Susan Mercado, Kirsten Havemann, Keiko Nakamura, Andrew Kiyu, Mojgan Sami, Roby Alampay, Ira Pedrasa, Divine Salvador, Jeerawat Na Thalang, Tran Le Thuy

Improving Urban Population Health Systems CENTER FOR SUSTAINABLE URBAN DEVELOPMENT | JULY 15-20, 2007

Responding to the Health Vulnerabilities of the Urban Poor in the “New Urban Settings” of Asia SUSAN MERCADO, KIRSTEN HAVEMANN, KEIKO NAKAMURA, ANDREW KIYU, MOJGAN SAMI, ROBY ALAMPAY, IRA PEDRASA, DIVINE SALVADOR, JEERAWAT NA THALANG, TRAN LE THUY

Acknowledgement governance need to be continuously applied to Background document prepared by the WHO the promotion and protection of health. There is Centre for Health Development in collaboration no “one-size-fits-all” solution, and actors will with the Alliance for Healthy Cities and in need to continuously navigate a fast-changing cooperation with the Southeast Asian Press environment in order to achieve results. Change Alliance for the Rockefeller Foundation Global is best facilitated through nodes of power and Urban Summit, 2007 influence among the urban poor, local governments and the public health sector that Disclaimer are growing and establishing cross-linkages This work was undertaken as work for the beyond geopolitical regions. National decision- Rockefeller Foundation Global Urban Summit, makers can create more supportive and enabling 2007. The views presented herein are those of environments for achieving fairer health the authors and do not necessarily reflect the opportunities for all by rendering visibility to the decisions, policies or views of the World Health health vulnerabilities of the urban poor through Organization. the skilful framing of public policy issues.

Abstract Executive Summary Rapid and unplanned urbanization in Asia has Asia is home to 60% of the world’s population. profound implications for population health. In the next few decades, estimates are that more With globalization, failure of governance has than 60% of the increase in the global urban resulted in inequities that translate into health population will also be in Asia. In a rapidly impacts that are most severe for the urban poor. urbanizing environment, different groups of Urban poverty and the growth of slums, informal people may be exposed to a wide range of risks settlements and squatter areas pose obvious from communicable and noncommunicable hazards and risks to health. Asia is one of the disease as well as violence and injuries. Different most rapidly urbanizing areas of the world with groups exhibit varying degrees of vulnerability or 60% of the global slum population or an exposure despite the fact that they “live in the estimated 550 million people who exist in same city”. These varying vulnerabilities are deprived, unsafe and unhealthy living conditions. translated into unequal physical and mental This paper reviews the literature on health in the health outcomes. The most extreme end of the urban settings of Asia and identifies examples of health inequity gradient in cities includes people interventions and innovations that reverse unfair in low-income informal settlements (“slums”1). health opportunities. Multiple sources of Currently, it is estimated that 60% of the world’s information and a broad range of indicators informal settlers and slum dwellers are in Asian (covering governance, health systems, cities. In South Asia, slums and squatter environmental health, political development and settlements constitute 58% of the total urban community participation) are used to population, compared to 36.4% in East Asia and complement existing knowledge on health impacts. Key innovations are summarized under six themes: 1) the urban poor as key drivers and 1 decision-makers in community upgrading; 2) There is no universal agreement on the definition of what a “slum” is, but for purposes of this paper, the local governments holding themselves general definition used by UN-HABITAT is “a wide accountable for healthy urban settings; 3) using range of low-income settlements and/or poor human infectious disease outbreaks as opportunities for living conditions.” (UN-HABITAT, 2003). These strengthening public health infrastructure; 4) deprived areas are further characterized by the improving efficiency in health promotion following attributes: a) lack of basic services; b) financing in cities; 5) applying information substandard housing or illegal and inadequate building technology to population health activities; and structures; c) overcrowding and high density; d) 6) optimizing social determinants of health in unhealthy living conditions and hazardous locations; urban settings. Within an evolving notion of e) insecure tenure, irregular or informal settlements; “healthy urban governance”, principles of good and f) poverty and social exclusion.

