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A synopsis of the Report of the Knowledge Network on Urban Settings
to the WHO Commission on Social Determinants of Health
Our cities, our health, our future:
Toward action on
social determinants of health
in urban settings
A synopsis of
the Report of the Knowledge Network on Urban Settings
to the WHO Commission on Social Determinants of Health
WHO Centre for Health Development,
hub of the Knowledge Network on Urban Settings
Acknowledgements
This document is a synopsis of the report of the Knowledge Network on
Urban Settings to the WHO Commission on Social Determinants of Health.
We acknowledge the contributions of the following:
Chair and Lead Writer: Tord Kjellstrom
Drafting Team: Susan Mercado, David Sattherthwaite, Gordon
McGranahan, Sharon Friel, Kirsten Havemann
Contributing writers: Fran<;oise Barten, Jaimie Bartram, Daniel Becker,
Cate Burns, Scott Burris, Waleska T. Caiaffa, Alana Campbell, Tim
Campbell, Diarmid Campbell-Lendrum, Rachel Carlisle, Carlos Corvalan,
Annette M. David, Jorge Jimenez, Jane Dixon, Kai Hong Phua, Kelly
Donati, Katia Edmundo, Nick Freudenberg, Sharon Friel, Sandro Galea,
Fiona Gore, Wei Ha, Trevor Hancock, Ana Hardoy, Andre Herzog, Philippa
Howden-Chapman, Andrew Kiyu, Albert Lee, Josef Leitmann, Vivian
Lin, Gordon McGranahan, Helia Molina Milman, Diana Mitlin, Frederick
Mugisha, Catherine Mulholland, Kaoru Nabeshima, Danielle Ompad, Abiud
M. Omwega, Giok Ling Ooi, Sheela Patel, Pat Pridmore, Fernando Proietti,
Eva Rehfuess, Jaime Sapag, David Sattherthwaite, Shaaban Sheuya, Ruth
Stern, Liz Thomas, David Vlahov, Lisa Wood, Shahid Yusuf.
Special thanks to Roby Alampay, who wrote and designed the synopsis and
provided all the photographs in this publication, except those on pages
20, 22, and 23.
© World Health Organization 2008
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The designations employed and the presentation of the material in this publication do not imply the
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use.
Printed in Japan
/World Health
Organization
Contents
I.
How urbanization impacts on global health
II.
Issues and challenges: the urban setting as a determinant of health
III.
What needs to be done
Acronyms
AIDS
acute immunodeficiency syndrome
CODI
Community Organizations Development Institute
HIV
human immunodeficiency virus
OECD
Organisation for Economic Co-operation and Development
SARS
severe acute respiratory syndrome
UNAIDS
The Joint United Nations Programme on HIV/AIDS
UN-HABITAT
The United Nations Human Settlements Programme
UNU
United Nations University
3
How urbanization impacts on global health
ore than half nf Farth\s six billion inhabitants
already live in urban areas, and still the world _
is becoming more urban. Jn 1975 only five cities
worldwide had 10 million or more inhabitants. The
number of such "megacities” will hit 23 by 2015,
with all but four of them in developing countries. On
top of this, by 2015 an estimated 564 cities around
the world - 425 of them in developing nations - will
each have more than one million residents. (UNFPA,
2002)
Tp be sure, urbanization is not inherently or
necessarily a negative force. Indeed, Tt can be- a
positive determinant of health in the appropriate
circumstances.
Urban areas are economic development centres,
for one thing-lLi^not-enly4imited economic options
in rural settings that drive migration to cities, but
also the presence of opportunities in metropolitan
areas.^The fact is that the world would not be at the
point of technical and social development it is today
without the “economic engines” that urban areas
have been since the industrial revolution started in
the late 18,h century.
The other side to this reality, however, is that 3
M
4
urbanization also poses challenges to societies.
It is no coincidence that the regions of the world
with the fastest growing urban populations are also
the regions with the highest proportion of slum
settlements - the most iconic illustration of the
relationship between unmanaged urban growth,
poverty and ill-healthGiven both its positive and negative impacts, it
is important to understand how urbanization itself
influences health matters and agendas. Urbanization
is its own force. It is so powerful as a trend and
a phenomenon that urbanization is a major
determinant of public health in the 21s* century;
The dynamics of cities, with their concentration of
the poorest and most vulnerable (even within the
developed world) pose an urgent challenge to the
health community.
The growth of cities and the concentration
and migration of populations into metropolitan
areas challenge global and local infrastructures and
resources, environment and health, and force all
societies and governments to reconsider policies,
interventions and the very socioeconomic indicators
by which they measure quality of life.
While cities and metropolises could represent
opportunities, poor management and governance,
inadequate infrastructure and failure to develop
policies for equity also tend to magnify the effects
oi poverty, inequity and health concerns in urban
communities.
simple consideration of rural versus urban
incomes, for example, can be misleading. Average
incomes in rural areas are often lower than in urban
areas. But within urban centres, the gulf between
the haves and the have-nots is often wider. An
affluent minority in cities tends to make the cost
of living in metropolises much higher than that in
rural settings. The prices of basic subsistence goods,
such as food, water and shelter, are generally higher
in urban areas, reducing the purchasing power of
urban incomes. There are also some basic necessities
that the rural poor may be able to secure outside
of the cash economy. Health conditions are also on
average better in urban areas, but here too averages
can deceive. Among urban poor groups, infant and
child mortality rates often approach and sometimes
exceed rural averages.
The living and working conditions in more
cramped urban settlements (e.g. unsafe water,
unsanitary' conditions, poor housing, overcrowding,
hazardous locations and exposure to extremes
of temperature) also create more acute health
vulnerabilities than those confronting rural citizens.
This is especially true among the urban poor and
vulnerable sub-groups, including women/ infants
and very young children, the elderly and the
disabled. Unhealthy living and working conditions
compromise the growth of young children, their
nutritional status, their psychomotor and cognitive
abilities, and their ability to attend school, which
affects their future earnings while raising their
susceptibility to chronic diseases at later ages.
The urban context can thus not only be
misleading with respect to health concerns. It can
also be aggravating to social problems - and unto its
own dynamics.
When urban centres fail to immediately provide
opportunities to overcome poverty7, for example,
poverty7 can tend to be compounded by7 the urban
context itself. Thus inadequate shelter in rural areas
can easily7 translate into worse slum settlements in
cities, where ill-health and diseases are more easily
bred and^ipread. The communicability of emerging
diseases like SARS and avian flu is magnified in
urban areas where people live and mingle closer to
each other. So with H1V/AIDS.
Not surprisingly, there are also more road
traffic injuries in cities, where the majority ofc,ars
5
6
and motorcycles arc found.
