily systems or of social systems. This is acknowledged as a highly approp
date activity for these sciences. In addition Antonovsky suggests that medical and
behavioural science should also focus on survival of systems. In the context of Health
Promotion this means that they should be applied to study of the origins ot health as
well as the origins of disease.
This approach to Health Promotion is based on a social model of illness and health.
The critical question in such an approach for I lealth Promotion is why certain individuals,
Therefore it largely avoids explanations of disease which are centred on individuals in
groups, households, communities, social classes and societies are better able than others
to withstand the onslaughts of economic exploitation, poor social conditions, noxious
environmental hazards, self-injurious conduct, virulent micro-organisms and accidents
it seeks to effect changes in social systems from the local to the global level. It places
major political and social issues within the orbit of medicine but sees medicine as only
The debate between social and medical models becomes irrelevant, if the contributions
both can make to the study of survival as well as of system breakdown arc emphasised.
part of the process of Health Promotion’.
177
176
O\
k
Health Bulletin 48/4 July 1990
Health Bulletin 48/4 July 1990
Target setting
Anthropology, Marketing, and Organisational Behaviour which all study change in
particular facets of human activity, the availability of models to understand change is
The second problem which resides in the WHO’s definition of Health Promotion is its
strong orientation towards action for change-for-the-better. The setting of goals which,
enormous.
if achieved, will bring much needed improvement to the health of populations or groups
is the logical policy to follow from this orientation. For example, in the Healthy Cities
Project much effort has been expended in devising appropriate indicators to measure
WHO statements make little reference to the available literature on behavioural and
future states of change. While an orientation towards the future and attempts at scientific
social change5. This is unfortunate because if the agenda for 1 lealth Promotion is change
in a broad sense, or it particular changes are required at local level to improve the life
evaluation using indicators are understandable and laudable, there is a danger that
targets for future achievement may distract attention from present Health Promotion
chances of individual communities, some reference to the models which may help in that
process would be appropriate6. Of course not everyone involved in I lealth Promotion can
be a polymath with respect to the breadth of the Behavioural and Social Sciences
However, if and when a Health Promotion intervention is planned at any level -
needs in existing communities. For example, epidemiological arithmetic may be
employed to assign targets for the health of total populations at some remote time in
the future. By targeting a 15% reduction in a specific disease in a particular community
by the year 2000 a future improved state of affairs is identified. But people are living
community, local, regional, national or even global—attention should be given to the
model of social and behavioural change that will operate’. Thought needs to be given
in that community now. They may find survival uncertain and difficult at the moment.
They will probably continue to do so in the year 2000 or 2010 and beyond. Community
to how an intervention will work. A clinician always knows what he or she expects from
particular actions. Processes may not be fully understood, but a framework (the real
health profiles often show that ordinary people are, unsurprisingly, very concerned with
problems of living in the here and now and with problems of surviving today, tomorrow
or next week. They tend to be much less concerned with problems of dying or not dying
by the year 2000, except in the most general sense.
medical model rather than the straw man frequently attacked by the social model of
health) exists to make sense of actions and to interpret results.
Social and Behavioural Scientific models have exactly the same role. The processes they
seek to describe may not be completely understood, but they do provide a useful means
A compelling argument can be made that the practice of Health Promotion should assist
or facilitate healthy living now. rather than set targets in the anticipation, or hope, of
of making sense of what is going on. This simple idea sometimes seems to be lost from
view in WHO statements in which Health Promotion is presented as a combination ot
a better future. (This is not to say that traditional preventive medicine should not aim
good intentions and ideological conviction rather than as a matter ol science.
to reduce premature mortality by the year 2000 or any other date, but Health Promotion
and preventive medicine should not be considered synonymous).
It can be argued that the cornerstone of such an approach to Health Promotion should
Conclusion
Health Promotion is a new. exciting and potentially very important development. But
be an understanding and development of coping processes and skills. For example, the
observation that a high rate of coronary heart disease is related to smoking may lead
there are difficulties with WHO's definition If the definition is to form the basis lot
to attempts tostop people smoking. An education or other type of preventive programme
may be developed. However, if the programme ignores the fact that (addiction and
not be portrayed as an exclusive alternative to medicine. It must work with medicine
practice, the three concerns of this paper need to be addressed. Health Promotion should
pleasure aside) some people routinely cope, or think they cope, with the stresses of their
towards understanding the origins of health in addition to the causes of disease. A focus
lives by using tobacco, and does not offer alternative coping skills or does not address
the origins of the stress, its chances of success are likely to be limited to those who can
on the future should not detract from current needs. Finally, any intervention should
find ways of dealing with stress other than by smoking. The very up-beat WHO approach
behavioural sciences.
be adequately informed by appropriate models of change drawn from the social and
to the future and the targets, the very creditable desire to change this for the long term
good, may be the undoing of a programme if it ignores people’s present problems.
Acknowledgements
I am grateful to Graham Watt who offered many helpful criticisms of earlier drafts of
this paper. Thanks also to Norah Adams.
Behavioural and social change
The third problem with the WHO definition is its scant attention to the sciences of
behavioural and social change. The disciplines of Sociology, Psychology and Social
Psychology are directly concerned with the kinds of changes which the Ottawa Charter
seeks to encourage. Sociology was founded on investigations of how societies as a whole
or their component parts have developed and changed. The discipline consequently
has many models of social change. Psychology takes as one of its core elements the
development and change of the individual. Social psychology focuses on group dynamics
and change. If to these three are added the disciplines of Political Science, Education.
178
References
1. World Health Organisation. Ottawa. Charter for Health Promotion: an international
conference on Health Promotion—the move towards a New Public Health Ottawa. IW6
2. Kickbusch I. Introduction 1-3. In Anderson R et al eds Health Behaviour Research and
Health Promotion. Oxford: Oxford University Press, 1988.
3. Antonovsky A. Health stress and coping. San Francisco. Jossey Bass, 1985
179
Health Bulletin
•JK/4 July I99()
How People Mai
p"^
'"age Stress and sl4v
Health for ,\||
HwUhP^
..... .
•motion 19x9, 4; 3|7_)()
*■ ‘•Penh.igcn World
-•-Hc.!,hMe,lrc,ne |W);
Pr"v'''^p’^^^|^'h Oe. 194te.|9gfc, by
• he Nuffield
i have noted live i
"“""ns,,f................................................................ ..........................
diseases:
w>mnuin
‘Once f•
and• forever
’. ()nce
•'hrosis and other'
">=C0„d,persis|
•—^'’ngefutaldjsordei
""l death, eg eysttc
part.
—n.l..cquiredt„„,|irii,ns usuihai
an amputated
'nswhichlfleVou
w
^^"'e no" retractable
^'neSs. SIrotes unJ
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>-ue XaXT Urini,rV ,r;,Cl
in ,heyoungXffiLtddedv'^
tion.-
1«()
P'C,UrC’ 'here arc a few diaer
00
fHeaCtU Trobkm
^Dimensions of
rDiird ^orCd Urban (Poor
VMh empfiasis on Metropolis (Bangalon, India
I
I
I
MJ. KalHath
Masters hi Public Health (M.P.H.) Programme 1595-1996
Student Number: 952791
'University of Limburg, Maastricht
21 August 1996
Submitted as M.P.H. course completion requirement to
Professoi'si Geijo Kok and Bart van de Boine,
Department cl Health Education. Faculty of Health Sciences.,
Umversih' of Limburg, Maastricht, Nelherlamds.
1
Contents
page
1
Introduction
1.1
1.2
1.3
1.4
1.5
1.6
1.7
Urbanisation Trends in the Developing Countries
3
3
3
4
4
5
5
6
2
Methods and Limitations
2.1
2.2
2.3
What is a Case-study
3
The Findings of the Study
3.1
3.2
Common Health Problems in Bangalore Slums
Urbanisation Trends in India
Features of Urbanisation Process in Third World Counties
Urban Poverty in India
Health of the Urban Poor
Health Care Provision
Study Question
How this Study was done
Limitations of the Study
Multi Level Aetiology
Individual Level Factors
3.3
3.3.1 Poor Awareness of Health Promoting Factors
3.3.2 Poor Awareness of the Environmental andSocialFactors
3.3.4 Neighbourhood / Community Level
3.4.1 Low Level of Belongingness and Commitment
3.4.2 Low Level of Social Support Network
3.4.3 Poor Community Organisation and Constructive Leadership
3.4.4 Negative Social Behaviours
3.5
Quality of Infrastructure
3.5.1 Quality of Housing
3.5.2 Quality of Sanitation
3.5.3 Quality of Water
3.6
Services Provided
3.6.1 Multiplicity of Agencies
3.6.2 Quality of Social Services Provided
Macro Environmental Factors
3.7
4
Literature Survey on 'Health of the Urban Foor’
4.1
An Exj^ination
7
7
7
9
10
10
11
12
12
13
13
13
13
14
14
14
14
15
15
15
15
16
17
18
18
2
4.2
Focus on Urban Health
4.2.1 Evolution of Interest
4.2.2 Disaggregated Data on Urban Poor
4.3
Aetiology of Hl health
4.3.1 Multiple Aetiology of Disease
4.3.2 A Classification of Multiple Aetiology
4.4
Macro level Factors
4.4.1 Poor Economy
4.4.2 Macro Level: Situation in India
4.5
Meso Level Factors
4.5.1 Housing and Health
4.5.2 Safe Water and Health
4.5.3 Facilities for Sanitation, Drainage and Health
4.5.4 Urban Health Services
4.5.5 Urban Pollution
4.6 Local Level Factors
4.6.1 Supportive Community Dynamics
4.6.2 The Family and Urban Poverty
Theories of Social Change and Health of the Poor
4.7
5
Implications and Requirements
5.1
5.2
International Experience
Macro Level
5.2.1 B alanced Urbanisation
5.2.2 Attitudinal Changes towards Urban Poor
5.2.3 Programmes for the Urban Poor
i
5.3
The Meso level
5.3.1 Programmes and Services
5.3.2 Devolution of Authority
5.3.3 Health Care Services
5.3.4 Educational Services
5.3.5 Reorienting Officials
Empowerment Process and Partnership with Non Governmental Organisations
5.4
5.5
Urban Basic Services for the Poor (U.B.S.P.)-a Model
5.6
Individual / Neighbourhood Levels
Summary
Refemices
Appendix
o
18
18
19
19
19
20
21
21
21
22
22
24
24
25
26
27
27
28
28
30
30
30
30
31
32
32
32
33
33
34
34
34
35
35
37
38
40
3
1
Introduction
1.1
Urbanisation Trends in the Developing Countries
The largest and most extensive migration in human history is taking place during our
contemporary times. This is the migration of the rural people to urban settings. The
predominant part of this migration is taking place in the developing world.
The urban population of the world estimated at about 2 billion for 1985, is projected to reach
3.2 billion by 2000 AD and 5.5 billion by 2025, increases of 56% between 85 and 2000 and
72% between 2000 and 2025. From 1985 to 1990, the population of the less developed
regions grew by 4.5% annually (see figure in Appendix). The level of urbanisation in
developing regions is expected to increase from 37% in 85, to 45% by the end of the century
and to 61% by 2025 (World Health Statistics Quarterly, 1991).
A significant proportion of the urban population reside in large agglomerations, which grow at
such a fast pace that the services and infrastructure provided cannot keep pace. In 1985 there
were 99 such agglomerations with population of over 2 million and 50 of them were in
developing countries. It is expected that by the year 2000, there will be 28 'mega cities’, of
which 22 will be in less developed countries. Mega cities are defined by U. N as cities with
more than 8 million inhabitants (World Health Statistics Quarterly, 1991).
The major contribution to the growth of cities is from natural increase (about two thirds),
however migration is equally important as the natural increase among migrant population being
high, as they are in the young age group 15-29. The third reason is because of reclassification
of settlements.
1.2
Urbanisation Trends in India.
In 1901, less than one out of ten persons (26 million) lived in urban areas in about 1900
I
I
settlements. In 1971 the ratio changed to one in five (110 million) in about 3000 urban
settlements. In 1981 it accelerated to one in four (160 million) in about 3300 settlements and by
2001 it is expected to be one in three (350 million) in about 4000 urban areas (Ribeiro E. F. N
1990).
Much variation is seen in the levels and rates of urbanisation among the twenty five states and
seven union territories that constitutes the country. The highest being Maharashtra with 35%
urbanisation and the lowest being Arunachal Pradesh with 6% urbanisation. Grouping urban
areas into three categories namely cities (100,000 population and above), medium towns
(between 20,000 and 100,000 population) and small towns (below 20,000 population), the
highest population growth is noticed among cities in the period 1901-1981 (26% to 60%). The
other two categories have remained the same or decreased. It is estimated that by the year 2001,
about a third of the urban population (112 million), will be living in 36 Metropolitan areas i.e.
.
■
4
population of one million or above the fastest growth being expected in the metropolitan areas
or large cities (Rebeiro E. F. N., 1990).
13
Features of Urbanisation process in Third World Countries
There are certain features that stand out in the urbanisation process that Third World countries
are experiencing, some of which aspects were different in the process that the Western nations
underwent earlier.
-The rate of urbanisation and the increase in urban population is very high.
-The urbanisation is happening in the midst considerably limited resources.
-The quality of life, in terms of conveniences, infrastructure, pollution and health levels is
much lower for the metropolises in the Developing World.
-The urban growth is taking place in an unplanned manner and the governmental efforts at
providing infrastructure and other supports, inadequate as they are, is occurring in a reactive
manner.
-A large proportion of the urban population 30-50%, are totally excluded from access to
facilities and services and glossed over in the planning process.
-There is an increasing number of urban poor or the "informal sector" of labour, who
employed casually in low paid, tedious jobs, with no security and some of whom are self
employed in petty street vending.
-There is increasing pollution of the urban air, land and water, as result of the economic
activities in the urban areas and because of the accumulation of wastes from commercial and
domestic activities.
1.4
Urban Poverty in India-
By official estimate (perhaps underestimated) 27. 7% of the urban population falls below the
poverty line, which in the year 1987-88 was estimated at 57 million people. Estimates of
poverty are based on the aveiage calorie intake of the household and does not take into account
poverty caused by environmental degradation and poor life supports. Expenditure groups in
which average daily calorie intake for the household members is below 2140 calories in urban
areas, is counted as belonging to below poverty line (Shah, 1990).
The manifestations of poverty are now quite obvious in the Indian cities and according to the
National Commission on Urbanisation include:
-proliferation of slums and bustees
-fast growth of the informal sector
-increasing casualisatio i and underemployment of labour
-pressure on civil services
-high rate of educational and health contingencies coupled with under utilisation of social
services
5
-undergrowth of physical and mental capacities and degradation of human resources
-growing sense of hopelessness, rising crime rate and group violence.
1.5
The Health of the Urban Poor
When one focuses on the health aspects of the urban poor in the developing world again certain
features are noticeable at a macro level. There appears to be stages through which the
population passes through in the health continuum, which is referred to by some authors as the
'epidemiological transition’ to explain the adjustments that the migrating population makes with
the new eu /ironment In its essence tlie explanation is that there is an initial phase of increased
illnesses from epidemics, infections and nutritional problems, followed by a phase of
decreased epidemics and communicable diseases, but still present significantly. This phase can
be prolonged with the coexistence simultaneously of the diseases of 'modernity'. This is
followed by the picture as seen in western societies when there is an increased occurrence of
manmade diseases or diseases of modernity.
When one moves from the macro picture to a micro level analysis one is constrained by the
paucity of health data related to the urban poor. The data that is collected is invariably of the
entire urban population and disaggragated data of the urban poor is rarely available. Isolated
studies available show that health status of the urban poor in the developing countries is
significantly worse than their better off neighbours and also worse as compared to the rural
counterparts. There appears to be a very large need of health related problems for the urban
poor.