In fact, across a broad range of social issues from air pollution to workplace hazards; from illicit
drug useandviolence and crimejo even the emerging
problem of obesity due to the pervasiveness of
inappropriate foods’ or lack of facilities and areas
for exercise - the urban setting is a factor that
exacerbates and complicates society’s public health
challenges.
And yet many societies affected by severe urban
poverty fail to even acknowledge a problem and
picture that can be incongruous to the self image
risks, noise and traffic generation.
In slums, the unhealthy and unpleasant
conditionToftei^^
segregation,
with the poorest living close to their ^workplaces
in the worst affected areas. Social inequity is a
key feature of these types of workplace and living
conditions, leading to social strife and clashes
between economic classes.
Today’s rapid urbanization and globalization
are inextricably linked. ^igraiio'D5_Lak£_ place not
just from provinces to cities, but also fr_om_cities to
cities - and from country to country.
of development and prosperity associated with city
centres. Consequently, while the 2003 Global Report
on Human Settlements (UN-HABITAT, 2003a) says
that 43% of urban populations in developing regions
live in “slums” (and in the least developed countries,
an average of 78.2% of urban residents are slum
dwellers) many countries do not plan systems for
safeguarding health during urbanization, and urban
poverty remains largely unaddressed.
In high-income countries, where 54 million
people live in informal settlements, the issue can be
glossed over simply because the problem tends to
affect immigrants, in particular.
Indeed, the poor appreciation of urbanization
as a health phenomenon has deep and far-reaching
implications.
For both its scarcities and excesses, urbanization
is generally associated with, among its most iconic
problems: poor working conditions in a large informal
sector among cottage industries, child workers and
sex workers. Deprived urban areas and informal
settlements arc often a mixture of living places and
workplaces. These workplaces often create health
hazards due to the use of toxic products, injury
Hand in hand, urbanization and globalization
are thus drivers of economies as well as of
potential conflicts, the spread of disease, and the
(ra n s fe re n c eo f s o cia nlibs u chasTI ru gab us e, child
labour, and the~exploitatibn oP women. Within or
be'tween countries, the v^^reYms'“sIum’’ancl “slum
dwellers" can generate discrimination and contempt
and lead to the urban poor being disregarded in
town planning and development decisions.
Thus we see that urbanization alsojnagnifies the
dynamicsof powerlessnessjandjhe^ marginalization
of the poor. Slum dwellers and informal settlers
may face stigma^ahcTsocTal exclusion by living-in a
settlement for which there are no official addresses.
They may not be able to vote, register, or even get
their^children into government schools or access
otTier~entitIements.
They are easily missed and undocumented in the
national census and even health surveys. The urban
context further lowers people’s ability to gain control
over their own conditions, society’s resources,
and the very unmanaged - and unmanageable
- environment that marginalizes and burdens their
lives.
Issues and challenges:
the urban setting as a
determinant of health
Among the litany of
issues that factor into the
health of urban societies
are environmental
concerns such as air
and water pollution,
sanitation, solid waste
management, and the
very lack of space that
compounds all these
problems.
n 2001, the WHO Commission on Macroeconomics and Health
affirmed that investments in urban health can create major returns for
economies. Whether it is an increase in life expectancy or healthier years
from childhood to old age, the benefits of urban health investments to
individuals and to society are indisputable.
Despite this, interventions to address health issues associated with
urbanization arc severely limited. A UN-HABITAT (2006) report states,
for example, that “development assistance to alleviate urban poverty
and improve slums remains woefully inadequate”.
The inadequacy refers to a range of issues, and not just the need to
foster economic growth and better incomes. While rising incomes have
been linked to improved health for individuals, on a community and
societal level, there are environmental, social and political problems that
I
7
must be considered, lest they negate the potential
health benefits of economic progress.
Among the litany of issues that factor into
the health of urban societies are environmental
concerns such as air and water pollution, sanitation,
solid waste management, and the very lack of space
that compounds all these problems.
Environmental concerns
The WHO report Water for Life (2005) notes that
almost half of the urban residents in Africa, Asia
and Latin America are suffering from at least one
disease attributable to the lack of safe water and
adequate sanitation. For many urban poor families,
many hours each day are lost carrying water from
distant sources, and the inaccessibility of waler
creates obstacles to basic hygiene around the home,
leading to diarrhoea, worm infections and other
infectious diseases spread via contaminated water.
The quality of the air is also compromised,
especially in slum dwellings. The absence of open
areas and greenery makes urban air vastly inferior
in quality to that which is available freely in rural
areas. The presence of factories and heavier
vehicular traffic within and around metropolises, the
disruption of air circulation by clustered buildings,
and ventilation closed off by houses cramped into
small, unplanned neighbourhoods, all contribute
to air quality that is not only stale, but also more
conducive to the spread of respiratory and airborne
diseases. One study suggests that in Bangkok, as
much as 29% of all cardiovascular disease deaths
may be due to current air pollution.
Down at the level of households, the available
air is tainted, even poisoned, by the burning of solid
fuels. The WHO/UNICEF report Fuel for Life points
out that more than three billion people - more than
half the global population - still depend on solid
fuels including biomass (wood, dung and agricultural
residues) and coal to meet their most basic energy
needs: cooking, boiling water and heating. This
is the reality both in rural and urban areas. The
inefficient burning of solid fuels on traditional stoves
indoors creates a dangerous cocktail of hundreds
of pollutants, and the dilemma that it poses (the
option between a cooked meal or noxious gases) is
aggravated in more confined urban settings, not to
mention compounded by higher risks for fires and
burn injuries.
Clearly, when it comes to what is harder to
access in cities - space, clean air, safe water - it is
easy to see how a lack of resources complicates and
negates the health potential of economic growth, on
the individual and societal levels.
Unmasking health inequity in urban settings
Data displaying health inequalities in urban settings is not routinely reported. There are however, examples to
provide us with strong and compelling evidence of unfair health opportunities. The extraordinary difference in
health status within Nairobi and between Kenya, Sweden and Japan is a case in point. Kenya has on average infant
and child mortality rates 15 to 20 times higher than Sweden and Japan. In Nairobi the average rates are lower than
in Kenya rural areas, yet the city has a strong gradient from poor to rich. In the slums of Kibera and Embakasi the
rates are a good deal worse than rural rates and are three to four times the Nairobi average.
Table 1. Infant and under-five mortality rates in Nairobi, Kenya, Sweden and Japan
Location
Infant mortality rate (IMR)
5
5
Japan
4
5
Kenya (rural and urban)
74
112
Rural
76
113
Urban (excluding Nairobi)
57
84
39
62
High-income area, Nairobi (estimate)
Likely < 10
Likely <15
Informal settlements, Nairobi (average)
91
151
Kibera slum in Nairobi
106
187
Embakasi slum in Nairobi
164
254
Nairobi
IMR = deaths per 1000 new born; U5M - deaths per 1000 children.
8
Under-five mortality rate (U5M)
Sweden
Source: APHRC, 2002
no infrastructure to deal with - floods, landslides
and fire. Urban houses arc more prone to extreme
temperatures, poor ventilation, and they more often
host multiple families. Relative to rural dwellers,
urban residents are also more exposed to biological,
chemical and physical agents like lead, asbestos and
radon, house dust mites and cockroaches.
The industrial areas they work in arc just as
poorly planned and zoned. Major disasters have,
in fact, occurred in metropolitan areas precisely
because industrial and residential areas arc often
too close to each other, if not altogether
Health conditions are on average better in urban areas, but
combined. This is especially true for
averages can deceive. Among urban poor groups, infant and
informal settlements or slum areas. The
child mortality rates often approach and sometimes exceed rural
Bhopal disaster, where 2000 people died
averages (Montgomery et al., 2003; Satterthwaite, 2007a). In
and more than 200 000 were poisoned,
Africa, the continent with the highest infant and child mortality
is one of the more infamous examples
rates, a recent summary of 47 surveys undertaken between 1986
of how the proximity of industries to
and 2000 found the health gradient summarized in the following
the urban poor represents disasters that
chart. (Garenne, 2006).
are waiting to happen.
The more hectic pace in cities,
Under-5 mortality differences accoding to socioeconomic status
and the need to get from one place to
and area of residence, 47 African DHS surveys, 1986-2000
another, also creates a demand for
more transportation. Not coincidentally,
therefore, urban areas carry much of
the traffic, most of the motor pollution,
and most of the road accidents in all
countries.
Even when it comes to food and
diet, urban citizens may have more
choices, more access, and more money
for purchases, but they can actually be
more challenged in nourishment than
their rural counterparts. The health and
nutritional status of the urban poor
may, in fact, be worse than that of the
rural poor, despite the concentration
discussed above. They also lead to more frenetic
of health facilities in cities. Research indicates that
and less managed - riskier and more hazardous
urban infants suffer growth retardation at an earlier
- environments for living. Indeed, the urban poor
age than their rural counterparts, and that urban
often end up living in unsafe conditions. The very
children are more likely to have rickets. While urban
burden of having more people competing for limited
diets are often more varied and include higher levels
space, work and resources increases the incidence
of animal protein and fat, rural diets may be superior
not only of diseases and physical injuries, but also
in terms of calories and total protein intake.
social ills such as illicit drug use, public drinking,
In Asia’s big cities, obesity is a paradox, and a
violence and crime.
growing problem. The overweight often live alongside
Meanwhile, the need to “create” more space
the underweight, sometimes in the same household.
almost inevitably beckons the haphazard
Diseases like diabetes, frequently the result of highconstruction of buildings using cheaper materials.
fat diets, are on the rise as urbanization brings major
Low income families may live in buildings
dietary changes.
characterized by insubstantial and fire-prone
One major problem for those living in cities is
materials, poor foundations, and hazardous
that while there has been relatively little change in
locations. The poor settle on marginal lands
their consumption of fruits and vegetables, there
that are more prone to - and yet have little or
tend to be very7 large increases in edible oils, animal
■’ui urban living is challenged even by I he
things and characteristics it genuinely has in
greater abundance. More people, for starters.
More jobs, more buildings, more roads, more cars,
more factories, and even more food. These are, in
themselves, legitimate indicators of improving
economies and greater options. But in the context
of the health of cities, these objects also qualify,
challenge, and ironically potentially negate the very
progress they are associated with. More economic
activities create the environmental challenges already
9
source foods, and sugar and
caloric sweeteners. Pul simply,
non-traditional and less healthy
- or actually harmful foods
- are more available, even
pervasive, as a result of lower
prices, changing production
and processing practices,
trade, aggressive marketing,
and the rise of supermarkets
and hypermarkets. Processed
foods, ready-to-eat meals and
snacks purchased from street
vendors, restaurant and fast
food outlets have increased
most among urban residents,
magnifying their opportunities
to eat a diet that features
higher intakes of fat, sugars
and energy.
Without policies, gover
nance structures, or proper
investments in infrastructure
to adequately deal with all the
above considerations, cities
demonstrate the adage that
more is not always better.
Cause and effect:
a cycle of social problems
Metropolitan areas all over
the world show an absence of
adequate management and
interventions.
The following problems,
10
Estimates for the proportion of people without adequate
provision for water and sanitation in urban areas, 2000
Sanitation
Water
Region
Number
%
Number
%
(millions)
(estimated)
(millions)
(estimated)
Africa
100-150
35-50
150-180
50-60
Asia
500-700
35-50
600-800
45-60
Latin America
and the
Caribbean
80-120
20-30
100-150
25-40
Source: UN-HABITAT, 2003b
Associated with the health hazards of poor water supply and sanitation,
poor drainage in urban areas is an ongoing problem both in developed and
developing countries. Large amounts of "stormwater” need to be diverted
from residential areas, and flooding is a major risk if drainage is not carried
out efficiently. High population density in urban areas also creates an
increasing problem with regard to solid waste that needs to be disposed
of. In rural areas, much of the waste is reused as compost, or it is burnt
or recycled to meet daily needs. In urban areas this is seldom possible and
accumulations of waste attracts rodents and become health hazards.
Housing and shelter quality: strong health determinants
Sheuya et al. (2006) reviewed the health determinants in relation to housing and associated a number of health
impacts with upstream social determinants. They are relevant both in developed and developing countries.
The Canadian Institute for Health Information (2004) showed the linkages and associations between housing
quality and social determinants of health in the Canadian urban setting. The report showed strong causal
relationships between ill-health and exposure to some of the following biological, chemical and physical agents:
lead, asbestos and radon, house dust mites and cockroaches, temperature and ventilation, and multiple family
dwellings.
Major risk factors of unhealthy living conditions
■
Risk factor
Communicable diseases
NCDs and injuries (including
mental health issues)
Defects in
buildings
Insect vector diseases
Rodent vector diseases
Geohelminthiases
Diseases due to animal faeces
Diseases due to animal bites
Overcrowding-related diseases
Dust and damp and
mould-induced diseases
Injuries
Burns
Neuroses
Violence and delinquency
Drug and alcohol
abuse
Defective water
supplies
Faecal-oral (waterborne and water-washed)
disease
Non-faeco-oral, water-washed and
water-related insect-vector diseases
Heart disease
Cancer
Defective
sanitation
Faecal-oral diseases
Taeniases and helminthiases
Insect- and rodent-vector diseases
Stomach cancer
Poor fuel/
defective
ventilation
Acute respiratory infection
Perinatal defects
Heart disease
Chronic lung disease
Lung cancer
Burns
Poisoning
Poor refuse storage
and collection
Insect-vector diseases
Rodent-vector diseases
Injuries
Burns
Defective food
storage and
preparation
Excreta-related diseases
Zoonoses
Diseases due to
microbial toxins
Cancer
Airborne excreta-related diseases
Enhanced infectious respiratory disease risk
Chronic lung disease
Heart disease, cancer
Neurological/reproductive diseases
Injuries
Psychiatric organic
disorders due to
industrial chemicals
Neuroses
Poor location
(near traffic,
waste sites,
industries, etc)
Adapted from WHO, 1997a
11
4cr quality: strong health
Het?