This area related to the health needs of the urban poor has received insufficient attention, until
the last one and a half decades, during which period there has been a burgeoning of interest.
The patterns of morbidity and mortality observed show relationship to the environment and
behaviours associated with the situation of origin, and of the situation in which the poor are
now secluded and also from the complex web of poverty associated factors. The picture is one
of:
-high prevalence of communicable diseases and malnutrition
-cardiovascular, mental diseases and neoplasm and accidents of various sorts
-alcohol, drug abuse, crime, child abuse and sexually transmitted diseases
Available studies suggest that infant mortality rates and disease incidences are several times
higher in the poorer neighbourhoods as compared to the averages in the whole city (World
Health Statistics Quarterly, 1991).
r
1,6
Health •Care Provision
The health care response to these problems have primarily been of the hospital oriented curative
type 'without specifically targeting the urban poor or their varied problems. The services remain
nder-utilised also because of their geographical and financial inaccessibility. This situation
.raises a question whether the 'health need assessment of the urban poor’ is adequate?
f
11
6
1.7
Study Question
Given the background as stated above it is important that a comprehensive understanding is
developed of the health related needs of the urban poor and what are the possible solutions and
responses.
What are the priority factors (variables) associated
with the health status of the poor, in the urban
ghettos (slums) of the metropolitan city of
Bangalore, in a developing country India, and at
what levels are they operating?
What can be done?
7
2
Methods and Limitations
2.1
What is a Case-Study?
Yin (1984) defines case-study as An empirical enquiry that investigates a contemporary
phenomenon, within its real life context when the boundaries between the phenomenon and the
context are not clearly evident and in which multiple sources of evidence are used. The case
study is an important scientific method, to answer the questions of 'why' and how, with
regard to a phenomenon that is currently happening. Case-study also retains the holistic and
meaningful characteristics of real life events. As case-study is not based on a sample population
it cannot be generalised to a population, however case-study can be used to generalise and
expand theory, or theoretical propositions.
2.2
How this Study was done
The study presented in this article is really a case study earned out during the period 1986-90,
of seven slums in the metropolis of Bangalore in India. The population living in these seven
slums was about 2000 families or roughly 13,000 persons. Several types of evidences are
incorporated in this study. They are:
1) Observations of the health problems, physical conditions of living and life style aspects of
the people, carried out, while doing health work for four years in this community. Fortnightly
every slum was visited in rotation, an average of three hours was spent in the slum community
during every visit The activities during visit included curative care and health education of
those individual patients referred by the health volunteers, making visits to the homes of those
families with specific problems and participating in women's meetings which consisted of
women's organisational activities and education on health problems. Activities related to
supervision and guiding of health volunteers were also carried out during these visits.
The perspective from which health problems were addressed consisted of a multidimensional
view of disease causation and an integrated approach to health promotion.
2) Observations of the outcome of interventions made specifically in the area of nutritional
supplementation and growth monitoring, health education, organised community actions
through trained health workers, for improving environmental sanitation. Emphasis was on
community participation in these activities, during the stages of problem identification, action
planning, implementation and review of actions. The community representatives were equally
active during the efforts directed at the city administration towards improving infrastructure and
services.
The monthly reflection meetings of the health volunteers were a source of insight into how the
community perceived their health problems, their relationship dynamics, and responses of the
I
8
administration to their initiatives. These observations however were not made with the vigour
required for an experimental study.
3) Information gathered from key informants, the health volunteers, who were representatives
of the communities. TTiere was a good rapport established with the key informants over the
years of involvement with their problems, which facilitated spontaneous sharing of their
perspectives, belief systems and emotional outlooks, which individuals are usually reluctant to
share. The key informant interviews took place with representatives from five slums in formal
situations and several others during informal situations.
4) Information from innumerable group discussions, most of which were in the context of the
health education classes held. Four specific focus group interviews were done for the purpose
of writing this report in four different slums.
5) Information gathered from secondary sources:
The following government officials were contacted-At the state level a joint director of health
and a statistical officer concerned with the health information, were interviewed from the State
Health Department and functionaries of the Slum Clearance Board were also similarly
I
interviewed.
.
-At the city level the deputy commissioner of the City Corporation and the person in-charge of
I
I
public health, the head of Family Welfare services were interviewed and a days visit was done
with the Mobile Health Team during their visit to the slums. Also two project officers
concerned with two programmes relevant for the slum people namely The Integrated Child
Development Scheme (I.C.D.S.), and Women and Child Welfare programme were
interviewed. The Bangalore Development Authority (B.D.A.) which also has jurisdiction over
several slums, it was not possible to contact. The officials were asked about their services for
!
the slum areas and the handicaps and possible solutions perceived by them.
In order to get access to the government officials often it was necessary to get the
recommendation of a senior beaurocrat, and the officials generally had a defensive posture and
i
were reluctant to pass on relevant documents.
-Five N.G.O.'s working in Bangalore slums were interviewed two of whom were working
with street children. Similarly a journalist with development orientation who had been wnting
on issues of urban poor and the public health professor of the local Medical College with
students doing studies in the slums were also interviewed on their perspectives on the problems
and solutions.
6) A list of locally available reports and articles pertaining to Bangalore slums were also made
use of.
,
7) As a melhod of forte validating the perspectives the first draft of the study was emulated
I
among colleagues in the Community Health Cell Bangalore, a health research resource group
on whose behalf this study was undertaken and among two N.G.O. colleagues and their
feedback was incorporated, on die urban slums.
!
■
9
As can be deduced, the enquiry did not initially start with a study question, but from an open
approach to understand the problems one was confronted with in the course of working with
the poor people in the slums. The study question was stated only at the end of the four year's
work, when the need was experienced to record the experiences as a descriptive and
explanatory report. At this point already certain patterns and relationships were evident. To
supplement the evidence, four 'focus group interviews' were held, as well as five lengthy key
informant interviews. The focus group and key informant interviews were held in an openended fashion, though a check list of points related to the factors and relationships that had
surfaced, served as a guide. Secondary data, oral and written were gathered, especially relating
to the infrastructure and services available in the slum areas.
At the time of presenting this report not many studies were available on this subject This has
been rewritten after further literature survey was entered into, to compare with findings from
other situations and with perspectives that were not present in this study. Hence in this report
the literature survey is placed after the "Findings from the study’.
2.3 Limitations of the Study
1) As stated earlier the collection of evidence, did not start with a study question, but it came to
be stated at a later stage, when information was being collected for reporting.
2) As a relationship was developed with the community studied over the years of involvement,
observer bias resulting from this factor has not been screened for.
3) The information collected, in the majority of cases came from the women, as they were the
primary participant of the health programme. In that context men's perspective are not
adequately represented.
4) The study population was primarily those associated with the programmes of one non
governmental agency. Any variability arising out of this factor has not been looked into.
5) The study period was 1986-90. Subsequently a multisectoral intervention aimed at the slums
in the whole metropolis has been initiated by the government which would have changed the
particulars related to infrastructure and services and affected the health situation. However in
the context of the regional, national and especially Third World phenomenon of Urbanisation,
the evidence and conclusions still have validity.
6) No quantitative survey was undertaken specially for the case study. However information
from the existing surveys of the N.G.O. mentioned has been utilised.
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3
The Findings of the Study
3.1
Common Health Problems in Bangalore Slums
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The diseases most commonly noticed in the slum clinic were the following:
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Children
malnutrition
diarrhoea's and dysentery and parasitic gut infection
acute respiratory illnesses and viral fevers
skin-, eye-, ear- and throat infections
vaccine preventable diseases
accidents and injuries
Women
malnutrition
pregnancy and delivery related symptoms and complications
menstrual irregularities and vaginal discharge
musculoskeletal pains
sexually transmitted diseases
psychosomatic complaints
hypertension (occasionally)
Men (less frequent consultation)
acute and chronic respiratory illnesses
injuries and accidents
skin and gastro-intestinal infections
sexually transmitted diseases
This pattern of commonly occurring illnesses were also found in the records of the Mobile
Health Team of the Corporation of Bangalore city which had responsibility for covering certain
slum areas.
On routine analysis the diseases could be related to the following risk factors, namely:
poverty, unhygienic local environment, poor personal hygiene, unsafe habits
and poor health knowledge, emotional stress and poor health seeking
behaviours.
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3.2
Multi Level Aetiology
The study indicated on further analysis that several types of factors were involved in causing
the health problems. These factors could be grouped under the different levels that they were
operating at and hence need to be addressed, if changes were to be made.
LEVEL
FACTORS
1 Individual
1 Awareness
a- poor awareness of health promoting factors
b- poor awareness of the environmental and
societal factors causing ill health
2 Sense of powerlessness and fatality resulting in low
motivation for change
2 Neighbourhood /
a- low level of belongingness and commitment to that
community
community
b- low level of social support network
c- poor community organisation and constructive leadership
d- negative social behaviours
3.1 Micro environmental
________________
la- quality of housing
lb- quality of sanitation
1c- quality of water supply
3.2 Institutional
2a- quality of the provision of basic amenities and
infrastructure
2b- quality of services provided_____________
4 Macro environmental
a- social
b- political
c- economic
d- cultural
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3.3
Individual Level Factors
3.3.1 Poor Awareness of Health Promoting Factors
1) Personal hygiene for well being-there is some understanding regarding the negative
outcomes of not being regular in habits such as bathing, oral and facial hygiene, washing of
hands especially before cooking and wearing of clean clothes, though reinforcing the concepts
would be useful The major hurdle is the availability of facilities as will be indicated later.
Low personal hygiene resulted in widespread occurrence of skin infections - parasitic and
bacterial, poor dental health, eye infections, and gut infections and parasitic infestations.
2) Balanced nutrition for health-the diet had a preponderance of carbohydrates and insufficient
other nutrients. Carbohydrate foods are also the cheapest items that can be bought. Food items
with poor nutritive value because of being old or overripe were also consumed as they were
available in small measures from the local vendors inside the slum.
Certain food fads or beliefs existing among the population affected the .quality of nutrients: An
example is the cereal polished rice which was costlier was preferred over the more nutrient and
cheaper but coarser cereal ragi due to the status value attached to the former.
Certain cooking practices contributed negatively to nutrition: Traditional items like chutneys
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and preserves which have good nutritional value were gradually forgotten by the new
generation of migrant women.
These reasons, combined with the poverty of the people resulted in high occurrence of
malnutrition among the slum dwellers, most noticeable and measurable in the small children.
The records of the voluntary agency working with them showed that 50%-55% of the children
below 5 years of age were at risk due to moderate or severe malnutrition, resulting in high
morbidity and mortality.
3) Preventive measures and care during illnesses-there was a low level of awareness regarding
the long term benefits of vaccine protection for certain illnesses whereas the short term
inconveniences from it were given more importance.
-There was a loss of knowledge regarding traditional nursing care and home remedies (grand
mother’s remedies) and hence illnesses were managed poorly. Additionally people had a strong
belief in the magical benefits of modem medicines and injections, which often contributed to
iatrogenic illnesses.
-There was little awareness regarding psychosomatic origin of symptoms which were attributed
to external uncontrollable causes such as the climate or the water used.
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4) Healthy child rearing practices-there was poor knowledge regarding the negative outcomes
of bottle feeding of infants, use of improper weaning foods and normal milestones of child
growth.
5) Healthy reproductive and sexual practices-the women did not have much understanding on
the physiological aspects of the reproductory system and also on the methods of contraception.
Hence they experience a lack of control over their bodies.
Though symptoms related to the genital tract are not uncommon certain negative cultural beliefs
delay seeking of expert care.
Similarly childbearing and lactation is associated with many cultural beliefs related to diet and
medicines, some of which seem to have negative consequences.
Hence a healthy balance of helpful traditional practices and beliefs and useful modem scientific
practices and understandings which is required for health was lacking among the urban poor.
3.3.2 Poor Awareness of the Environmental and Social Factors
Although factors operating at different levels are contributing to the ill health of the people, this
awareness is lacking among the urban poor. However the urban poor have internalised certain
negative beliefs about themselves and their situation which hamper their problem solving
energies. They have a negative self image, believe they are wrongdoers, that they do not have a
right to belong to the urban community and the reasons for their situation are internal to
themselves such as 'their fate’. This negative image undermines the motivation for change and
for taking health seeking initiatives.
3.4
Neighbourhood and Community Level
3.4.1 Low Level of Belongingness and Commitment
Slum dwellers have lost their roots in the original community of origin (villages) but have not
developed belongingness and relationships in the new environment. Lack of tenurial
entitlement contributes to this situation, which is also caused by the absence of shared cultural
backgrounds (as people from different language and ethnic groups are thrown together),
temporariness of stay in one place, and the estrangement they feel in the urban situation.
Hence it becomes difficult to develop a community spirit which is necessary for the
psychological growth of the individual and development of supportive community norms.
3.4.2 Low Level of Social Support Networks
Neighbours have the same high levels of needs and very little resources to offer real support
whether material, informational or emotional.
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This results in widespread occurrence of psychosomatic symptoms and low coping abilities.
Excessive alcohol consumption among men and a significant number of women was noticed in
Bangalore slums (the discussion groups came up with a percentage of 90% for men and 10%
for women).
The support structure of the family was also affected in many cases resulting in single parent
households (mostly women as the single parent) or in the phenomenon of street children.
3.4.3 Poor Community Organisation and Constructive Leadership
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No representative form of organisation or leadership existed in the community (except what
was developing as a result of the intervention of the voluntary agency). The legitimacy for the
traditional leadership, was that either they had physical power or financial or status power and
their interest in the leadership position was purely for monetary benefit. Hence the community
could not effectively mobilise themselves, to name their problems and work out solutions that
improved the quality of their lives.
Another related problem was that people possessed very little documents which were needed
to identify them to become eligible for welfare programmes. Hence they were dependent on
these so called leaders who were 'middle man' link to the authorities.
3.4.4 Negative Social Behaviours
Some anti-social elements took refuge in the slums, as there were no functioning civic authority
to discipline them, and they had the blessings of local politicians.
In certain locations, criminal activities were pursued by them such as drug trafficking,
prostitution and violence. This added to the insecurity experienced by the slum dwellers
especially the women. Stress related Health Problems are quite rampant in the slums.
3.5
Quality of Infrastructure
3.5.1 Quality of Housing
In the majority of slums no intervention on housing had been carried out by any agency. In
such locations housing were of very poor standards. They were overcrowded-in small one
room dwellings where 5-7 people lived. There was little ventilation as rows of such huts were
separated by only a small space of 2-3 feet. They were made of mud and waste materials. The
occupants were exposed to risks from air pollution because of poor ventilation, smoke from
kerosene stoves used for cooking as well as fumes from industrial activities that were carried
out in the neighbourhood.
Respiratory illnesses were a common problem among slum dwellers.
15
3.5.2 Quality of Sanitation
The immediate narrow surroundings were used by the slum dwellers for washing and bathing
and for defaecation by the children. The small drains flowing between these rows of huts got
periodically blocked by the domestic wastes and overflowed. In the rainy season the overflows
not only covered the pavements, but also entered the huts.
The rubbish dumps were located in the slums and they were cleared infrequently as the
responsible authorities were ill equipped for this task and the slum dwellers could not exert
pressure on them. Hence their contents frequently overflowed spreading infective material
around.
Public toilets were very few in the slums and private toilets did not exist. Since their
maintenance was also poor they were another source of infective material.
The occupants were at risk from water borne infections, rheumatic complaints related to
dampness and accidents from house collapse. Diarrhoeal diseases were a common problem
among slum dwellers.
3.5.3 Quality of Water
The water sources were limitted in the slums. There were 1 water tap for 20-50 families and the
duration of water supply was limitted to 2 to 3 hours per day during normal periods. Hence
safe water was a precious commodity in Bangalore slums which was procured after much
effort.
Hence using this water for personal hygiene was less of a priority for the slum dwellers
resulting in high occurrence of skin infections and parasitic infestations. Endangered drinking
water contributed to high incidence of water borne diseases.
3.6
Services Provided
3.6.1 Multiplicity of Agencies
During the study period die slums studied came under the authority of three separate
government bodies: The Slum Clearance Board, The Bangalore Development Authority and
The Corporation of Bangalore City. Each of them were only partially responsible for the
infrastructural and service needs of the people living under their jurisdiction. By default the
remaining needs became the responsibility of die other governmental departments such as the
health department or the Bangalore city Water Board. However these departments did not
recognise it as their responsibility and did not have specific programmes to serve them. The
three government bodies mentioned had insufficient funds allocated for the required
infrastructural and service provision. In addition the programmes were not tailored for the
particular requirement of the slum dwellers for example the Slum Clearance Board built several
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low cost buildings which were not suitable for tlie people. They found the construction low
quality, inconvenient and above all the m jnthly payment instalments too high.
Only a small proportion of the programmes planned do actually reach the community. The
government departments function in beaurocratic ways, giving rise to innumerable delays and
coiiuption is a pervading problem. The institutions are not accountable downwards to the
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community and the slum dwellers neither have knowledge of the programmes or have the
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coercive power to exert influence.
3.6.2 Quality of Social Services Provided
The slum communities require intensive input of certain social services given their
backwardness. The important services required are Health, Education, Community
development including support for income generation. The programmes that exist are poor
quality and suffer from various problems. There is insufficient allocation of funds, beneficiary
identification is poor, need assessment is very superficial and the programmes implemented are
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generally ineffective. As has been mentioned earlier since the slum dwellers possess very little
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identification documents they become ineligible for programmes. Since programmes are
gene . .Tv planned and implemented vertically, meaning they are planned by a central agency,
without consideration of the local conditions and actors, they fail to get the beneficiary's
participation. Such programmes also lack monitoring and evaluation affecting their quality. As
an example the children from the slums find it difficult to get into the government schools for
not having Kbirth certificates and other documents. Those who attend schools have generally
poor performance and high dropout rates. Whereas a mom appropriate programme would be of
the non-formal type with emphasis on skill, training.
Similarly the health services provided by the City Corporation consisted of mobile curative
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teams which made weekly visits to the slums to provide curative services. However the need of
the community was primary health care, available on a continuous basis and secondary care
with smoothly functioning referral structure.
I
The non governmental sector consisting of for profit and not for profit organisations also
render certain se^wices in the slums. They however possess much less resources and the? scale
of operation is small. Many General Practitioners (GPs) have established their practices • round
the slums and are available on a continuous basis for curative service such as first aid and
symptomatic treatment of illnesses. However they take no responsibility for preventive care or
appropriate referrals. Certain voluntary agencies offer sendees of non formal education,
pre'/onlive care, sanitation or housing. Their ser/lces ace often piece-meal and little co
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ordination exists between the agencies invol ved in adjoining areas.
Given the above situation, the outcome is that the qualify of services available to the slum
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dwellare poor. An inference that comes up strongly is that there is a lacuna in the nation’s
illf'Hi
phaaiiig process for the urban poor.
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low cost buildings which were not suitable for the people. They found the construction low
quality, inconvenient and above all tlie monthly payment instalments too high.
Only a small proportion of the programmes planned do actually reach the community. The
government departments function in beaurocratic ways, giving rise to innumerable delays and
corruption is a pervading problem. The institutions are not accountable downwards to the
community and the slum dwellers neither have knowledge of the programmes or have the
coercive power to exert influence.
3.6.2 Quality of Social Services Provider.
The slum communities require intensive input of certain social services given their
backwardness. The important services required are Health, Education, Community
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development including support for income generation. The programmes that exist are poor
quality and suffer from various problems. There is insufficient allocation of funds, beneficiary
identification is poor, need assessment is very superficial and the programmes implemented are
generally ineffective. As has been mentioned earlier since the slum dwellers possess very little
identification documents they become ineligible for programmes. Since programmes are
generally planned and implemented vertically, meaning they are planned by a central agency,
without consideration of the local conditions and actors, they fail to get the beneficiary’s
participation. Such programmes also lack monitoring and evaluation affecting their quality. As
an example the children from the slums find it difficult to get into the government schools for
not having 'birth certificates and other documents. Those who attend schools have generally
poor performance and high dropout rates. Whereas a more appropriate programme would be of
the non-formal type with emphasis on skill training.
Similarly the health services provided by the City Corporation consisted of mobile curative
teams which made weekly visits to the slums to provide curative services. However the need of
the community was primary health care, available on a continuous basis and secondary care
with smoothly functioning referral structure.
The non governmental sector consisting of for profit and not for profit organisations also
render certain services in the slums. They however possess much less resources and their scale
of operation is small. Many General Practitioners (GPs) have established their practices around
the slums and are available on a continuous basis for curative service such as first aid and
symptomatic treatment of illnesses. However they take no responsibility for preventive care or
appropriate referrals. Certain voluntary agencies offer services of non formal education,
preventive care, sanitation or housing. Their services are often piece-meal and little co
ordination exists between the agencies involved in adjoining areas.
Given the above situation, the outcome is that the quality of services available to the slum
dwellers re poor. An inference that comes up strongly is that there is a lacuna in the nation's
planning process for the urban poor.
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3.7
Macro Environmental Factors
'Hie slum dwellers experienced their community as being marginalised or cut off from the rest
of the society. Their concerns which had roots in the outside society, apart from the factors
already mentioned, were the following:
1) Poverty-Roughly more than two thirds of the women participating in the group discussions
stated they had to work to support their families. A large number worked as daily labourers
especially in the construction sector getting employment three or four times a week. Another
large number worked as domestic help and needed to work in two to three households long
hours to gain subsistence income. Both the groups were grossly low paid. About one in ten
were self employed foot path vendors, whose income was slightly better than the previous two
categories.
The working conditions and remuneration were grossly inadequate for them but they were
forced to continue as they badly needed the additional income. At the time of the study the
women involved in domestic help were struggling to establish as an association to make
demands of the state for minimum working conditions with the encouragement of an agency.
2) Land tenure-The legal ownership of the house-site held the key to tapping into the
infrastructural and service provisions of the State. However various almost insurmountable
problems and inaccessibility to decision making powers were experienced by the poor which
put them at the mercy of the 'slum lord-politician-beaurocracy axis.
3) Harassment-The police raided the slum areas periodically and beat up the inhabitants
indiscriminately in pursuit of alleged miscreants. Continually the poor experienced being
denigrated or insulted by the police.
The beaurocracy showed a lack of responsiveness to their grievances and had to be routinely
bribed to obtain documents required to access welfare programmes. The government
procedures appeared completely alien and beyond their capacity to make it work. The hostile
and unsympathetic attitudes of the government hospital functionaries did not engender trust.
The local slum ruffians with their connections to criminal groups outside created a sense of
physical insecurity.
4) Helplessness-The slum dwellers and their associations felt completely helpless in
influencing the macro environment to better the quality of their life. On the other hand the
external situation frequently created life threatening crisis situations which oppressed them and
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produced a sense of hopelessness.
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4
Literature Survey on 'Health of the Urban Poor'
41
An Explanation
The literature survey was done through a CD ROM search of Medline express and PsycLit up
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to 1996 using the key words: urban health, urban renewal, child welfare, primary health care,
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health promotion, urban poor, developing countries, empowerment, epidemiology etc. The
data base of the Library of the Royal Tropical Institute was also searched using similar
keywords but specifically for India. This procured additional materials specific for India. Most
of the identified materials could be procured through the Inter Library Loan scheme. It was
found that out of this a priority list of materials contained most of the relevant data and the rest
contained peripheral information.
The chapter on Findings of tlie Study are presented prior to the chapter on Literature Survey on
Health of the Urban Poor. This unusual order is followed as the study took place in that
chronological sequence as mentioned in the chapter on Methods and Limitations. The literature
survey enlarged the perspective and brought some quantitative measures to support the findings
of the study. The particular aspects that got emphasised include the emerging perspective on
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urban poor in the Indian Government and how this perspective relates to the ground reality in
terms of policies, planning, and infrastructure and services; the physical environmental needs
of the slums and positive experiences in meeting them from different countries which are
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reflected in the solutions suggested. It also affirmed the creative energies of the urban poor,
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one experienced at the micro level.
In its essence the literature survey done was consistent with the findings of the micro level
study except for minor variations. Literature shows increased cardiovascular diseases and
cancer, which were not observed at the micro level. This could have been because the scale of
observations at micro level were too small to detect the increase of these problems or secondary
level investigative facilities may be required. Substance abuse especially alcoholism, which
appeared to be major health and social prob'em have lesser priority in the literature. This may
relate to the type of literature accessed as Indian Urban Health literature was sparse. For the
same reason the more recent developmental programmes and seemingly pro-poor policies could
not be adequately assessed for their scope.
The Literature survey outcome presented below will need to be related to within this limitation.
4.2
Focus on Urban Health
4.2.1 Evolution of Interest
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Trudy Harpham and Carolyn Stephens (1992, p. 111-120) traces the interest in urban health to
the late Seventies. The Alma Ata Declaration of Primary Health Care popularised the
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multidimensional multisectoral causation of health/ill health. This was seen mainly in the
context of rural health where most of the people of the Third World lived, and Urban areas
were thought to be already well served by the curative institutions present there. The seminal
paper published by W.H.O. and U.N.I.C.E.F. and authored by Alessandro Rossi- Espagnet,
drew attention to the health problems of the urban poor by stressing two arguments-one the
rapid urbanisation process that is going on in the Third World countries and two the rapid
growth of tlie numbers of urban poor and the inequalities in need that was becoming a reality.
This spurred interest in urban health p’ 'blems and urban health care. In the succeeding decades
considerable research and writings have resulted in this area.
4.2.2 Disaggragated Data on Urban Poor
D.R. Phillips (1993, p. 93-107) analysing the Third World trends in urbanisation and health
states that there is considerable disparity between the health of the urban poor and their richer
counterparts though the lack of disaggragated collection of statistics may not show it His paper
introduces the idea of'Epidemiological transition' that the urbanising Third World societies go
through-that there are progressive stages with corresponding epidemiological picture. While
life expectancy might be higher in many urbanised countries, the morbidity has not changed,
the inhabitants are suffering from different forms of ill health chronic and degenerative rather
than infective. In the more underdeveloped of the Third World countries there may be a double
burden of diseases both the infective type and the chronic and degenerative type. These
conclusions appear to be drawn from macro level data and the connections between ill health
and intermediate variables operating at micro levels are not brought out
T. Harpham and C. Stephens (1991) lists several studies that shed light on intra urban health
differentials in Third World countries and states that the main picture that emerges is the link
between poverty and mortality, without reference to intermediate variables. Difficulties also
arise due to the differing categorisation of causes of death used in different countries.
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4.3
Aetiology of Ill health
4.3.1 Multiple Aetiology of Disease
Caimcross, Hardoy, and Satterthwaite (1990) argue that the links between housing in the
broader context (which includes the physical structure, the environment around it, the location
and the infrastructure and services provided) and health for the urban poor has been ignored for
various reasons. Engineers and architects have concentrated on the physical aspects of housing
related to norms and legal requirements and ignored the health outcomes as these were not
clearly defined, though vaguely perceived. Traditionally research related to health outcomes
were carried out by health professionals, who focused on Epidemiology and Biological factors.
Policy recommendations arising out of such research stressed, health care solutions. With the
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popular acceptance of multisectoral causation of health the links between these aspects began
to be explored. The recent trend towards 'Selective Primary Health Care' according to the
authors is the same old medical orientation, which excludes aspects such as water, sanitation
and housing.
4.3.2 A Classification of Multiple Aetiology
They present a systematic classification of the factors causing health problems of the urban
poor, which is reproduced in summary form below.
BACKGROUND
INTERMEDIARY
FACTORS
UNDERLYING
FACTORS
FACTORS
1 The strength and
1 Physical / Environmental -including
1 Knowledge of health
prosperity of the
characteristics of the house (e.g..
enhancing behaviour at
national economy.
amount of space, physical materials)
2 National society
political structure,
and the workplace (including quality of
the individual/household
level.
indoor environment and the degree of
2 Knowledge of health
laws and the ways and
protection from injury by machines,
enhancing behaviour at
means by which they
toxic chemicals etc.) characteristics of
community level and
are enforced.
the house site (e.g.. risk of flooding,
level of community
3 Distribution of
landslide or other natural disaster) and
organisation.
income and capital
location especially in relation to health
3 Use made of health
assets within the
services.
2 Infrastructure and service provision
care system and other
quality and quantity of water, provision
facilities.
society.
These set the context
for sanitation and drainage, garbage
for any individual's
disposal, health care, emergency
possibility of obtaining
services, public transport, etc.
adequate income and
3 Socio-economic characteristics of the
the possibilities for
government to provide
person concerned-diet, income and kind
of work, time available to cook
infrastructure and
nutritious food, take care of children, to
services.
improve housing and other health
promoting activities. Also legal status
and location within society which
influences whether help can be got in a
public services and
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crisis.
4 Age and gender -in relation to certain
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specific health problems.
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4.4
Macro Level Factors
4.4.1 Poor Economy
When the macro level 'background factors' in the above scheme are looked at, common for
most Third World countries is the poor strength of their economies and the bleakness of the
future of these economies. The world market is unfairly acting for them, the real value of the
primary commodities produced by them continue to diminish and cost of manufactured items
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and technologies continue to rise. This trend does not promise any improvement as far as the
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resources allocated by the governments or trained personnel available or technologies for urban
infrastructure and services development for the poor. Economic prosperity also partly
determines the income of the poor, though the distribution of wealth plays an important role.
Nurul Amin (1992, p. 119-130) argues from a market economy perspective that, the Third
World nations have uncritically adopted Western nonns, standards and legal statutes pertaining
to urbanisation and the urban poor or the 'Informal Sector', that is impractical. The
urbanisation process in these countries are happening in the midst of great paucity of resources
unlike the situation that existed in the West.
In the Housing sector most of the housing structures of the poor are below the standard and
hence illegal. In the Economic sector access to credit and services provided by the state is
!
blocked from the urban poor, due to the requirements of documents on permanent registration
or the need for collaterals etc. Proactive policies and programmes to support the self employed
economic initiative of the poor are conspicuously absent, and what is present is harassment of
various sorts. Amin argues that in the resource starved Third World countries where the
governments are unable to provide the required infrastructural, institutional and service
facilities, the broad macro level or the 'market' needs to be broadened to include the urban
poor.
4.4.2 Macro Level: Situation in India
Kirtee Shah (1990) states that in India the urban economy is characterised by the inability of the
formal wage sector to expand fast enough to absorb the increasing labour force resulting in the
expansion of the non wage and informal sector. The share of actual consumption of the lowest
thirty percent of the urban population has remained at the same level over the years.
The urban growth in India has taken place in an unbalanced fashion, with the metropolises
growing the fastest. The macro economic policies (Ravindran, 1990) further reinforced this
concentration. Major cities receive a disproportionately larger share of the total national
expenditure on education, subsidies for water power, transport etc.
Frank Jan Borst (1989) chronicles the evolution of policies relating to the urban poor in India.