,; .•••;*. •<
Shev
: eviewed the health determinants in relation to housing and associated a number of health
impact-'
.earn social determinants. They are relevant both in developed and developing countries.
The Cat:c '.
'.s jtute for Health Information (2004) showed the linkages and associations between housing
quality and social determinants of health in the Canadian urban setting. The report showed strong causal
relationships between ill-health and exposure to some of the following biological, chemical and physical agents:
lead, asbestos and radon, house dust mites and cockroaches, temperature and ventilation, and multiple family
dwellings.
Major risk factors of unhealthy living conditions
Risk factor
Communicable diseases
NCDs and injuries (including
mental health issues)
Defects in
buildings
Insect vector diseases
Rodent vector diseases
Geohelminthiases
Diseases due to animal faeces
Diseases due to animal bites
Overcrowding-related diseases
Dust and damp and
mould-induced diseases
Injuries
Burns
Neuroses
Violence and delinquency
Drug and alcohol
abuse
Defective water
supplies
Faecal-oral (waterborne and water-washed)
disease
Non-faeco-oral, water-washed and
water-related insect-vector diseases
Heart disease
Cancer
Defective
sanitation
Faecal-oral diseases
Taeniases and helminthiases
Insect- and rodent-vector diseases
Stomach cancer
Poor fuel/
defective
ventilation
Acute respiratory infection
Perinatal defects
Heart disease
Chronic lung disease
Lung cancer
Burns
Poisoning
Poor refuse storage
and collection
Insect-vector diseases
Rodent-vector diseases
Injuries
Burns
Defective food
storage and
preparation
Excreta-related diseases
Zoonoses
Diseases due to
microbial toxins
Cancer
Airborne excreta-related diseases
Enhanced infectious respiratory disease risk
Chronic lung disease
Heart disease, cancer
Neurological/reproductive diseases
Injuries
Psychiatric organic
disorders due to
industrial chemicals
Neuroses
Poor location
(near traffic,
waste sites,
industries, etc)
Adapted from WHO, 1997a
11
• \ factors in as well as results
c!
. \t: crime and violence, mental
illncs .
depression, substance abuse, road
traffic ciurban migration, the exploitation
and marginalization of migrants, women and
children, and even climate change. All of these tend
to have magnified incidences and impacts in cities,
emerging as both causes and effects in a cycle of
social problems.
Violence and crime
Poverty and underdevelopment themselves
undermine peace and order, of course, but the very
design and management (or lack thereof) of the city
environm • u . ■
. ^acerbate the chances of
crime and viol< ■'-< taking place.
Due to poor planning, weak infrastructure, lack
of police presence, or even, just bad street lighting,
there are spaces in cities where rape, robbery and
violent crime have higher probabilities of unfolding.
This reality has many costs, whether in high-income
or developing countries. Violence and crime can
undermine a city’s economic prospects. Beyond
this, fear and insecurity pervade people’s lives, with
serious implications for trust and well-being among
community members. Precisely because crime is
often associated with poverty (and violence with
desperation), the poor in cities get isolated in their
homes while the rich keep to their own
segregated spaces.
Annual growth rate of urban people living in slums, 1990-2001
Mental health, loneliness
and depression
Goal 7, Target 11 of the Millennium Development Goals is:"...by
2020, to have achieved a significant improvement in the lives
of at least 100 million slum dwellers.” Other MDGs also deal
with conditions of importance to health (although the extent of
urbanization is often not taken into account as the context of the
goals), most of which are the result of social determinants. If the
MDGs are achieved, many slum dwellers will benefit, but even
the 100 million target is modest considering the rapid growth of
slums. Sub-Saharan Africa is the world’s most rapidly urbanizing
region, and almost all of this growth has been in slums. This is also
the case in Western Asia. The rapid expansion of urban areas in
Southern and Eastern Asia is creating cities of unprecedented size
and complexity with new challenges for providing decent living
conditions for the poor. Northern Africa is the only developing
region where the quality of urban life is improving by this measure:
in this region, the proportion of city dwellers living in slums is
decreasing by 0.15% annually (World Bank, 2006a).
12
Because the urban poor must
contend not only with their daily
survival struggles, but also with social
stigma, isolation and marginalization
- not to mention the pervasive violence
discussed above - their insecurity and
poverty are compounded by increased
vulnerabilities in their mental health.
Community-based
studies
in
developing countries show that 1251% of urban adults suffer from some
form of depression, and that among the
underlying causes of poor mental health
in urban areas are lack of control over
resources, longterm chronic stress,
exposure to stressful life events and
lack of social support.
Money and employment issues, high
costs of living, harsh living conditions,
and physical exhaustion from lack of
convenient access to transport further
aggravate chronic stress and predispose
individuals and families to mental
health problems.
In Dhaka for example, a comparison
of mental health status between slum
and non-slum adolescents shows low
self-reported quality of life and higher
“conduct problems” among males living
in slum areas.
Substance abuse: Smoking,
drinking and drugs
Both the violent and criminal climates
as well as the mental stressors in cities
in turn feed into another social ill: substance abuse,
including smoking, drinking and the use of illicit
drugs. Chronic stress and easy access to harmful
products in the urban setting create additional risks
for substance abuse and dependency.
The most recent health statistics suggest that
because smoking is most prevalent in the lowest
income households in developing countries,
populations that live in poverty in the urban setting
would also be likely to exhibit higher prevalence rates
of tobacco use. Ironically, however, they would also
have less access to health care, thus perpetuating
the vicious cycle of illness and poverty.
Meanwhile, excessive alcohol consumption
is both a symptom and a cause of poor mental
health. It causes several types of physical ill-health
(e.g. damage to the liver and nervous system, and
increased risk of injuries), which, combined with the
mental health problems, undermine the personal
and family economy and aggravate poverty.
In some countries, such as Russia, the results
of high alcohol consumption have been dramatic,
significantly reducing average life expectancy in
recent years.
It can therefore be a major factor in health
inequalities between different population groups.
In some countries, the negative health impact of
alcohol consumption is as large as that of tobacco
smoking.
Road traffic injuries
WHO says that worldwide around 1.2 million
people are killed in road traffic accidents every
year. The annual number of injured could be as
high as 50 million. Developing countries already
account for more than 85% of all road fatalities,
their pedestrians, passengers, and drivers suffering
from poor infrastructure, weak law enforcement,
and compromised traffic regulations (which are
particularly lacking in low income communities).
All these problems are bound to worsen because of
urbanization.
Most cars and roads are concentrated in cities,
and the World Bank predicts that the number of cars
and motorcycles in cities will increase by a factor
of four by 2050. But it is not just about the number
of people and number of vehicles. China’s rate of
road deaths is 15.6 per 100 000, despite the fact
that the number of China’s vehicles in relation to
population is low compared with the USA, which,
despite having one of the world’s highest vehicleto-population ratios, has a road death rate of just
5.6 per 100 000. Thailand and the Republic of Korea
have worse rates still at 20.9 and 22.7 deaths per
100 000, respectively.
Once again, it is the urban poor who bear the
brunt of this impact. As cities and countries are still
developing, the poor tend to be hurt as pedestrians
and cyclists.
13
A web of interlinking determinants
A conceptual framework for urban health was suggested by Vlahov et al. (2006) and was adapted for the report.
The core concept is that the social and physical environments that define the urban context are shaped by
multiple factors and multiple players at multiple levels. Global trends, national and local governments, civil
society, markets and the private sector shape the context in which local factors operate. Thus, governance
interventions in the urban setting must consider global, national and municipal determinants (left) and should
strive to influence both the urban living and working conditions as well as intermediary factors that include
social process and health knowledge. The framework assumes that the urban environment in its broadest
sense (physical, social, economic, and political) affects all strata of residents, either directly or indirectly.
Interventions can also work upwards to influence the key global, national and municipal drivers. The health
sector has an important role to play, for instance via the "healthy cities” approach.
A conceptual framework for urban health
Urban living/
working
conditions
Intermediary
factors
Empowerment
and capacity to
participate
Physical
environment
Social support
networks
Housing quality
Infrastructure
Services
Access to health
and social
<
services
And even as their communities earn more
purchasing power, they remain at a higher risk, as
their preferred mode of transportation shifts to
private motorcycles, which again have a higher risk
factor than cars, highlighting the difference between
rich and poor.
Climate change
Many major cities in the world are located on the
coast or along rivers and are vulnerable to climate
change because of rising sea levels, changes in ram
patterns, and flooding. In Mumbai, several million
poor people live in squatter settlements prone to
flooding. In Rio de Janeiro the most at risk arc those
in low income settlements on hillsides vulnerable to
landslides and flash floods. In Shanghai most people
live in low-lying areas, and Yangtze River floods
have in fact already caused massive health and
economic impacts in recent years. Ironically, these
megacities are also at risk of waler shortages due
to climate change. As rainfall variability increases,
14
1 r
Exclusion and
inclusion of
vulnerable groups
Health
Outcomes
Health-relate
knowledge
Health seeking
behaviour
water sources dry7 up. Meanwhile, floods tend to
contaminate water sources.
Beyond water concerns, heat waves are an
obvious concern in a hotter climate. They affect all
populations, but in cities their effects are exacerbated
by the urban “heat island” effect, resulting from
lowered evaporative cooling, increased heat storage
due to the lack of trees and vegetation, and the hard,
heat-generating features of the cityscape. Most cities
show a large heat island effect, and are thus generally
warmer than surrounding rural areas by 5’C to ll’C.
Higher temperatures increase health risks and lower
the productivity of people. Incidences of heat stroke
rise. Elderly without access to running water and
proper healthcare are particularly weakened and
vulnerable..The irony is that the vast majority- of the
people at risk - the urban poor - have contributed
least to the ongoing global climate change. Air
conditioning (which contributes to the heat island
effect), for example, is generally not within the
arsenal of poorer households to reduce the health
ris
d by warmer ditn< • . Fh
po-- own productivity decreases, while their
susceptibility to heat-induced illnesses and injuries
increases.
by urban pressures. Immigrants, for example,
whether coming in from rural areas, other cities, or
even other countries, are often the first and most
dominant inhabitants of slums. Driven out of one
community to another, ethnically, culturally, or
Highly vulnerable sectors: woman,
religiously defined communities can all too easily
children, the disabled, and migrants
fall into ghettos, still far from the opportunities
One of the ultimate ironies of the current urban
they seek.
story is how city life can create and exacerbate
Meanwhile, like immigrants, women, children,
vulnerabilities among people drawn to them
and the disabled face particular disadvantages and
for opportunities. Certain segments of society
vulnerabilities in the urban setting.
are particularly at risk, finding the very societal
The difficulties faced by women and children arc
biases they are trying to escape further magnified
particularly intertwined. Consider that in East and
South-East Asia, up to 80% of the workforce in
export-processing zones is female. This raises
the question: Who takes care of the children
The poor need cleaner household fuels
while
the women are at work? Adequate child
The WHO report Fuel for Life points out that more than
care
is
rare among urban poor families whose
three billion people, living in both rural and urban areas,
women are in the labour force. For that matter,
depend on solid fuels including biomass (wood, dung
child care is compromised even when urban
and agricultural residues) and coal to meet their most
poor women are managing households.
basic energy needs: cooking, boiling water and heating.
As in rural settings, it is still urban
The inefficient burning of solid fuels on an open fire or
women, usually, who must make up for cities’
traditional stove indoors creates a dangerous cocktail of
weak infrastructures and fetch water, gather
hundreds of pollutants. These families are faced with a
firewood and buy food and other resources
terrible dilemma: cook with solid fuels, or pass up a cooked
for the home. Urban poor children, then, are
meal. With increasing prosperity in some regions, cleaner,
often literally left to fend for themselves.
more efficient convenient fuels are gradually replacing,
Schools, already inadequate and inaccessible,
traditional biomass fuels, coal and other less efficient and
fall in families’ priorities. Children take to
more polluting energy sources.
the streets to beg or make a living hawking
cigarettes, food, flowers or trinkets, in any
Proportion of urban poor and rich using solid fuels
case susceptible to exploitation, crime, road
in the household, 2003.
accidents, violence, smoking, drinking or
substance abuse.
When urban females also happen to be
young, the double vulnerability to exploitation
and abuse is especially magnified. Prostitution
and sexual abuse are high in urban settings,
as are incidences of HTV/A1DS and other
sexually transmitted diseases. UNAIDS (2006)
estimates that average urban HIV prevalence
is 1.7 times higher than it is in rural areas,
and that the prevalence is also considerably
higher among girls than among boys.
Finally, people with disabilities such
as blindness, deafness and paraplegia
are also likely to be vulnerable to health
threats associated with social exclusion or
discrimination. These vulnerabilities may
be most prominent in urban areas due to
the challenges of a high population density,
crowding, unsuitable living environments (c.g.
high staircases, road curbs, intense traffic)
Source: Rehfuess, 2006
and lack of social support.