Before the Seventies the approach to the housing needs of the poor was the 'Slum Clearance'
and relocating them in multistoried tenements. Some of the ideological attitude underlying was
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that slums are eyesores and source of infection and ill health to the rest of the urban populace,
4
slum dwellers do not have a class consciousness and are incapable of producing solutions and
hence it must be done for them. However the Slum Clearance Policy was not successful in the
context of the grossly insufficient allocation of resources for this purpose, and the mismatch of
the constructed tenements to the social habits and preferences of the beneficiaries and their
economic conditions.
Failure of this policy and the rapidly increasing numbers of the urban poor, and the influences
of John F.C. Turner's ideas of 'self help housing' the new policy of 'Slum Improvement'
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came into being. The programmes have the goal of providing the basic infrastructure and
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services for maintenance and a minimal level of land tenure ship. This approach has met with
mixed results, as it has resulted in problems such as the poor being pushed out of sites they
have helped to develop as the price of land started skyrocketing.
The theoretical underpinnings of this policy have been questioned by Neo-Marxist thinkers and
academics. They claim that this is a means for strengthening the capitabst system by the cheap
cost of reproduction of the labour, incorporation of the 'petty commodity production '(the
informal housing) into the capitalist market Whereas the problems of the urban poor stem from
the operation of the capitalist economic system.
In the late Eighties a more comprehensive policy is emerging based on the recommendations of
the National Commission on Urbanisation (1988).
4.5
Meso Level Factors
4.5.1 Housing and Health
Several case studies done in the recent decade bring out this link clearly. The health of the
inhabitants are affected as the slums are located in environmentally poor locations. Frank Jan
Borst (1989) states that about sixty five percent of the slums in the major metropolises of India
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are located in government property, but inhospitable due to being prone to flooding, or
degraded from environmental reasons. The main reason for this fact being that there is less
chance of eviction and hence the greater de facto tenure ship it provides. There is some degree
of variation in this proportion of slums on government or private property based on the history
and the availability of land in the major metropolises.
A Case Study
In a detailed study of three slums in the city of Allahabad in the state of Uttar Pradesh,
H.N. Mishra (1990) and team could identify the following. Over two-thirds of the cities
households live in one roomed flats or shacks. In one of the slums studied (Cheetpur) the
household income for the majority of families was below $200 a year (about Rs. 6000). Forty
percent of the households live in one room, with another forty four percent living in two
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rooms. Half of all households have less than two square meters area per person. The main
source of water was a well which was frequently contaminated and one public stand pipe for
the 500 odd people. There was no drainage, no public or private latrines resulting in open air
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defaecation. Problems of hygiene were confounded by the fact that animals were kept by the
households within the rooms. There were two electric poles from which illegal connections had
been taken. The school provisions were inadequate.
The health situation was deplorable. Anaemia was quite common, sixty percent of the
population had the skin infection scabies, fifty percent had worm infestation by stool test
Dietary survey revealed, that most of the population had a dietary intake of less than 1500
calories-less than the minimum required. Among the 143 children's death recorded in the
period 1970-84, all were due to infections and accidents. Of these 143 deaths 73 died as infants
before reaching one year of age, all from infective causes.
They conclude that though it is difficult to attribute precise reasons for the health conditions,
the inadequate provision of water which was exposed to contamination, lack of provision of
hygienic disposal of waste and the very low incomes and hence poor food intake were the
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important factors as well as the lack of emergency and life saving services.
Goldstein (1990) associates three factors of housing as causally resulting in health problems:
the site of the settlement, the physical environment, and the social environment. They are
interrelated and there importance varies from settlement to settlement
Dangerous land site and the overburdening of the capacity of the site by dense settlement of
crammed houses increase the risk of drowning, falls, burns, cuts, bites and accidental
poisoning.
The environment in and around housing offers a range of habitat that is exploited by arthropod
pests and vectors of diseases (Schofield, et al., 1990). The pests include flies, mosquitoes,
cockroaches, bedbugs, ticks and mites which cause several infectious and parasitic diseases.
Designers and builders pay attention to only those aspects of construction that have a bearing
on the structural integrity of the houses. Good design and appropriate materials can reduce the
risk of pest infestations.
A third aspect of vulnerability exist, which can not be attributed to poor housing or
environmental conditions directly, but to the social environment, namely: social deviance,
criminal behaviour and mental illness.
Several problems are noticeable in the housing sector which point to governmental inaction and
inappropriate responses ( Schofield, et al., 1990; Knudsen & Slooff, 1992).
Lack of assurance of security of tenure which is important for individual and
community participation in building and maintenance of the immediate
environments.
Poor access to institutional credits and training for house construction
Lack of promotion of low cost indigenous housing and low
cost house improvements which can limit vector borne diseases.
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4.5.2 Safe Water and Health
Sandy Caimcross (1990) states that in 1985 midway through the decade of stress on water and
sanitation in the Eighties, more than 300 million people in the Third World did not have access
to safe water, and another sizeable number was underserved. They depended on contaminated
surface water for their needs. The importance of quality of safe water is well understood, but in
this context the quantity is even more important The author points out that a review of over 70
research studies done by Esrey & Habicht in 1986 on the relationship of water and health
concluded that quantity of water was equally important. Insufficient quantity of safe water is
linked to the endemicity of diarrhoeal diseases which takes a high toll through infant and child
deaths, whereas contamination of protected water which is more sporadic results in epidemics
of Cholera, Typhoid etc. Insufficient quantity is also associated with various skin and eye
infections. The following table referred to by Sinnatamby (1990) expresses the importance of
availability of water clearly:
Typical effects of improved water supply and sanitation on diarrhoeal morbidity.
Condition
Median reduction in diarrhoeal morbidity (percent)
Improved water quality
16
Improved water availability
25
Improved water quality and availability
37
Improved excreta disposal
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(Source: Esrey et al, 1985)
Consumption of water is related significantly to the nearness of water source, and rises from
below 20 litres per capita daily to a more appropriate level of around 60 litres per capita per day
as the source is brought to within 100 metres of residence. As a rule in Third World countries
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the authorities are not able to meet the consumers demand for water and hence have to resort to
intermittent supply of water. Those who are least served are the poorest, who must then buy it
from waterless, as this is an indispensable commodity. She quoted studies to show (Briscoe,
1985) that twenty to thirty percent of the urban poor buy water at an enormous price of about
one-fifth of their daily earnings. This cost goes up higher as the sources become scarcer.
4.5.3 Facilities for Sanitation^ Drainage and Health
It is essential for human health to remove safely and regularly the waste materials, both solid
and liquid produced in the household, as well as drain the surface water that collects in human
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habitations. The health related outcomes come from, contamination of food, water sources and
the immediate living environment by pathogens ,causing various infections and illnesses. They
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commonly cause gut infections, skin infections, various vector borne infections such as
malaria, filaria and schistosomiasis.
Gehan Sinnatamby (1990) opines that more than two billion people-about sixty percent of the
Third World population have no access to sanitation. As most of the urban poor live in
informal or illegal settlements, less than sixteen percent have any access to sanitation, which
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could be much worse in particular slums.
In the Dharawi slum area in Bombay (Borst, 1989) there was approximately one toilet for over
300 people and one public tap for every 320 people. Even in improved slum areas the amenities
could be quite deficient according to the same author. As the tenements of the urban poor are
located in inhospitable terrain and are also illegal, they have greater need for sanitation and
drainage but little chance of obtaining it
Trudy Harpham and Carolyn Stephens (1991) listing studies linking health outcomes and
causative factors among the urban poor, (though there is a paucity of such studies) shows that
there were direct causal relationship found between, availability of safe water, sanitation
facilities and quality of dwellings and the infant and child mortality, in the different countries of
the Third World where the studies came from. There was a significantly high correlation in
some studies, between mother’s education and infant mortality.
4.5.4 Urban Health Services
The Urban Health Services did not come up for critical scrutiny for long time as the assumption
was that as a large share of the health care resources are already concentrated in the urban
areas, the services are adequate. As mentioned earlier attention began to get focused on the
deficiencies in the existing system internationally from the 80's, when W.H.O. stressed this
area (Harpham & Stephens, 1992).
According to World Health Statistics Quarterly (1991, p. 234) it is now widely accepted that
P.H.C.-approach offers the best possibility of solutions given the complexity and
multidimensional aspects of the health problems of the urban poor.
The problems in tinkering with the existing sectoral health programmes to make them into
effective primary health care programmes, are multifold. Among the constraints faced in the
urban poor areas are:
the heterogeneity of communities, widespread individualism and a low sense of
collective responsibility.
the difficulty of reaching the poorest groups, i.e. the homeless, jobless and the
street children to name a few.
the difficulty of obtaining voluntary work from people who are struggling for survival
and are crucially dependent on cash incomes.
the multiplicity of agencies resisting co-ordination, opposition from the medical
establishment, politicians and public to the changes in the way resources are allocated.
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the problems faced by the city administration by the scale and tempo of urbanisation
(World Health Statistics Quarterly, 1991).
As a result the distribution, availability and utilisation of health facilities and services are not
related to the population distribution and the needs. Paradoxically health units located in the
periphery, closer to the poor communities are under-utilised and bypassed as the facilities are
poor and understaffed. Whereas the centrally located facilities are overcrowded and improperly
utilised. There are large groups of the poor who are underserved and have accessibility
problems (World Health Statistical Quarterly, 1991).
In India two different approaches are developing simultaneously to address the deficiencies in
urban health care (Harpham & Stephens, 1992). In the slum improvement / slum development
approach, the health services are integrated with other services and supports under one
umbrella. In the second type the unisectoral approach the effort has been to strengthen the
primary health care services, with the important policy recommendations given by the
'Krishnan Committee', in the early 80's. The recommendations specified the structure and
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staffing pattern of the revamped services which were to be located in the slum itself. However
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the scheme was not implemented by most Municipalities, partly because other components for
an effective delivery system were not addressed and partly because sufficient funds were not
allocated by the central government
In Greater Bombay Municipality which did implement the scheme, the effectiveness was found
to be unsatisfactory as outreach work was not done by the health post staff who were diverted
for other work. The poor people continued to use the hospitals for minor ailments and thus
continued to over use the facilities (Harpham & Stephens, 1992).
4.5.5 Urban Pollution
The major problem of pollution in urban areas is that of air pollution. The major contributors
and their relative importance varies from city to city. In cities with high concentration of
industries, they are the major contributors through the chemicals released into the air. The
burning of high sulphur fuels such as coal or oils by industries and the domestic burning of
wood or coal also contributes. The exhaust gases from poorly maintained motor vehicle
engines, the high levels of lead in the petrol together with the congested streets, contribute
significantly to urban pollution (World Health Statistics Quarterly, 1991).
High levels of air pollution have been linked to high incidence of Bronchitis, Asthma and
Pneumonia.
The industries contribute to the pollution of local water sources by the discharge of untreated
effluents into open sewers. Water sources are also polluted by poorly managed waste dumps
(Our Common Future, 1987).
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In most instances there is little or no incentive for industry to cut down on polluting emissions
or effluents, as there is inadequate monitoring and penalising mechanisms for pollution control
(World Health Statistics Quarterly, 1991).
4.6
Local Level Factors
4.6.1 Supportive Community Dynamics
Research suggests that 'social support' may directly enhance health regardless of stress level
and protect people from negative consequences of stressful situations. Communities where
members provide one another with various forms of support such as emotional support,
instrumental support (tangible aid and services), informational support and appraisal support
(feedback, affirmation, social comparison) would be at less risk of negative effects of stress
than in communities where mutual support does not exist (Israel, 1994).
Several constraints to the development of supportive dynamics among the urban poor
communities have been suggested by authors. Hall has proposed a model that includes several
aspects related to the community and some outside of the community (Borst, 1989):
The environment, natural and built- community feeling and solidarity develop easier,
when there is distinct physical and psychological boundaries.
Heterogeneous population- when there is heterogeneity due to class and cultural and
linguistic differences residents are less likely to invest time in community activities.
Resident's perception- traditional links with community of origin are considered to be
more important than the links with present neighbourhood.
Social and economic interactions- functional areas (geographic) may be present with
social and economic interactions which can facilitate community networks.
Local leadership:
Non existent or competing local leadership can be a constraint. Community
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development may be contrary to the interests of the slum leaders as it will disturb the
existing dependency relationship.
Conflicting goals of existing Voluntary Associations may
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come in the way of community coming together.
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Suitable premises- availability of central focus points strengthen the community feeling
by giving the population a physical means to interact.
Established local politicians and beaurocrats outside of the community- community
building is not in the interest of local politicians and government officials all top often,
who benefit from the existing dependency relationship and the axis with the slum leader
and hence will oppose in diverse ways.
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The Macro environment- the attitude of the larger environment such as the State,
Agencies with interest in the slum or of the population in the better of neighbourhoods
have an influence on the community dynamics.
The negative role played by slum leaders and the consequences of the axis with
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politicians and beaurocrats have been quoted as a particular impediment to community
building (Borst, 1989; Asthana, 1994).
4.6.2 The Family and Urban Poverty
The family structure breaks down in the face of the risks, pressures and deprivations of urban
poverty (Lepore et al., 1991). The consequences are gravest for women and children and are
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being recorded to be a major problem. The following excerpt is illustrative (World Health
Statistics Quarterly, 1991, p. 205-206).
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A significant proportion of urban households are headed by women without family or social
support. Many have to seek employment to support the family and are confined to low income
occupations with long working hours resulting in the younger children being deprived of care
and protection. They also run a persistent risk of pregnancy in their search for male support,
are often malnourished, exposed to mental stress, sexual harassment and abuse.
Children-the urban environment is particularly hostile to children due to lack of parental
supervision or abandonment, early childhood labour and other consequences of urban poverty.
The number of street children have grown and the circumstances in which they live seriously
jeopardise their health, safety and moral welfare. Estimated to number about 80 million the
abandoned children suffer inevitably the consequences of lack of sanitation, clean water,
occupational accidents, sexually transmitted diseases, drug abuse, crime and a deep sense of
insecurity and emotional conflict. Sexual exploitation is another serious problem, with
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thousands of young girls and boys as young as twelve years having been sold into prostitution,
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child pornography and drug trafficking (World Health Statistics Quarterly, 1991).
4.7
Theories of Social Change and Health of the Poor
Public Health has contributed to interest in the term Empowerment, with the recognition of
powerlessness as a broad risk factor for disease, and, consequently, empowerment as a health
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enhancing strategy... Community empowerment is defined as a social action process in which
individuals and groups act to gain mastery over their lives in the context of changing their
social and political environment’ (Wallerstein & Bernstein, 1994, p.142).
Referring to the Brazilian educator Paulo Freire, the authors say that he advocates a
participatory education process in which people are not objects or recipients of political and
educational projects, but actors in history, able to name their problems and their solutions to
transiorm themselves in the process of changing oppressive circumstances. According to Freire
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Community Empowerment starts when people listen to each other, engage in participatory /
liberatory dialogue, identify tlieir commonalities and construct new strategies for change.
Labonte (1994) clarifies empowering professional and institutional health promotion practices.
He offers an empowerment model for concerned professionals and institutions, consisting of
five levels: personal care, group development, community organisation, coalition advocacy and
political action. Capacity needs to be built at all the five levels. He cautions on the difference
between the understanding of empowerment for the professionals and that for the community,
both of which are separate. Professionals and professional institutions can aid up to a point, by
helping to make the oppressive structures more amenable and sensitive to the organised
demands of the disadvantaged communities.
In the context of the multiplying problems of powerlessness of the urban poor to influence their
environment, the critical ideas from theory point to -community empowerment and linkage to
policy and political solutions that decrease health and socio-economic inequities.
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5
Implications and Requirements
5.1.
International Experience
International experiences in Third World countries in reversing the rural urban migration trends
have been equivocal. Most developing countries governments have been concerned about the
consequences of the rapid growth of their cities. Concern has been expressed for the
overloaded public services, inadequate social infrastructure, environmental degradation and the
large resources needed to deal with the problem (U.N. document, 1991).
There are several implications to the multidimensional causation of the Third World urban
problems in which the low health status of the urban poor is one outcome. The health problems
cannot be seen in isolation and solutions have to be found at multiple levels. Health
professionals cannot rigidly draw the line on what constitutes their responsibility, as it is
necessary to have a broad perspective of the framework in which better solutions can be found.
Actors at different levels of influence in the nation, need to be involved and develop effective
co-ordination with each other.
Several researchers and lobbyists (Hardoy & Satterthwaite, 1990; Shah, 1990; Amin, 1992)
suggests that though there are reasons to be pessimistic about the future of Third World cities
and towns, there are positive trends that need to be supported.
Looking at the Indian situation certain actions need urgent attention, which are listed below.
5.2
Macro Level
5.2.1 Balanced Urbanisation
Concerted efforts need to be made by those responsible in the government such as the Ministry
of Urban Development and the Planning Commission to decelerate the trend towards rapid
unplanned urbanisation and rapid growth of metropolitan and large cities. A comprehensive
policy that corrects regional and city imbalances need to be implemented
5
Though the fifth five year plan documents onwards spoke of need for balanced urbanisation
process, concrete actions did not result. The assumptions appeared to be that by tackling rural
poverty would take care of urban poverty. However there is now a recognition that both need
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to be addressed with sufficient emphasis and vigour.
The National Commission on Urbanisation’s policy guidelines (Rebeiro, 1990) have set a
comprehensive policy perspective, on the urbanisation process in the country and have specific
recommendations. The Commission recommends that future strategy for urbanisation in India
must ensure adequate investment in selected growth centres and regions, so that they develop
self sustaining economic growth and offer avenues for employment to the surplus population
of not only surrounding villages, but also nearby towns which are stagnating. Commission has
assessed that at least Rs. 30 billion would be required to achieve this in the Sth plan period.
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Approximately 329 cities or generators of economic momentum (GEMS) have been identified
by the commission based on physical location, availability of water and energy and
transportation. Similarly 49 Spatial priority urbanisation regions (SPURS) have been identified
covering the whole country, and cutting across state boundaries.
Political leaders at the national level and policy makers and implementors in the urban
development ministry, need to act with vision and determination recognising that the drift have
been allowed to go along for too long.
5.2.2 Attitudinal Change towards Urban Poor
There needs to be an attitudinal change towards the urban poor from the different segments of
the society.
There needs to be a recognition by the decision makers, policy makers and political forces that
wield power in the Egalitarian society, that the two faces of urban life -one of vast luxury and
the other of extreme misery, need to be changed. Economic reasons dictate that the nation
should get the full benefit from the productive potential of this segment of the population.
Political alignments beginning to take shape at the national level suggests that the poor are
starting to articulate their needs increasingly.
The economic contributions of the urban poor need to be recognised for its full extent and
value, and supported concretely. It needs to be recognised that it is the lowly paid efforts of the
urban poor -the unskilled construction workers, city cleaners, contract labourers in industry
and commercial establishments or self employed foot path vendors or the multitude of self
employed petty manufacturers in the slums, that contribute to the wealth of the towns and cities
and determine the direction of their growth. They need to be enabled to share in the benefits
and the quality of life that are available in urban life.
It needs to be recognised that slums are the result of the unaided effort of the poor (not
supported by the government or the private sector), to find creative solutions to the urban
housing crisis. Hence their energies, initiatives and entrepreneurship need to be supported by
the government. At the same time it need to be ensured that conditions for the health of the poor
and the rest of the urban population is safeguarded. This calls for enabling statutes, policies
and legal provisions that provides access for the poor to -resources, technology, information,
skills and protection, both in the housing sector and for productive economic activity.
Explaining further such measures include, protection from exploitation in the informal labour
market, access to credit, loans, skill training and provision of facilities for informal
entrepreneurship. Proportion of newly developed urban areas need to be assigned for
economically weaker sections, so that they are protected from the skyrocketing urban land
market. Standards for house construction and facilities need to be made relevant and
appropriate to the needs of the poor. Such actions are in contrast to the present situation which
is one of denial of access through ill conceived norms, statutes and standards. Official
perception of the urban poor sec them as wrongdoers and lead to harassment, not to speak of
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the violent governmental actions, such as slum demolitions without providing suitable
alternatives.
5.2.3 Programmes for the Urban Poor
The national government needs to invest sufficient resources, for development of housing,
infrastructure and services.
The resources allocated need to be sufficiently large taking into account that 30%-50%
urbanites in many of the cities are the poor. In raising the resources creative use of legislations
like 'The Urban Land Ceiling Act’, and allotting of unutilised land already in government's
possession under different departments needs to be done.
The planning of these investments should be done carefully, so as to address real priorities,
rather than being frittered away in elite projects as has often happened in the past Providing of
tenurial rights and the essential infrastructure for a healthy environment are important issues in
this context
The National Commission on Urbanisation has presented to the government in 1988 (Shah,
1990) "a 13 point programme package titled the 'New Deal for the Urban Poor', aimed at
improving the income and consumption levels of the urban poor. The programmes aim at
extending the access of the poor to basic environmental and social services, ensuring better
utilisation and suggestions for changes in the legal, institutional and administrative set-up for
effective delivery. The programme package is estimated to cost Rs. 10,75 billions, over a five
year period. The programme is expected to bring income and employment benefits to 4.4
million families and 6.3 million families are expected to receive multiple service benefits."
5.3
The Meso Level
5.3.1 Programmes and Services
The Urban Development Ministry need to encourage low cost and appropriate technologies in
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provision of infrastructure.
The programmes developed need to be directed at low cost solutions for the housing and
infrastructural needs of the poor, eliciting their participation in the need assessment, planning,
implementation and monitoring of the implementation. In such a context there is greater
possibility of solutions that are appropriate and sustainable. Solutions are culturally appropriate
which takes into account, the cultural and lifestyle preferences of the people. They are
sustainable which builds upon local technology and available materials, upgrading the
technology where necessary. This would also give an impetus to related local cottage industries
and increasing employment potential.
Several studies in the past two decades have brought out the feasibility of using local
technology and locally available materials for house construction, with appropriate measures to
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take care of the disease producing agents that are prevalent with tropical conditions. Much
innovative work has also been done in the area of low cost sanitation, latrines, sewerage
systems and solid waste removal technologies, which are culturally appropriate and have
community building dimensions. Importantly such low cost programmes have also
demonstrated cost recovery. The community can be trained and enabled to maintain these
services-which is a much better situation than depending solely on inefficient, beaurocratic
government machinery.
The programmes need to be comprehensive, which includes not only the housing and
infrastructural aspects, but also services and community organisation and participation.
5.3.2 Devolution of Authority
The state level Urban Development Ministry Departments needs to devolve effective authority
to Urban . ocal Bodies and Community Institutions.
The Urban Local Bodies over the decades have become stunted and weak due to lack of
decentralisation at the state level (Mohan, 1990). They lack in resources, trained personnel and
prestige. The funds have tended to be devolved on an ad hoc basis, while the centralised
agencies took over more and more of the functions, several of such bodies lack representative
leadership. However these institutions have the responsibility for the creation and maintenance
of infrastructure and services. These Bodies need to be strengthened through elected
leadership, devolution of powers and finances, as well as need to raise additional finances
creatively. They also need to revamp the archaic and unsuitable norms and standards that
prevent poor people access to their resources and services.
They need to work in close collaboration with local community institutions, who can represent
each individual's need. At the moment by and large local community organisations are non
existent or are non representative.
5.3.3
lealth Care Services
The Mi ' try of Health needs to ensure that the organisation and implementation of Health
Services for the Urban Poor is based on the principles of Primary Health Care.
There is need for a system of collecting health data that is specific for the urban poor and which
is disaggragated from the general urban health data, so that health care need identification and
monitoring of the programmes can be effective.
The health service needs to give emphasis to preventive and promotive health aspects as well as
to a credible curative service. A large proportion of the health problems of the urban poor
require preventive and promotive interventions.
An effective system would incorporate community participation through 'health
volunteers/health committees' and appropriately trained primary health care staff, supported by
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sufficient resources of'rational drugs' and appropriate m dical technology.
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The referral system for responding to complicated problems needs to work. Health care
institutions particularly in the Voluntary Sector have much to contribute to the city’s referral
network. The whole system need to be accountable to the poor communities.
5.3,4 Educational Services
The educational services of the Ministry of Education needs to be flexible and need oriented.
They need to take into account the employed status of the children, employment oriented
practical skills and lack of interest of the poor in purely academic education.
5,3.5 Reorienting Officials
The ministry of Urban Development and the various institutes for urban studies along with
their State counterparts need to bring about a reorientation of the officials concerned with urban
programmes.
There is need for reorienting the concerned officials at the municipal regional and national
levels, to become sensitive to local realities and problems, peoples cultural preferences, their
initiative and creativity and the feasibility of indigenous appropriate technologies. Their
academic training in approaches and technologies applicable for conditions elsewhere, are not
suited often for solving the escalating problems of the urban poor.
Different method of functioning is called for, which is multisectoral and integrated, where the
various programmes are co-ordinated under one Body.
5,4
Empowerment Process and Partnership with Non Governmental
Organisations (N.G.O.’s)
The Ministry of Urban Development along with the other concerned bodies and State
Departments need to recognise that the ultimate goal of development is empowerment.
Active community participation and devolution of powers regarding decisions on resources to
the community, are two essential ingredients for the success and sustainability of programmes.
Governmental programmes historically have not had much success in engendering positive
community dynamics, developing constructive leadership or community participation. Theories
of Community Organisation and Empowerment, make it clear that it is a process that has to be
enabled and nurtured, based on democratic principles. Even the weakest segments in the
society need to be enabled to express their needs, and to take actions themselves, within their
boundaries to change the dehumanising conditions. N.G.O.’s working for non-profit motives,
at the micro level, have demonstrated their effectiveness in being facilitators and agents of
change. They have also developed with the community's participation, creative and appropriate
technologies, management practices and participative monitoring and evaluation procedures.
Hence for effective development and running of the programmes, a tripartite partnership
consisting of peoples organisations, credible local N.G.O.’s and government agencies is
35
favoured. The goal being eventually the peoples organisations will take over the responsibility
for the development of the community and the resources and supports will be provided by the
government.
The Structural Adjustment Policy of the international financial institutions advocate
'Privatisation'. In developing infrastructure and services for the poor privatisation may not be
appropriate uniformly, but would be useful in selective situations (Caimcross et al., 1991).
'Privatisation of natural monopolies such as piped water, sewers and drains, presents
governments with special problems, since there are no competitive pressures to help keep
down price and encourage improved quality. Allowing private enterprises to provide certain
services which are provided inadequately or not at all by local government is worth
considering, especially if the services are not natural monopolies.'
However involvement of N.G.O.'s in this context can be quite appropriate as they have the
capacity to provide quality service at low cost
5.5
Urban Basic Services for the Poor (U.B.S.P.)- a Model
Ministry of Urban Development needs to vigorously implement U.B.S.P. and credible
N.G.O. 's need to actively participate in critiquing and implementing this programme.
A positive event in India is that as an outcome of the recommendations of the National
Commission on Urbanisation (1988) and some successful urban experiments, a comprehensive
and multisectoral nation-wide programme is evolving with the participation also of
U.N.I.C.E.F. The Urban Community Development Projects (U.C.D.'s) with bilateral support
also have a comprehensive approach. They are a small step in addressing the urgent needs of
the poor through a programme. Political support for larger commitment of resources and
development of enlightened leadership at the different levels including the local level are
essential for the success of the programme.
5.6
Individual / Neighbourhood level
At the individual/neighbourhood (small community level), several needs have to be addressed
This is best done by the organisations of the poor themselves with facilitatory help from the
Government programmes and concerned N.G.O.'s.
Awareness of the individuals and neighbourhoods of the multidimensional causation of disease
and how they operate in their situation need to be enhanced.
Knowledge and skills relating to preventive/promotive aspects of health, within the individual's
control such as: personal hygiene, immunisations, balanced diet, injurious habits, appropriate
care of the children and the ill and reproductive health, to name the important areas need to be
enhanced.
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Knowledge and skills relating to developing and sustaining community initiatives for
improving environment and accessing resources (governmental and others) and developing
autonomy needs to be fostered..
An important issue to be addressed is the status of women, through development of women’s
organisations, raising the economic power of women and enhancing their access to resources.
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6
Summary
There is a very large problem among the Third World urban poor, regarding health and quality
of life. Research is deficient in this area. The magnitude of the problems were not anticipated
until less than two decades ago.
At the macro level, the international economic order and the particular economic situation of a
country have a direct bearing on the process of urbanisation in a Third World country. This
factor compounds the migration pressures generated by the economic activity in urban centres.
India, like most other Third World countries, has not been successful by and large in planning
for or allocating adequate resources to take care of magnitude of needs of the growing urban
populations. Proactive measures to produce a balanced growth of urbanisation have been
missing. One surprising result is the virtual lacuna, of policies and programmes specifically
meant for addressing the needs of urban poor.
At the meso level in India, the functioning of the various institutions, infrastructure and
programmes in relation to urban poor, are not suited to produce the best results. Whereas a
participatory, intersectoral and well co-ordinated approach with flexibility to incorporate
innovative experience is required, the present efforts often end up with little meaningful results
for the poor.
At the micro level of local communities, various forms of division are inherent as result of the
process by which urban communities came into being. The dynamics resulting from the self
interest of local politicians, beaurocracy and other vested interests, further deepen this division.
The multiple levels of aetiological factors cause a complex situation of poverty and deprivation
and health contingencies, which were studied by qualitative methods in several slums in the
metropolis of Bangalore. These findings are presented.
Literature survey of Indian and Third World country experiences show a more or less common
pattern of aetiologic factors and outcome results-deprivations of different kind.
The recommendations focus on macro level actors, the state and the beaurocracy, intermediate
actors namely institutions and non governmental organisations, and at the micro level the urban
poor themselves. The urban poor have demonstrated considerable innovativeness and tenacious
energy. Determined efforts from all sectors are needed in the face of this calamity that is already
upon us.
i
38
7
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40
Appendix
AVERAGE ANNUAL URBAN GROWTH RATE, LESS DEVELOPED REGIONS
AND MORE DEVELOPED REGIONS, 1970-1975 TO 2020-2025
TAUX ANNUEL MOYEN DE LA CRO1SSANCE URBAINE DANS LES REGIONS MOINS DEVELOPPEES
ET DANS LES REGIONS PLUS DEVELOPPEES, DE 1970-1975 A 2020-2025
5
4
a>
O)
co
§ 3-
Ȥ
& 2
s
1
®
1 i
0
1970 - 1975
1985 - 1990
1995 - 2000
2020 - 2025
Years — Annees
More developed regions - Regions plus developpees
Less developed regions - Regions moins developpees
Wld hlth statist, quart.. 44 (1991)
1
Urbanisation and Health
Input for meeting with Dr. Ravi Narayan, Society for
Community Health Awareness, Research and
Action (Sochara), Bangalore, PHM India
09. September 2008
m>
medico international
Urbanisation - Trends
•
The majority of people in the world (3.3 bn., UNFPA) are living today
in urban areas
•
Since 1950 the urban world population has more than quadrupled.