15
Social determinants of great importance in the spread of the HIV/ASDS pandemic
HIV/AIDS accounts for about 17% of the burden of disease in Sub-Saharan Africa, and it is a major reason for
the deteriorating health outcomes in some African countries (Goesling and Firebaugh, 2004). As illustrated
below, the prevalence is generally higher in urban areas. UNAIDS (2006) estimates that average urban HIV
prevalence is 1.7 times higher than the rural rate. The prevalence is also considerably higher among girls
than among boys. Especially in urban areas, young women are at particular risk due to different aspects
of gender discrimination (Van Donk, 2006). As a sexually transmitted disease, HIV/AIDS clearly has social
determinants. These social determinants go well beyond the obvious link to sexual behaviour, however.
Indeed, a tendency to focus narrowly on voluntary sexual behaviour, and the ABC admonition to "Abstain,
Be faithful, use a Condom”, has undermined interventions to reduce the spread of HIV/AIDS (Ambert et al.,
2007; Mabala, 2006; Van Donk, 2006).
HIV prevalence (%) for selected sub-Saharan African countries
15-49 years old, by urban/rural residence
□ urban
rural
Many of the poverty-related conditions that contribute to the spread of other infectious diseases, also
contribute to the spread of HIV and the progression to and impact of AIDS. Malnutrition lowers immunity and
increases viral load in HIV-infected persons, making them more contagious (Stillwaggon, 2006). Helminths
(worms) associated with bad sanitation make people more susceptible to HIV, speed up progression to AIDS,
and greatly increase the transmission of HIV from mothers to babies (Ambert et al., 2006).
A range of urban conditions influence the spread of HIV or the severity of the illness:
•
•
•
•
•
Overcrowding and high population density
Inequitable spatial access and city form
Competition over land and access to urban development resources
Pressure on environmental resources
Pressure on urban development capacity and resources
Some of the most important social determinants relate to the position of women in society, and the
physical space and authority girls have to protect themselves from unwanted sexual overtures, harassment
and rape (Mabala, 2006; Van Donk, 2006).
The WHO report Water for Life (2005a) describes the dire situation for poor people without access to
water. Diarrhoea, worm infections and other infectious diseases spread via contaminated water, and lack of
water creates difficulties for families to carry out basic hygiene around the home. Almost half of the urban
population in Africa, Asia and Latin America is suffering from at least one disease attributable to the lack of
safe water and adequate sanitation (Table 2) (WHO, 1999; UN-HABITAT, 2003; Garau et al., 2005). In addition,
lack of convenient access to drinking water means that many hours each day may be wasted on carrying water
from distant sources. It is mainly women and girls that end up doing these chores. Proper sanitation is just as
important for keeping infectious diseases at bay (WHO, 2005a). Women and girls are again vulnerable as many
of them, for reasons of culture and modesty, will not attend to their sanitary needs during daylight hours if they
are forced to use a communal latrine due to lack of household toilets.
16
What needs to be done
ust as economic, environmental and sociopolitical
factors interlink to aggravate problems in urban
health, so are the solutions to these challenges
diverse, complicated and tied to each other. There
is a broad spectrum of interventions that must be
implemented and coordinated to create truly healthy
cities.
People must be educated on their own
environment, risks, rights, responsibilities and
capabilities. Communities must be organized and
empowered. And leadership in all sectors and at
all levels must be circumspect in planning, policy
formulation and infrastructure investments. Creating
heathy housing and neighbourhoods is a priority,
b u t“tlie~hon6rT of “he a 11 h^z communities” must b e
clear? This Includes theprovision oFcTrmkmg water
and sanitation, improved energy supply and air
pollufioh~cbntrol. Governments and communities
need to promote and~~facilitate good^nutritiorTand'
physical activity aswell asTreate~safer ancThealtfSer
workplaces. MeanwhileTnRmy communities require
effective actions to prevent and mitigate against
social ills such as urban violence and substance
abuse^
Such recommendations, of course, are not new.
There have been many international documents
such as the 1987 Brundlland Report (also known
as Our Common Future), the UN’s Agenda 21 in
J
1992, the UN-HABITAT II report in 1996, and the
Johannesburg Summit on Sustainable Development
in 2002, that have time and again reiterated the
need for holistic interventions for healthy societies.
And yet while the UN Millennium Summit in 2000
and the Millennium Development Goals have spelt
out a minimum agenda for action, most of the
recommended and proven policies are not pursued.
For example, one of the MDGs is, by 2020, “to have
achieved a significant improvement in the lives of
at least 100 million slum dwellers”. Slx years after
the MDGs were launched, however, national and
international investments to address issues of urban
inequity have been limited, and consequently, urban
growth in developing countries continues to result
in the growth of slums.
One major problem for urban reformers all over
the world is that even good politicians and leaders
face significant constraints in their effort to bring
about change. They are constrained by the very
weakened environment they must attend to. They are
hamstrung by a lack of resources. They stumble and
wade through rhe same crumbling and inadequate
infrastructure upon which their citizens try to live
and navigate a living. In the meantime, while they
work for reform, they must also pragmatically make
do with the legacy of decades of bad governance and
weak policies still in place. Finally, there are the very
17
Slum upgrading in Thailand
iie Fhai government is implementing one of the most ambitious upgrading initiatives currently underway
(Boonyabancha 2005). Managed by the Thai Government’s Community Organizations Development
Institute, the initiative channels government funds in the form of infrastructure subsidies and housing loans direct
to community organizations formed by low-income inhabitants in informal settlements who plan and carry out
improvements to their housing and to water and sanitation or develop new housing. It has set a target of improving
housing, living and tenure security for 300 000 households in 2000 poor communities in 200 Thai urban centres.
This initiative has particular significance in three aspects: the scale; the extent of community involvement; and
the extent to which it seeks to institutionalize community-driven solutions within local governments so that they
address needs in all informal settlements in each participating urban centre. It is also significant in that it draws
almost entirely from domestic resources - a combination of national government, local government and community
t-
contributions.
characteristics of the communities they are trying
to help. Ill-fed, sick, under educated, marginalized,
divided and disenfranchised in unplanned, poorly
managed environments, the social capital that
leaders will ultimately rely on is itself in dire need of
healing and rejuvenation.
The challenges facing an urbanizing world
seem daunting and they are certainly complex.
Another way of putting this, of course, is that the
litany of challenges already discussed above is also
an outline of the interventions that, experts say,
urban reformers must pursue if they are to succeed.
Investments in this broad spectrum of interventions,
coupled with fairer distribution of resources, are
vital.
Acknowledging and highlighting resources
What must be stressed is that substantial
experience and adequate resources for such
interventions are already available. Even financially,
with a gross world product of USS 40 trillion per
year, the capital needed to eliminate intolerable
living conditions for the urban poor and significantly
reduce health inequality is achievable. Notably, $30
trillion of this global economic output comes from
affluent countries alone, and this figure is rising
at more than $1 trillion per year. Health and
development experts note that the mobilization
of a mere 20% of this annual increase in average
economic output of developed nations would be
enough to support health equity programmes
in low7 income countries. And yet most OECD
countries fail to deliver on the recommendation
to allocate 0.7% of annual GDP to international
development cooperation funding.