•
It will increase further to 5 bn. people until 2030, most of the growth
taking place in smaller cities.
•
Whereas Africa and Asia are the least urbanized continents in
relative terms their urban population will grow by nearly 1.5 bn.
people between 2005 and 2030.
•
This growth is not paralleled by an increase in employment
opportunities in the formal sector, especially not in sub-Saharan
Africa; a development being described as urbanisation of poverty:
•
One third of the urban population in the world lives in slums or
informal settlements that dont meet basic infrastructure necessities
l
1
Urbanisation - International Events and Actors
•
•
•
•
•
•
•
•
•
1976, 1996 United Nations Conference on Human Settlement, Habitat 1
&2
1978: United Nations Centre for Human Settlements (UNCHS)
1987: World Commission on Environment and Development (WCED),
report ‘Our Common Future’, also known as the Brundtland Report
2002: UNCHS transformed to United Nations Human Settlements
Programme (UN-Habitat) under the UN Economic and Social Council
(ECOSOC)
2002: World Urban Forum (WUF), a biennial gathering open to all
partners of the Habitat Agenda including local authorities, non-profit and
for-profit organizations
2004 United Cities and Local Governments (UCLG), local authority
network
2005: WHO Commission on Social Determinants of Health - Knowledge
Network on Urban Settings (KNUS)
2005 African Ministerial Conference on Housing and Urban Development
(AMCHUD)
2007 UNFPA report ‘State of the World Population 2007’ emphasize the
people’s right to live in the city as well as the opportunities of urban
growth
Selforganizing Initiatives
• Shack / Slum Dwellers International (SDI), a grassroots
network founded in 1996 representing the interests of
the urban poorwww.sdinet.org
• Brasilien: Movimento Sem-Teto do Centro, (MSTC)
• Sudafrika
2
Multidimensional View of Urban Poverty
• inadequate and often unstable income,
• poor quality, hazardous, overcrowded, and often
insecure housing,
• inadequate provision of basic services (safe water,
sanitation)
• inadequate, unstable or risky asset base,
• inadequate public infrastructure (e.g. transportation)
• inadequate protection of rights through the operation of
law and
• voicelessness and powerlessness within non-responsive
political systems and bureaucratic structures
UN-Habitat, State of the World's Cities Report 2006/7: The Millennium Goals and
Urban Sustainability. Malta: Earthscan, p. 25).
Urbanisation and Health
• Disaggregated data on common health
problems show striking intra-city
inequalities between the wealthy and the
urban poor, who are carrying a double
burden of disease (chronic,
noncommunicable diseases and high
prevalence of infectious diseases).
3
Health Risks of Urban Poor
Shelter deprivation
Malnutrition
Environmental pollution
Traffic
Violence
Climate Change
HIV/AIDS
Katastrophic Health Expenses
Shelter Deprivation
• Poor quality housing: no insolation, no safe heating:
Acute respiratory infections
• Poor Water, Sanitation: waterborne diseases, diarrhoea
• Overcrowding: Spread of infectious diseases, measles,
tuberculosis (In Nairobi, for instance, 60% of the
inhabitants live in 130 informal settlements covering 5%
of the urban area.)
• Hazardous Locations: prone to natural (e.g. flooding,
land slides) and technological (e.g. industrial toxic
pollution, Bhopal) disaster
4
Water and Sanitation
30.0
2S.0
20,0
£
C9
11
E ’M -|S
I
i o.o • -
S.0
aoJ-BHiL
Ga maroon
ESifapia
Kan ya
Ngsria
South .Africa
|b Hutt al B Non-Siutn
Dominican
Rsfsubfe
Eanglaiasi-:
hsSa
Pakistan
Siam |
Fig. 3: Diarrhoea prevalence among children under five years in selected countries according to
settlement type. Source: Own figure, based on UN-Habitat 2006 according to Demographic and Health
Surveys 1995-2003.
Malnutrition
• High food prices in cities
• No space to grow own food
• Unsafe and unhealthy Street food
(microbiological contaminationgastrointestinal infections; dense fatty,
suggar/salt rich -overweight/
diabetes/cardiovascular diseases
5
Income and Nutrition
eac-r-
1
56.0
4<X0
t aao
s.E
20.0
1R0
n
I'll
I
0,0
Cameroon
I
II
Nigeria
Brasil
Dominican
Banglaaesh
Indis
Pakistan
| B Rural BNOT-Slum OSIttm |
Fig. 4: Percentage of malnourished children under five years in selected countries according to
settlement type. Source: Own figure, based on UN-Habitat 2006.
Environmental pollution
• Indoor air pollution: open heating/cooking without proper
ventilation — respiratory infections
• Outdoor air pollution: traffic, industrial
• Industrial contamination of water / soil
6
Traffic
• 1,2 mio. deaths and 50 mio. Injuries
• Poorly planned, overcrowded public transport services
• Insufficient safety controls
• Means of mobility of poor are least protected (walking,
bicycles, rikshas, motorbikes, buses)
• In some cities of the developing world accidents are
already the leading cause of death in the younger age
groups
• Continues to increase because of increasing
motorisation
Violence
• Especially visible in younger age groups.
• In Sao Paulo and Rio de Janeiro mortality rates for the
age group 15-24 showed a continuous decline between
1930 and 1980 before they started to increase again due
to urban violence.
• A comparison of the wealthiest and poorest
neighbourhoods revealed that mortality rates were up to
eleven times higher in the poorest neighborhoods.
• A high prevalence of violence in a neighborhood also
affects the mental and psycho-social well-being of its
residents because of fear, critical life events, and a lack
of control over resources and social support.
7
Climate Change
• Poor neighborhoods are most vulnerable to climate
disaster (floods, hurricans, cyclones) because being
located on steep hill sides (e.g. Vargas, Venezuela), in
poorly drained areas or in low elevation coastal zones
(LECZ), (e.g. Bangladesh)
• Flooding of latrines lead to contaminated water sources
and promote the spread of water-borne diseases.
• Worldwide LECZ cover only 2% of the land area but 13%
of the world urban population an almost 500 million
people, respectively, live there
HIV/AIDS
• Urban poor (expecially young women) have higher
prevalences and are more vulnerable to STDs
• Work migration / traffic routes and corridors
• high unemployment rates and low salaries promote
transactional sexual activity among the urban poor
• Also higher rates of sexual violence
8
Rural-Urban HIV/AIDS Prevalence
35
30
25
■
$ 20
■
8
.ft
i15
10
5
, is ,
Li , Milil ,
Ghana
Sanegal
Cameroon
Shiopia
MSi
■
■■
s
I■
■u 11 L
I
, Mm ,
0
Burkina Faso
■
■
Uganda
Zambia
Zimbabwe
Lesotho
|■Urban PRarai|
Fig. 5: HIV prevalence among 15-49-aged adults in selected countries. Source: Own figure, based on
Demographic and Health Surveys 2001-2006.
Access to Health Care
• Less problems with availability of health
services but with affordability
• Out of pocket payments in private and
public health services are further
aggravating poverty
• 100 Mio. People annually become poor
because of catastrophic health costs
9
Intersectoral challenges for health promotion
• Improving the general and specific
determinants of health
• Making Health services accessible and
affordable for all, particulary the poor
General Challenges
•
•
•
•
•
develop national urban strategies
strengthen local authorities, which need to have the capacities to
manage local problems (need political power, decision-making
capacity and access to revenues based on the wealth generated in
cities)
promote self-reliance and citizen involvement: support of the
informal sector, facilitation of loans to small entrepreneurs, building
cooperatives and neighbourhood associations, provision of tenure to
illegal dwellers and easement of building and housing regulations.
provide better serviced, better-located, legal alternatives to illegal
plots’ as well as advice and technical assistance on how to improve
building, health and hygiene
tap more resources (conflation and provision of underused private or
public estate, the support of urban agriculture and the recycling of
solid waste)
World Commission on Eenvironment and Development (1987). Our Common
Future (Brundland Report). Oxford: Oxford University Press.
10
Strenghening local authorities and citizen involvement
Democratisation and decentralisation to the lowest appropriate level
in order to achieve a balance of power, enabling the poor to put
across their interests, also against higher social strata.
Based on the acknowledgement that every person has a right to live
in the city.
Local governance: inclusive, participative decision-making
processes and the devolution of political, administrative and
financial power away from central governments to subnational and
local authorities.
Underlying aim: Reorient governance to the needs of the urban
population and make it transparent, accountable and responsive.
The role of the central government is it to facilitate a conducive
environment, i.e. through fiscal transfers, municipal elections and
spatial planning
•
•
•
•
•
UN-Habitat, State of the World's Cities Report 2006/7: The Millennium Goals and
Urban Sustainability. Malta: Earthscan
Challenge of Financing of Urban Development
•
The UN Millennium Project calculated that a slum upgrading
package for 100 million current slum dwellers plus new construction
on vacant land for 700 million potential new slum dwellers would
cost on average $1,800 per person and $1,440 bn. in total (UNHabitat, 2006).
•
UN-Habitat favours a mixed financing by donors, governments, local
authorities relying on the national capital market and an extended
revenue base as well as beneficiaries making use of savings and
housing microfinance.
11
Health specific Challenges
•
optimise the social determinants of health and thus to reduce existing
health inequities within cities:
•
Social determinants on environmental hazards and threats (i.e. unsafe
water, exposure to extremes of temperature and noise)
•
Economic barriers (i.e. poverty, education, cost of medical care)
•
Values, Behaviour and Lifestyle (i.e. health literacy, stigma)
•
Social and political exclusion (i.e. community decision-making
processes, access to welfare or social support services
WHO Kobe Centre (2005). A Billion Voices: Listening and Responding to the
Health Needs of Slum Dwellers and Informal Settlers in New Urban Settings
http://www.who.int/social_determinants/resources/urban_settings.pdf
Strategies for improving urban Health challenges
•
Improving governance, good governance being characterized by
‘participation, rule of law, transparency, responsiveness, consensus
orientation, equity, effectiveness and efficiency, accountability and
strategic vision’
•
Responsibility and power should be shifted to local authorities and
their partners at the local level.
•
In order to be successful local level interventions have to be
ecological and population-based, integrative as well as system
based.
•
Strategic actions should focus on slum-upgrading, improving access
to quality health care, targeted health promotion, integration of
health, welfare and education services and sustainable urban
development.
WHO, Kobe Centre, 2005
12
Why wasn’t there
good governance in the past?
• Existing power relations and the fact that there are also
those interest groups who already have a beneficial
connection to the state. Accordingly,concede that ‘those
with greater resources of experience, money or skill can
game the local system as they can a national
government’. Therefore establishing good governance is
not an easy process but it may act as a strong ethic and
political vision to follow.
Sven Voigtlander, Jurgen Breckenkamp, Oliver Razum (2008) Urbanisation
in developing countries: Trends, health consequences and challenges,
Bielefeld, 2008 (unpublished)
13
■
Background
Monitoring the Expenditure and Outcomes to
• Two-year project (August 2009 - July 2011) on maternal heath services of
improve Health Services for Urban Poor Women
in Bangalore
BBMP maternity homes m Bangalore
• Thematic areas of study include
- Antenatal care
- Delivery
- Postnatal care
- Immunization
- Family welfare services
Ms. Prarthana Rao
Programme Officer.
Participatory Governance Research Group (PGRG)
Public Affairs Centre
www.pacindia.org
• Tools used in the study
- Citizen Report Card (CRC)
- Community Score Card (CSC)
Citizen Report Card (CRC)
Aspects covered in a CRC
• A Citizen Report card is a simple but powerful tool which is
built from surveys with actual users of public services.
• Feedback from Users on experiences with public services is
collected, analyzed and disseminated, in a systematic and
transparent manner.
• The findings, which are backed by hard facts and figures, can
be used equally by institutions from both sides - the civil
society, can demand and lobby for improvement, while the
service provider can use the findings to initiate or strengthen
reform measures.
• The CRC approach evolved by the Public Affairs Centre
(PAC) has been considered an international best practice to
improve public services.
e
• ACCESS and USAGE
• Quality and RELIABILITY of the service
• COPING STRATEGIES
• RESPONSIVENESS of the staff
. CORRUPTION & Hidden Costs
• SATISFACTION with the services
• SUGGESTIONS FOR IMPROVEMENT of service delivery
II
^T-8: ^IF4
SlT>l<
I<
HH-8: HOUSEHOLDS BY AVAILABILITY OF TYPE OF LATRINE FACILITY
TFT
TFTTfffr
hP.m i <1
Total
TFT mH*!* T
'WT/hi* T?5!
number of
households
'1P 4 I T
mP+i< T TTrnr # Tf^TT T ttf7Type of latrine facility within the premises
’J 14s! >4
4I'd4 f+'d*4 j^si ^/
TfT
Flush/pour flush latrine connected to
’^fTTT f/
'113'1 4i4J.
IH4/
Pit latrine
TFT mP-M' H
hFJh sh-y 1*44/
TT-HT
SFT yuilT)/
4Pi4.
■4's-4 I f^FTT
7t4t Hi'Ti t
______ Service Latrine-
4 551 41 Jilrll
RT-TT o’jf’t.
t/
SFT ?! di 41
T rTT Ji l <14
Number of
Alternative source
TT oH'-Thl/
households
TTrfr/
TfT/
Without
Night soil
TFTT t/
having latrine
system
With slab/
slab/open
disposed
Night soil
Night soil
not having
ventilated
pit
into open
removed by
serviced by
latrine facility
drain
human
animal
within the
554141* 3TT
facility within
the premises
'stFl T^T/
improved pit
premises
1
2
4
3
5
6
7
Of Ft - 41
Ki
8
11
10
9
12
Urban
premises
4+P-M + TFT/
Piped sewer
Total
Rural
No latrine within
Tfft/
Number of
Other system
Tfrar
9|i 41 '-I'd gfTOT
households
Septic
Septic tank
tank
'-iPh* T 1*04IH4 44
JlPl'T.