The question therefore is not whether
societies have the material and social capital to
18
effect change, but whether its members and leaders
are willing to invest and mobilize these resources in
creating fair and equitable opportunities for health
for all people of all nations.
Empowering the people
At the city level, there is an increasing emphasis
among governments, donors and urban development
experts on empowering urban residents, the urban
poor most especially. Without their participation and
empowerment through education, network building,
capacity building, and grassroots organizing,
communities and residents are themselves the
weakest link in their own chain of aspirations.
Thailand, for one, has therefore invested heavily
in what it calls the Community Organizations
Development Institute (CODI), w'hich over the
years has demonstrated the power and potential of
organized communities. Among other initiatives,
CODI channels government funds in the form of
infrastructure subsidies and housing loans direct
to community organizations formed by low-income
inhabitants in informal settlements. It is the
members of the community who plan and carry out
Health and development experts
note that the mobilization of a mere
20% of this annual increase in average
economic output of developed nations
would be enough to support health
equity programmes in low income
countries.
• s to lheirhousin ,
<{,m.
• lop new housing a; • - • • ■
idia, the Comrnitu
Resource
Organ-.ions (CORO) networked with other like
minded organizations to provide technical support,
research and advocacy to its members among urban
residents. These services have enabled members to
access better housing. In South Africa, a group-based
microfinance scheme combined with a participatory
learning and action training programme has helped
to raise household incomes and people’s options for
services.
Such examples show clear benefits to recognizing
the value of social capital as part of a wider health
and social sector programme. The development of
social capital - the fostering of what experts call
“social cohesion”, a process of developing shared
values, shared challenges and equal opportunities
within a community - is especially significant in that
it allows communities and citizens to compensate
for weak and dysfunctional government structures.
The CODI experience in Thailand, for example,
is notable not just for its scale. It is also exemplary
for the extent of community involvement it features,
and the extent to which it seeks to institutionalize
conununity-driven
solutions
within
local
imp
Or' k
governments. Il is also significant in that it draws
almost entirely from domestic resources. Such
examples demonstrate how an urban society needs
its own people to sec themselves not as trapped
victims, nor even simply as opportunity seekers, but
rather as active stakeholders - the most important
ones - in the improvement of their environment.
Community participation is and will always be key
in all other interventions that urban societies need.
Emphasizing multiple
and simultaneous interventions
Since 1996, UN-I-IABITAT has been documenting
interventions that effectively address the most
critical health and other problems in human
settlement development. The database includes
more than 1700 initiatives from nearly 200 countries,
but an analysis of the best practices suggests that
interventions concerning the environment, housing,
urban governance and urban planning - in that order
- are the proven priorities.
Building healthier environments
lor living and working
------ It is uniortunatethat-the traditional challenges
of access to clean and sufficient drinking water,
19
appror :i
wstems, safe and
efficients
•• >•. stems, and safe
and health'
j
. ... to be major problems
for one bidie:.: i
bvmg in deprived areas in
cities around the world.
The urban environment, after all, is a product of
a web of factors and interventions, and the benefits
of investments in improving it therefore come in
ways that are not always appreciated at first glance.
Improving water, sanitation, housing and the air,
ultimately leads not just to physical well being, but
Example of an urban cash
transfer programme:
Mozambique’s Food
Subsidy Programme
When the programme was designed,
beneficiaries of the Food Subsidy
Programme were to be those who were
extremely food insecure”, i.e.," consuming
only 60% of their minimum caloric
requirements”. Programme designers argued
that” inadequate food consumption in urban
areas is principally due to lack of purchasing
power and therefore, a cash transfer was
judged to be the appropriate intervention”. In
each urban center of Mozambique, the money
needed to pay all registered beneficiaries of
the INAS Food Subsidy Programme is deposited
into a dedicated bank account and withdrawn
each month by local INAS officials, under
police escort. Distribution occurs at various
" pay points" around town. Sometimes these
are under a tree in the open air. No pay point
should be further than 30 minutes’ walk
from a beneficiary’s home. Official identity
documents (including birth certificates to
verify age) must be produced, firstly to
enroll on the INAS programme and secondly
to collect benefits. Where necessary, INAS
officials assist applicants to obtain these
documents, including getting photographs
taken and completing the forms. Payments are
usually made on the same day each month,
and waiting times range from under half an
hour to two hours but can take longer. This
regularity and predictability is appreciated by
beneficiaries, who point out that they depend
on the money and that it helps them to plan
their spending if they know the money is
definitely coming on a certain day. Sources:
He IpAge, IDS and SCF-UK, 2005
to deeper
'.:ial concerns, such
as empioymi:
education, social
opportunities, and even peace and order.
One study concludes that in developing regions
the benefit of a $1 investment in improved water
supply has a value ranging from $5 to $28. Clean
water, after all, affords people healthier bodies,
better food, more sanitary households, more
sanitary habits, stronger and livelier children, and
more productivity in their work. Efforts to lower
air pollution in cities, similarly, lead to a range
of healthy developments that are not always as
obvious or as expected as, say, lower incidences of
respirator diseases in the urban population. For
example, it has been found that more people walk
or use bicycles as a result of cleaner air, and not
just as contributing factors to clean air. This then
mitigates against another scourge of urban living:
less opportunities and space for exercise. In slum
areas, encouraging residents to shift from burning
biomass and charcoal to more efficient modern
fuels, such as kerosene, liquid propane gas and
biogas, not only brings about the largest reductions
in indoor smoke; it also cuts the amount of fuel
needed, minimizes the risk of fires and burns, and
can actually result in more savings that can go to
other health needs.
Outside of homes, because urban air quality
is most notoriously linked to vehicle exhaust,
interventions for better air inevitably lead to
investments in more efficient public transport
systems, which in turn have the added benefit of
reducing road accidents.