^ir/
open
Public
latrine
13
14
1
H'l * 578/District - Chamarajanagar 578
TFT
244,198
57,295
10.150
9,061
2,830
31,653
1.012
1.974
TFfnr
203,748
31,279
2,593
6,034
1,407
20,036
577
187
H4^4
40.450
26,016
7,557
3,027
1,423
11.617
435
1,787
fTFT - ’pTTTT 579/District - Gulbarga 579
TFT
465,245
118,792
60.489
43,657
5,457
2.031
1.489
311,531
13,911
2.382
7,846
1,812
911
165
153,714
104,881
58.107
35,811
3,645
P’l'dl -
1.120
1,324
16
0
16
599
186,903
4.937
181.966
Total
445
172,469
3.386
169,083
Rural
154
14,434
1,551
12.883
Urban
3,687
32
1,950
346,453
25.426
321,027
Total
347
0
448
297.620
16,423
281,197
Rural
3,340
32
1,502
48,833
9,003
39.830
Urban
TTT 580/District - Yadgir 580
200,424
22,523
3.795
14,857
1,424
865
290
1.061
0
231
177.901
14,395
163.506
Total
Tpftr
161,665
6,938
1,187
690
510
134
109
0
96
154,727
10,239
144,488
Rural
n4'rl4
38,759
15,585
2,608
4,212
10,645
355
156
952
Irrt - tftr 581/District - Kolar 581
0
135
23,174
4,156
19,018
Urban
TFT
330.990
141,675
39,187
38,394
6,781
50,894
1,653
3,268
543
955
189,315
14,285
175,030
Total
226,245
57,664
6,218
14,834
4,231
30,799
688
380
56
458
168,581
4,156
164,425
Rural
HJl ■rl4
104,745
84,011
32,969
23,560
2,550
Pl F t -
487
497
20,734
10,129
10,605
Urban
TFT
282,311
102,957
25,436
26,217
4,368
42.697
1,871
1,322
249
797
179,354
7,052
172,302
Total
TFfTT
220,309
50,677
4,667
12,574
2,789
28,410
1,137
314
38
748
169,632
5,957
163,675
Rural
62,002
52,280
20,769
13,643
211
49
9,722
1,095
8,627
Urban
224,745
179,589
15,857
47,463
4,035
104,596
1,766
5,022
528
322
45,156
2,979
42,177
Total
162,398
122.643
7,058
25,836
3,020
84,850
1,334
120
302
123
39,755
1,528
38,227
Rural
62,347
56,946
8,799
21,627
1,015
19,746
432
4,902
226
199
5,401
1,451
3,950
Urban
y 1'41^1
734
20.095
965
2,888
582/District - Chikkaballapura 582
1,579
14,287
734
1,008
fF^i - ^I’jT TTFftT 583/District - Bangalore Rural 583
321
HH-Series Tables, Census of India 2011
( ) Postnatal care
( ) Home visits (Field visits by health workers)
( ) Specialist care (which type?):
( ) X-ray and scanning facilities (specify):
v. List all government schemes implemented in the Health Centre
5. Functioning and problems
i. Availability of doctor(s) on working days (days and timings)
ii. Does the doctor(s) work in another hospital?
iii. Average no of patient visits on normal day of functioning
iv. Does the Health centre display the user fee board? (If yes, please provide list of fees)
v. If possible, ask one of the staff what equipment they are lacking and list here
vi. Is there a committee formed in the
Raksha Samiti?
Health Centre, e.g. Board of Visitors, Arogya
I
■
^r-8:
Trf^STT ^7 M'bK ^7
I Vi
|< '4 P.q I <
I
HH-8: HOUSEHOLDS BY AVAILABILITY OF TYPE OF LATRINE FACILITY
TTT
'-iP 4 |<I ft
y iMrur
1/
H < I •f"i 'J
Total
TFT tW7 T
H^I^T/'-Tl < TFST S| | -41 r-i >4
number of
households
tP.t tf ft
hP+k if Jfi'HHq ^f 3if^r=rr T WF’/Type of latrine facility within the premises
nl
Pit latrine_______
Tfrfr HFff if
<p,d/
i -m i -n n i
TF-JJTr omPt.
'si'ii y ^i/
t/
TPTTTTTT
T^T/
Without
Night soil
With slab/
slab/open
disposed
Pit
into open
drain
Flush/pour flush latrine connected to
’jf^’STT #/
TTTT TtF-
frfeTcTT/
irfFT?
jFT yu| |f|/
Number of
wrfr/
Septic
Septictank
tank
Other system
households
Piped sewer
having latrine
system
ventilated
facility within
the premises
l-iF
TFT ’tPH' if
yRy stow/
tjt flTTrFT/
improved pit
HT
TFTT
^il
fFT TTTTF
Number of
5TT?nt/
TJ TTTFT/
households
Night soil
Night soil
not having
removed by
serviced by
latrine facility
human
animal
within the
2
4
3
5
6
7
8
10
9
11
Total
Rural
No latrine within
Urban
sA -q i '1 y Hfryr
Service Latrine
premises
1
if sfrnFT fr
TfTTT Tff/
premises
4 ttT',4 T
H/
Alternative source
y i 4 jI Pi't.
’jfrir/
TI ”1 <4/
open
Public
latrine
12
13
14
1
frrFT - Jy^ 572/District - Bangalore 572
21,745
3.432
18,313
325.175
90.228
234.947
5.581
8,096
3.776
5.276
122.457
37.061
85.396
Total
1.181
410
317
467
52,262
3,799
48.463
Rural
4.400
7,686
Dtft - fstt 573/District - Mandya 573
3,459
4,809
70,195
33,262
36,933
Urban
17.601
4.053
90.783
1.167
1,460
167
644
266,760
5,637
261,123
Total
12,228
2.424
74.264
966
265
96
541
256,523
3.814
252.709
Rural
37,201
5,373
1,629
16.519
201
1.195
fFFT - ettt 574/Distrjct - Hassan 574
71
103
10.237
1,823
8.414
Urban
171,212
50,705
20,140
4,148
94,051
90,891
4,066
11,822
3,060
70,209
89,381
80,321
46,639
8,318
7TT
425,291
394,069
52,741
248,191
2,859
y i4i”i
220,806
194,578
7,124
116,948
1,850
dy fI y
204.485
199.491
45,617
131,243
1.009
Riii -
21.456
37
89
576/District - Kodagu 576
WT
138,303
112.626
9.580
80,464
2,549
94
118,509
93,421
7,807
64,544
2,389
1.277
65
19,794
19,205
1,773
15,920
18.482
17,205
1,277
1,322
y i*Tiui
29
45
577/District - Mysore 577
WT
688,422
378.503
240,414
18,470
5,658
107,667
2,456
2,717
<i 14i ui
401,655
108,475
9,591
12,431
4,086
79,149
1.631
698
nJ 1
286,767
270,028
230,823
6,039
1,572
28,518
825
2,019
TFT
2.377.056
2,254 599
1.715,904
169,046
TFfiTT
207,628
155,366
27,377
31,954
h-iTh
2.169,428
2.099.233
1,688,527
137,092
TFT
426,578
159,818
43,943
y
354,049
97.526
6.742
72.529
62.292
429.292
339.911
TT^TT
y 14 i ,Ji
1,005
914
91
613
108
442
258.080
8,327
249,753
Total
397
0
423
249,020
7,050
241.970
Rural
108
19
9,060
1,277
7.783
Urban
89,557
353
87
31,222
1,888
29,334
Total
264
50
12
12
0
269
68,101
229
26,228
869
25.359
Rural
40
4,994
1,019
3,975
Urban
46
89
25,677
1,411
24.266
Total
46
88
25,088
1,187
23,901
Rural
0
1
589
224
365
Urban
19
19
0
1,102
309.919
9,177
300,742
Total
870
293.180
5,539
287,641
Rural
232
16,739
3,638
13,101
Urban
1,088
23.842
216
(jI'Ii - TfaTT 4iv! si 575/District - Dakshina Kannada 575
160
f^TFr -
320
HH-Series Tables, Census of India 2011
vii. Any problems experienced with hospital, such as corruption, availability of doctors,
availability of medicines, availability of tests, attitude of staff, access to schemes, etc.
viii. Case studies (attach)
•*
■
^T-8:
i
'.-iM©SHTT
1<
I<
HH-8: HOUSEHOLDS BY AVAILABILITY OF TYPE OF LATRINE FACILITY
M P' cf l U
HpdH.I
•IpH*, if
•j hH ui
H J| Z'l -4
l/
Total
number of
"dF-t4
STFR/Type of latrine facility within the premises
d'e-41
TFT '-1P dJ if
TFF/TF TF&T sA d I d 4 l+dd ipi f.l
"4 1 --I 4 Tt
households
Id4/
TJT
_______Pit latrine______
Flush/pour flush latrine connected to
TF-TT
dfFH i-fi d I d 4/
’irfr Trffif
Service Latrine
dP-dddP-i’r. St>/
sft yuiiTl/
yvilTl/
Septic
Septic tank
tank
Other system
households
Piped sewer
having latrine
system
’jf?hrr nff/
Total
Rural
TFT ■< P d' if
No latrine within
Urban
TfTTT
premises
P'M'h ^TT/
TF-'rpTT o-i Pt-
‘FT-HF n-iM
TFT 75<l <11
^7 TFV Ji M d * I
Number of
Night soil
-ji i a i o/
TT 3'14HI/
households
slab/open
disposed
Night soil
Night soil
not having
Pit
into open
removed by
serviced by
latrine facility
drain
human
animal
within the
fTT <fpd/
■iish Tit'
Number of
-H-'sm I Rtd +
ji I n I
y.dldF S^d
’TFT ’T|T./
t/
’TIT/
With slab/
Without
facility within
ventilated
the premises
improved pit
premises
1
TTpfPT
H.I'H
■'J Ni
TTPfT’T
2
3
4
5
•FlfpJ
u i4i *>1
’FT^FT
’TFT
9
11
10
fFFT - PTTTrrf 566/District - Chitradurga 566
951
3.822
2,850
62,615
747
2,260
36,834
572
379
25,781
3,075
590
fjfFT - <514 uf ff 567/District - Davanagere 567
12
14 Ji Id +
’FT if/
l”1 ■4/
open
Public
latrine
13
14
1
123
25
98
1,550
1,018
532
247,001
228,180
18,821
8.573
6.570
2,003
238.428
221,610
16.818
Total
Rural
Urban
101
69
32
1,739
477
1,262
216,794
191,566
25,228
11,669
5.226
6.443
205,125
186,340
18.785
Total
Rural
Urban
129
129
0
489
422
67
116,010
98,232
17,778
8,178
2,657
5.521
107,832
95,575
12,257
Total
Rural
Urban
94
1,675
29,540
99
74
76
21,683
1,098
7,857
577
20
23
f^dI - Risufi^ 570/District - Chikmagalur 570
0
0
0
148
121
27
31,505
28,639
2,866
1,300
739
561
30,205
27,900
2,305
Total
Rural
Urban
26,890
17,601
9,289
2,676
119,393
720
458
610
124
91,508
2,283
110
334
393
27,885
fjTdl - ’pFF? 571/District - Tumkur 571
119
119
0
429
258
171
104,804
98,778
6,026
2,870
2,256
614
101,934
96,522
5,412
Total
Rural
Urban
38,787
16,519
22,268
7,078
4,407
2,671
325
145
180
1,372
731
641
429,573
405,017
24,556
9,165
6.187
2,978
420,408
398,830
21,578
Total
Rural
Urban
354.143
282,019
72,124
■07,142
53,839
53,303
23.137
4.436
18 701
12.094
7,947
4,147
404.840
272,929
131.911
188,046
81,363
106,683
84 558
5.545
79.013
17,049
7,578
9,471
76,409
748
3.557
3,885
64.109
523
376
2,686
12,300
225
3.181
1.199
Rftt - PTTtqr 568/District - Shimoga 568
402,139
257,060
145,079
286,129
158,828
127,301
51.269
5.726
45,543
48,446
16,163
32,283
5,148
2,876
2,272
246,313
174,548
71,765
214,808
145,909
68,899
8.371
2.556
5.815
174,881
120,301
54,580
272,173
215,334
56,839
167,369
116,556
50,813
16.684
4.053
12,631
636,394
495.885
140,509
206,821
90,868
115,953
45,563
4.975
40,588
fFFT ^TFT
8
7
6
Alternative source
175,434
129,943
45,491
3.609
3,055
554
1,605
514
1.091
569/District - Udupi 569
108.261
62.436
45,825
1.630
973
657
3.805
682
3,123
319
HH-Series Tables, Census of India 2011
6.
SkeJj saafcr^rSozb^dD^ z^riidS) ^dJaer^ dowo^d djsoddrteb
rtoc^ort
^So^oi)Ort
w
V
(rtock/aorsD)
7.
5aabr|e^d(§ zjds^o c^djae^ &ou^dc&e?
•
^d5D0 edjseKzS 3eod
^od
^dde
—’
r^
a
^d
&
3o?3ojX)
^c&F^r&>;&3dD^
^oijr^edd
Q -0
«4 —’
?TT
"Ml
'd H vi
M+K
dI
^^<11 < nfld l<
HH-8: HOUSEHOLDS BY AVAILABILITY OF TYPE OF LATRINE FACILITY
Total
number of
TFTTp’Rif
households
’jfWsrT W/
Mp ■HJ if SfHl'PT ’ft
Total
Rural
S'fHFTT/
TFT "1D *1J if
No latrine within
Urban
Service Latrine
T 04 [rf.
I <1'4 gfTETT
premises
4'+P;il+ ^TT/
’TTPTType of latrine facility within the premises
if sflMM'M
*i«s4l
fl 4
i T fr
hD
m Pq i < i :ft
’TFT
TZF'T/TF’ 7FX sA’l IM4
S’flMIH-U ’fr
•H 'OJ |
TTT %l
’T’fr TFft if
Pit latrine
4Rd/
Flush/pour flush latrine connected to
oFF null41/
dRi* St/
Ml34 4l4J
«l r. 141 jimI
T^rf/
Number of
Number of
M vil'-Tl/
ttttf ttft
^TT yjT/
tz
TFT r.il-'-U
households
Piped sewer
FfT/
Without
Night soil
JIMI %l
having latrine
system
With slab/
slab/open
disposed
Night soil
Night soil
not having
facility within
ventilated
Pit
into open
removed by
serviced by
the premises
improved pit
drain
human
animal
latrine facility
within the
Septic tank
Other system
Ji I d 4 *'l
households
premises
1
2
4
3
259,396
213.217
46,179
47.931
25,565
22,366
5.491
2.814
2,677
31.944
14.105
17,839
215,602
137.799
77.803
45,668
12.732
32.936
10,544
2,687
7.857
26,948
6,107
20,841
372,054
157,960
214,094
212.091
36.449
175,642
137,804
2,306
135,498
55,403
22,477
32,926
WT
4ll4l«T
319,912
226,803
93,109
189,843
114,752
75.091
15,494
5.748
9.746
130,523
73,188
57,335
’TFT
yi
325,456
254,181
71,275
121,420
71,774
49,646
14,623
3,960
10,663
60,653
31,317
29,336
’fry
y i4'ivi
481,704
291,383
190,321
156,110
35,296
120,814
84.313
4,020
80,293
25,567
7,118
18,449
<rpr
y i *Ti 'Ji
y 141
-lyTi-ar
’fni
UT4trT
HnfPT
7
6
5
8
9
Rftt - fWf 560/District - Koppal 560
215
269
7.715
117
167
6.465
98
102
1.250
561 /District - Gadag 561
477
1,101
3.221
2,903
137
1.727
242
1,551
340
859
1.494
1,352
Prt - ai<.4!£ 562/District - Dharwad 562
734
2.033
10,653
4,680
185
7.517
1,565
2,175
468
549
3.136
2,505
P <11 - -d d J, TTm 563/District - Uttara Kannada 563
345
34.174
1,361
7,570
149
1,128
28,935
5,317
196
233
2,253
5,239
f^FTT - ^idfl 564/District - Haveri 564
796
35.458
4.403
4,546
299
1,981
30.113
3,490
497
2,422
5,345
1,056
Rl01 i ■ft 565/District - Bellary 565
2,227
904
37.368
4,135
477
311
20.852
1,955
427
1,916
16,516
2,180
2,017
1,658
359
f^FTT -
11
10
Alternative source
*i 14 ji R =!••
^if/
?A-4H4/
open
Public
latrine
12
13
14
1
0
0
0
280
239
41
211.465
187,652
23,813
35.878
25,448
10,430
175.587
162.204
13.383
Total
Rural
Urban
0
0
0
474
281
193
169,934
125,067
44.867
21,389
7,801
13.588
148,545
117.266
31.279
Total
Rural
Urban
173
98
75
6t 1
126
485
159,963
121,511
38,452
13,024
2,408
10,616
146,939
119,103
27,836
Total
Rural
Urban
0
0
0
376
287
89
130,069
112,051
18,018
7,346
2,561
4,785
122,723
109,490
13,233
Total
Rural
Urban
229
218
11
712
396
316
204,036
182,407
21,629
8,814
4,430
4,384
195,222
177,977
17,245
Total
Rural
Urban
11
11
0
1,585
552
1,033
325.594
256,087
69,507
53,650
29,564
24,086
271,944
226,523
45,421
Total
Rural
Urban
88
HH-Series Tables, Census of India 2011
318
^r-8:
^fsTtuT
HH-8: HOUSEHOLDS BY AVASLABiLITY
Tt
’ •'T
^■TFT
'<: 7^’/Type of latrsne facility within the premises
qfrxp-^
’77^-T
qi
Tr
'FF
F
if SH-lk-H ^f
Total
Rural
Total
d4!
Tft-TR
TYPE OF LATRINE FACILITY
number of
households
TtF 'tP jF F
TTF/’iF 'TFST
yffFTFF
■^ar t/
f^FF FJl
ifrFTFF/
Fiusn/poui flush latrine connected to
Tn“. ‘■FF’
^7/
FF-HF
________ Pit latrine
’Tfr ffTt if
■‘•A4 F eQ d/
FFFF -< Iri j
r
t/
~T 7TFTT
WFtr/
7F?.’’ Tf?1,. ;/
Tsf ?/
If-
~T^TZ
households
Pipes sewer
1:41/
Without
Night soil
^TrfTtZ
having latrine
system
With siab/
slab/open
disposed
Night soil
Night soil
not naving
ventilaieo
Pi-
into open
removed by
serviced by
latrine facility
dm in
human
animal
within the
ff7)
Other system
facility within
the premises
improved pit
Urban
premises
Number of
Septic tank
No latrine within
Service Latrine
TfFF jfH'-Ff
Number of
households
d
fFt/
Alternative source
’FFFFTt
open
Public
latrine
premises
1
2
4
3
b
7
6
~37-/T73'
8
10
9
11
12
13
14
1
29,'STATE • KARNATAKA 29
1,711,701
155,429
1.745,410
43,709
61.802
7.740
28,995
6,430,515
504,217 5.926.298
Total
805.618
90,803
1.127,230
25,245
9.328
2.052
13,388
5,629.682
272.968 5,356,694
Rural
4.514,862
'2.994,610
160,870
2.833,740
906,083'
618.180
64,626
18,464
52,474
T^iFT - ifFTra 555/District - Belga urn 555
5,688
15,607
800,853
231.249
569,604
Urban
963.825
316.225
94,312
186.213
17 946
10,257
2.521
343
2,278
647,600
74.989
572.611
Total
708 069
131.009
11,322
93,036
14,149
8.242
958
204
1,588
577.060
42,997
534,063
Rural
255,756
185.216
82.990
93,177
3,797
2.015
1,563
139
690
70.540
31.992
38.548
Urban
13,179.911
.6r749,396
7,864.196 ■'
2 234,534
3.315,715
TFFT -
2,355
1.510
845
55e/District - Bagaikot 556
>T.-7T
355 3?7
; 36.813
: 25.744
32.981
3,37 6
3.021
228
398
167
898
288.564
35,618
252,946
Total
TPtt’T
233 746
17,187
2,059
10,188
2,209
1.935
175
145
360
221 559
16,411
205,148
Rural
110,63.1
43.626
23.685
22,793
1,167
115
51
538
67,005
19.207
47,798
Urban
405,076
73,300
42.428
22,692
34,408
297,368
Total
1,600
3.911
456
292,468
25,000
267,468
Rural
97,092
57.784
‘•'0,828
13,781
109
0
109
331,776
15,516
4,381
2,738
1,643
1,001
307.984
545
39,308
9,408
29,900
Urban
21
0
21
1.145
429
716
240 716
9,605
231.111
Total
216,397
7,033
209.364
Rural
24,319
2,572
21,747
Urban
95
948
285,011
30,573
254,438
Total
32
437
237.877
17.951
219,926
Rural
63
511
47,134
12,622
34,512
Urban
VF-’
.-vV^^Fr
1.686
53
253
fTF1 - f3FT$7 557/District - Bijapur 557
f^FT -
’2.805
20.983
14,850
39,838
237.380
2 952
10,723
76.141
51.822
11,898
tHt
353,337
-J 14'l 'JT
264,274
74.326
26,397
47,929
313.521
•Ff
95.063
2.069
1.562
507
271
105
166’
349
144
2C5
I
558/District - Bidar 558
4.229
29,115
7,176
3.877
3,299
25,407
33.573
4.709
6.285
3.485
13,363
3.235
5,134
21,922
20.210
1,474
1 151
2.083
1,260
567
4.286
352
3.934
2.146
693
Qi'di - *i«^ 559/District - Raiciiur 559
790
449
341
2.519
262
2.257
317
HH-Series Tables, Census of India 2011
i
I
Plan for Delivery ,of Family Welfare
Services in Slums (Bangalore City) Based on The Need Assessment of Slum
Dwellers (EPP-VIII)
•AS Mohammad
•
■ evvw
Dept, of Community Health
SL John's Medical College, Bangalore 560 034
Bangalore is the fastest growing city of India with a total PoPy'^ontohf/Jm0®:°1o3f
(^census). This unprecedented, unplanned growth has
^aith
many slums and lack of basic civic amenities. Bangalore has
™
services provided by the net work of hospitals, health centres, ma ter 'ty
dispensaries but these facilities are not available to ower s^t.on of Uie .urban
community for various reasons. Out-reach services of these institu io
or are inadequate to meet the Primary Health Care needs of the slum dweller.
.
in the present proposal efforts are made to identify problems and to strengthen the
the existing facilities as per the requirement. Strengthening of out reach servi
involvement of community in taking care of its health needs are the mam points ot the
present proposal.
Various strategies for improving the delivery of family welfare/primary heahh care
services to urban poor could include the following
a) Development of effective out-reach services
bl Strengthening of infrastructural facilities
cj Involvement of Private Medical Practititioners and NGOs and
c) Intensive 1EC (information, Education & Communication) compaign.
A health centre will serve a population of 50,000. Family welfare and Primary health
’ care services will be provided through link workers, domiciliary visits of ANM/LHV. To
.• •
K
26
I
ii
I
j
palienTfacililies w?h 25 beds' Fo^S0^003^S Wi"bS up9radecf'!c> have in- .
i
will be selected. The services wilHndude
-i
’ S°me °
ex'si,'r’9 ma'emity homes
1 • Care of pregnant.women include treatment of specific-nulritional disorders.
2. Safe (ieliveries.
3.
‘
’ -•
Postnatal
care including
care ol new born
i
•4. Nutritional care uptdjhe age of five.
'
5. immunization against vaccine preventable diseases
!
;■
6 Advice, supplies and facilities tor Family Welfare
8. T.ea.™eo, o_,™or!i,men,s SXXand 'aC'a,i°n' elc-
SE^NaUP.OF^EALTH^^^s AfJD up GRADED-
<1
i elakh by 1995.
^ned. The break-up
I ol health centres and upgraded heallh cantres
~/
Required
Existing .’.-T___ - •
Addl. requirement'
----------------
1
•
•
97 >
27^
gg
ugraded Health Centre
■
y
'■ "
-------------------------- 1--------------------------- L_
r’
a4
• 30 Maternity Homes
'r^4
•
"
Slrenglheoing lb terns ol stall, equipment, dregs and contlhgehcles ’
•*»*«* *»» stall quaners (o„ly
Se"in8. * 0'
' • phateXne"asWtas?
Year
I - II
New centres (60)
20
15
Strengthening of 37 HCs
5
5
Strengthening of 24UHCs ’ •• 6 '
5
« be 'taken In
d
III
IV
10 •
10 ■
8
12
5
5
taken up from the periphe^oUhe city. UPHCS
V
7
5
3
Total
60
37
24
56,1109 UP °f nSW cc3ntres will be .
27
i
j
I
I
I
F.0
OR GA NIZA TION CHA R T
’ COMMISSIONER/ADMINISTRATOFI
h
HEALTH OFFICER
Additional Health Officer-.
'
••■(FW&MCH)
i
Non-Government Organisations :
■
Private Medical Practitioners
Administration and Monitoring Unit
• Deputy Health Oliicer (FW & MCH)
. . -Statistician '
•UDC'
■
~
1
Training Unit
• • Apex training team
i
I E C Unit
• Exin. Education Oliicer
.• Exin. Educat.or
- Driver cum projectionist
!
?
Upgraded Health Centre
* l
Sr. Medical Oliicer
Gynecologist cum Aesd. IMO ■
Paediatrician
• ,
Anaesthetist (Part time)
Stall Nurse
Clerk
Pharmadst cum store keeper
Latt.-Tech nrdan
O.T. attendant
Statistical assistant
Peon
Sweeperess
Chowkidar
Driver
I
:
' I
r
1
. 1 .
1
. 1
4
2
3
TASKS
1 ■
1.
1 ’
1
3 .
1
1
•
Out patient services
Specialised MCH Care
Conduction ol Normal and high risk
• • deliveries
MTP '
Sterilization
Inpatient care ol Gynae/Obs. cases
Laboratory services
Referrals
Supervision ol Health centres
I
I
r T
. Health Centre (HC) HC
HC
I
___________
Lady .Medical Oliicer
1
LHV/PHN
. 2
ANM/Health worker (Female) 7
Health worker (Male)
1
•Computer cum derk
. 1
Peon.
!•
Sweeper cum ctjdwkidar
1
Dias (link worker)
10
HC
TASKS
Treatment ol common ailments ol mother and children
Induding darrhoes (mild dehydration)
Ante Natal. Natal and Post Natal care
Immunization
. Vlt. A lor prevention of blindness
,ORS for diarrhoea
•'
Supplementary Nutrition
Family Planning
• IU0 insertion. Condom and Oral pill distribution .
Urine (Albumin A sugar) and Blood Esamination
Referral for StenSzanoh. High risk & completed cases to.
.... upgraded Health centre and other Hospitals' '*
Surveillance cl vaccine preventable diseases & Diarrhoea.
tt is suggested to introduce various records and reports at various levels, right from
the field staff, HC, and UPHC, to monitoring unit. .So the information can flow both ways
. i.e. from field staff to the decision maker and vice versa. ■
•28
i
A,
ft
Training is an important component ol the proposal. Its major objects is to instal an
oul-rcach/extension bias in the health functionaries. Training will be carried out a
different levels for different categories of Health workers.
:
TRAINING PLANT
Calergwies
1. Apex raining
team
Venue ol
Training
Trainers
Ouradorp
National'
Institute ol
Health and
Family
Welfare
Services.
NEW DELHI.
Faculty
from
NlHAFWS
3 working
days
a) Emerging Urban Health
needs and problems
ol slums.
b) Project Strategy for
delivery of Family
Welfare Sendees.
c) Communication
Technology
d) Planning and organisation
ol training programmes and
management techniques.
Faculty
from
H.F.W.I.C.
2 working
days
a) Motivational technology with Lecturer/discussions
special reference to F^mfy Demonstration and
Welfare.Field training
b) Inter personal
communications.
Faculty
from
H.F.W.I.C.
4tJays
a) Planning, organisation and Lecture/discussions
evahjation of training
group discussions
communication techniques and field training.
in health and family we’Uve.
production and testing of '
training & communication'
materials.
b) Extension techniques.
planning,organisation and
testing of training/
communication centres
2. Sr. WeccaJ
H.F.W.I.C.
Officers,
specafsts.
Gynaecdosisi
Paedaridan
3. Extepscn
Educarr
I
H.F.W.I.C.
Training
Methodology
Training
Needs
Lectures/discussions
and.group
discussions
J IMOs. PHNs. H.F.W.I.C.
IHVs
Faculty/
H.Officers
SMOs.
Extension
education
officer
5 Days
a) Problems ol Urban Primary
Health Care, new
b) Use ol communication
strategy In training
c) Awareness creation,
motivational technology.
d) Management techniques
e) Clinical update
f) Moorioring and Supervision
lectureAvorkshop,
group discussions
□no fioio experience.
5. Health worker Health centre
SMO'MO
Extension
Educator
5 Days
a) Update in prevention and
promotive health care
b) Anlenatai checkups,
• dehveries Postnatal
Cieck’Ups,
c) Jqentificaiion of high risk
LectureAvorkshop
■ eld experience and
Poetical training/
demonstration
i
I
I
29-
t
J
I •
Nt'
Caiergories
Venue ol
Training
Trainers
Duration
Training
Needs
Training
Me thou ./og y
mothers.
oi Care ol new bom & infants
e) Motivational techniques
■ person to person
communication
I) Maintenance of various
records and reports.
6. Link workers
(Dai)
Heal i h'
Cenire
PHN-tHV,
ANM
Extenjson
Educasxs
X Days
a) Contacting community tor
Lectures^roup
awareness creating.
cliscussion
b) Motivating women
Demonsraoon.
particularly pregnant
Roleplay
’ women.
. • •
Fiekf oossr/ation ano
c) Update on delivery method, real sriuajen.
aseptic delivery, care ol
pregnant women, postnatal
care, care ol inlams and
care of minor ailments in.
the community.
7. Private
i
practitioners.
. NG Os arc • '
Karnataka :■
Slum
Clearance
Board(KSCB)
workers.
.
Health
Olhce
Health
Officer
cons-sted
by erension
educaiors
1 Day
orientation
rseminar.
a) Orientation to innovation
approach/extension
approach.
Lecture, rtsviouai
presentations and
discussrors
8. Angawadi
worker
Health
centre
LHV/PHN
Extension
Educacr
1 Day
cnenation
a) Contacting community lor
awareness creating.
0) Motivating women
parocularly pregnant
women lor ANC and T.T.
Immunization.
Leoure/Roe play.
A survey conducted in slums of Bangalore revealed that 85% of population is
availing the services of Private Medical Practitioners (PMPs). Il is because of fact
that they are in large number and have high level of local acceptance and respect,
particularly in slum areas. So. the success of implementation of the programme of
strengthening of family welfare services in urban areas will also depend largely on the
involvement of PMPs and NGOs providing these services.
During the interviews with PMPs. all PMPs expressed their willingness to
participate in the Government Health programme. So, it is proposed in the plan to
identify the PMPs and NGOs and involve them in the following activities :•
30
e
TA?; FOR INVOLVEMENT
InsliluDon '
• Nursing Homes
^’Immunization
•
Polydmics
clinics'
dispensaries
...
.. t
J
Family
Planning •
Nursing homes
' ■ Poly dime
’ cbnic-- ■ ■ -
. Dispensaries
i •
MCHANC.
Natal
PNC
OAT
'■
Nursing homes
Poly Clinic
ClinicDispensaries
Nursing homes
Poly clinics
• dimes'
dispensaries
Task
Supplies
(free)
Records
Immunization
Vaccines
Cold chain
List of
Immunised
ol eligible
children
. attending
institution
equipment
F P services
; induding
lUCDs
Oral Pills
Appro
priate'
MTP(onty)
. • Nursing
homes)
Condoms
register •
of sch/ices
• - ..-done-
■<
. Motivabori ' - •.y . Iron and
for regis
Folic add
tration <S
and TT
referral to
appropriate
tnstituDon
Assessment
. of degree
of dehydra
OAS Pkts
bon and
UFWC/ ..
area
■ ANM
children
doese wise
Mothers TT
•y
Report
To
.
;
■ Appropriate
register
ol hvork
done
.. •
Area
UFWC/
ANM
•
Area
UFWC
ANM
’: *
Appropriate
register ol
work done
Aren
UFWC/
ANM
treatment
HcaJtti
Education
do
. Motrvaoon
A advice
on Preven
tive Ivteasures
ANM.'lHV and ™,e
Lea nets
Posters
etc.
in ,„e cond X JSKS2
aullVIlies..
31
*
- Media
RF_DEV_3_B_SUDHA.pdf
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