Upgrading cities
Indeed, the concept of healthy cities recognizes
that investments in crucial interventions trigger a
cascade of other desirable characteristics for urban
communities. Creating a healthier living environment
looks not just at housing, but also the need to make
workplaces and other centres of civilian activity safer
Bangalore, India: UNU
20
and more safely accessible for
Cameroon, 57% of the
A raft of social interventions
their intended purpose. Put
population is employed in the
another way, a neighborhood
- from reducing urban
informal sector, as are three
or a community is not just
quarters of those employed in
violence and substance
a cluster of houses. The
the city of Karachi, Pakistan.
complete picture includes
In most sub-Saharan African
abuse to fighting
schools, hospitals, police,
countries, the informal sector
communicable diseases
places of work as well as
dominatesurbanemployment;
recreation, accessible markets,
- themselves become easier in countries such as Mali,
good roads, adequate drainage
Uganda and Zambia, over
to deliver and realize, given
and sewage, and the fact that
70% of urban workers are
leadership benefits from the
informally employed.
an overall environment
healthy participation of its
Acknowledging
all
more conducive to positive
communities then - including
citizens.
informal settlements and
Even the way informal
change.
slums - as potential and actual
settlements are now dealt
contributors to local economies further validates the
with shows that governments are learning this
holistic healthy cities approach to managing urban
key lesson. Traditionally, governments have four
areas. Such a holistic approach benefits individual
different options in relation to slums: remove them,
and societal productivity, which improves people’s
upgrade them, prevent them or ignore them. Most
finances and the community’s economy, leading in
governments implement a mixture of these - though
turn to such rewards as more food security, more
few actually have the policy, plans and capability to
accessible health services and then, in a virtuous
prevent them - but upgrading is now recognized
circle, to more individual and societal productivity.
as the most effective way to improve conditions in
With the interplay between the empowerment
most instances.
of rhe people, as mentioned above, and a more
One reason is because it is cheaper to build onto
enlightened and confident regime of circumspect
existing investments. Upgrading also avoids the
leadership and policies, cities worldwide see that
dislocations that impact on people's livelihoods and
their financial, social and material investments
social networks. But most important, this trend of
pay off socially - and in all of these respects, more
upgrading recognizes the importance of the informal
sustainably. A raft of other social interventions economy (and implicitly, “informal housing”) for
from reducing urban violence and substance abuse
cities’ economies. In Accra, the ratio of informal
to fighting communicable diseases - themselves
to formal workers is seven to one. In Yaounde,
21
Supporting grassroots-driven
improvements: The International
Urban Poor Fund
Over the last six years, an International Urban Poor Fund has helped low-income urban dwellers to
secure land for housing, either through obtaining tenure of land they already occupy or on alternative
sites, and assists them to build or improve their homes and access basic services. Since this Fund was initiated
with the support of the Sigrid Pausing Trust, it has channelled around $4.6 million (£2.6 million) to over 40
initiatives in 17 countries.
The funding allocations are small - typically $10 000-50 000. The initiatives seek to keep down unit costs,
which can be as little as one-seventh of that of professionally-managed initiatives. Community members
contribute their savings and labour and where possible use this external funding to leverage contributions
from local government. Supported activities include:
•
Tenure security (through land purchase and negotiation) in Cambodia, Colombia, India, Kenya,
Malawi, Nepal, Philippines, South Africa and Zimbabwe.
•
Slum”/squatter upgrading with tenure security in Cambodia, India and Brazil.
•
Bridge finance for shelter initiatives in India, Philippines and South Africa (where government
support is promised but slow to be made available).
•
Improved provision for water and sanitation in Cambodia, Sri Lanka, Uganda and Zimbabwe.
•
Settlement maps and surveys in Brazil, Ghana, Namibia, Sri Lanka, South Africa and Zambia.
•
Exchange visits by established federations to support urban poor groups in Angola, East Timor,
Mongolia, Tanzania and Zambia, and develop initiatives.
•
Community-managed shelter reconstruction after the tsunami in India and Sri Lanka.
•
Federation partnerships with local governments in shelter initiatives in India, Malawi, South
Africa and Zimbabwe.
The Fund is unusual in that funding goes directly to grassroots savings groups who have a central role in project
development and management and who manage the political process, persuading local politicians to have an
interest in the work but preventing them from controlling activities. In addition, decisions about what should
be funded are made by the federations of slum and shack dwellers, through their own international umbrella
group (Shack Dwellers International). Source: Mitlin and Satterthwaite, 2007
become easier to deliver and realize, given an
overall environment more conducive to positive
change.
Promoting healthy urban
governance, management and planning
What will accommodate all these changes is
good governance. Empowered and enlightened
leadership at local levels is just as important as
policy reform. To help the one billion people who
live in informal settlements today (and to avoid a
1 billion increase in the number of people living
in such conditions in the next 25 years), bold
steps are needed to improve urban governance
so as to enhance and facilitate all of the above
interventions.
Governance does not just mean “government”.
There is a need to educate and raise the capacity
of formal leaders at every level of government,
just as much as they should learn to appreciate
the value of their citizens’ being organized and
allowed to participate in community building.
22
Crucially, good governance can have a positive
impact on urban health even before spending and
investments lake place. By recognizing the simple
power of planning, and by then setting priorities and
directions, good governance practices can already
change and protect people’s lives.
Nakuru, Kenya
urban governance" is . . ■ • ! : .<on
for
. sful action. Participant.”; approaches
can create ownership and empowerment if specific
interventions arc aligned with the community’s
expressed needs and demands. Il is important
to ensure that resources, including finances, are
available from within and outside the community.
This creates “hope” for improvements. Among the
proven elements for building good governance arc:
Assessing the urban context, as in
understanding how urbanization itself
affects social and health issues.
Identifying stakeholders, as in clarifying
the people, groups and organizations that
have interest and control over urban health
concerns and factors.
Developing the capacity of stakeholders
to take action and build social capital and
cohesion, because any action involving policy
change requires that sufficient knowledge,
skills and resources are in place.
Assessing
institutions
and creating
opportunities to build alliances and ensure
intersectoral collaboration, since it is
institutions that determine the frameworks
in which policy reforms take place, and
it is institutions that can safeguard such
improving policy environments.
Mobilizing
resources
necessary
for
social change. This may require better
redistribution of resources.
Implementation including strengthening the
demand side of governance: assessing and
ensuring people’s participation from the
organizational and legal perspective, taking
into account their need and right to have
access to information, and also factoring in
the need for government transparency and
social accountability.
Advocacy for up-scaling and change of policy
and advocacy to relevant stakeholders at
different levels.
Monitoring and evaluating of process and
impacts including opportunities for setting
up systems for monitoring at an early
stage.
Enabling and sustaining more
equitable health systems and societies
Finally, the challenge lies simply in the reminder
that for the sake of sustaining any positive changes,
all interventions must somehow be made to
strengthen and benefit each other. Resources must
be accessible and beneficial to all. Community
participation brings lasting solutions. But then real
participation can only be created within the realm
of good, “healthy”
governance.
When
all actors and_factoxs
come together, only
(Tien will urban health
equity be achieved.
Optimizing positive
determinants
and
creating_____ synergy
between ^health, the
urban environment;
governance
and
society creates and
contributes to liTi
enabling environment
for more effective
and efficient health
systems. This would
also ensure that all
benefits - primary
health care, healthy
cities, responsive go
Shanghai, China
vernance, productivity
and opportunities - are equitable. Where the benefits
arc adequate and accessible to all, social, political,
and material capital is constantly replenished,
paving the way for truly sustainable and equitable
health systems and societies.
23
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