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28% in Southeast Asia. In absolute figures this The role of key players – the urban poor, local translates to more than 550 million people. governments and urban health systems – are noted throughout the paper. Innovations in This paper reviews the literature on health in the population health that impact the urban poor in urban settings of Asia and proposes a closer Asia have been driven by agents and examination of how unfair health opportunities stakeholders who have been able to shape the can be overcome by addressing social new political space created by globalization, determinants of health and improving urban urbanization, decentralization, democratization governance. Evidence of improved health and advances in information technology to outcomes (using health and/or disease indicators) create opportunities, build capabilities, achieve is considered only one of several sources of greater security, empower, engage and mobilize information on the effectiveness of innovations. support for policy and action to improve the Using a social and development framework, we urban living environment for vulnerable have considered a wide range of other health- populations. related indicators , such as governance indicators (participation, political commitment, The key innovations are summarized as follows: enforcement of laws, protection of human rights, decency and fairness), health systems indicators 1) The urban poor as key drivers and (efficiency, capacity and institution-building, decision-makers in community sources and uses of funds for health), upgrading (Examples: Society for the environmental health indicators (better quality Promotion of Area Resources Centre of housing, cleaner indoor air, less pollution) and (SPARC), India; Asian Coalition for political and community indicators (public Housing and Rights (ACHR); perception, community participation, social Shack/Slum Dwellers International and cohesion, support for policy, adherence to public its members, the Women’s Development health policies , e.g., quarantine measures) as Bank Federation, Nepalese National equally valid evidence of the impact of Squatters Federation, Philippines innovations in urban health. Homeless People’s Federation, National Slum Dwellers Federation/Mahila Milan We therefore propose that a platform for the and Homeless International; evolving notion of “healthy urban governance”2 Community Organization Development seeking to improve the social, political, physical Institute (CODI), Thailand; Self- and economic environment in cities is crucial to Employed Women’s Association improving the health of the urban poor and may (SEWA), India; Orangi Pilot Project, be considered as a strategic pathway for healthy Pakistan). urbanization.3 2) Local governments holding themselves accountable for healthy urban settings 2 (Examples: Alliance for Healthy Cities WHO Centre for Health Development. 2007. Report – “twinning” of Marikina City, of the Knowledge Network on Urban Settings to the Philippines and Ichikawa City, Japan; WHO Commission on Social Determinants of Health Asian Network of Major Cities; “Asian (unpublished). Infectious Disease Project” – New Delhi, 3 “Healthy urbanization”, as defined by the WHO Centre for Health Development, refers to the process Hanoi, Jakarta, Singapore, Taipei, of enabling cities to achieve health and equity through Tokyo and Yangon; WHO eight key principles, the “8Es”: environmental Collaborating Centre on Healthy Cities sustainability, empowerment of communities, and Urban Health, Tokyo Medical and engagement of all sectors, energy efficiency, Dental University, Japan; Community elimination of extreme urban poverty, enforcement of participation research project on security and safety, equity-based health systems and communities living in boats, Hue City, expression of cultural diversity. Viet Nam and research on drug abuse,

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Vientiane, Laos; WHO Centre for Health Development – action-research 6) Optimizing social determinants of on healthy urbanization – Bangalore, health in urban settings (Examples: India, Suzhou, China and Kobe, Japan; Tobacco-free sports (World Cup Series, Healthy Cities, Kuching Malaysia; Olympics and Southeast Asian Games) Mongolian Association of Urban in the host cities in Republic of Korea, Centres, Ulaanbaatar, Mongolia; Japan, China and Viet Nam; walking for Confederation of Indian Industry (CII) health in Singapore; life skills and pre- and the Indian Business Coalition on employment training in Marikina City; AIDS (IBCA); the Thailand Business fuel regulation policy on compressed Coalition, an alliance of more than 100 natural gas in India). companies; Corporate Social Responsibility Asia Magazine, Asian Healthy urban governance, as an evolving Institute of Management). approach to reducing the health vulnerabilities of the urban poor in Asia, is achievable. Principles 3) Using infectious disease outbreaks as of good governance need to be continuously opportunities for strengthening public applied to the promotion and protection of health infrastructure (Examples: health. There is no “one-size-fits-all” solution, Coordinated city and national action on and actors will need to continuously navigate a SARS and avian flu in Hong Kong, Viet fast-changing environment in order to achieve Nam, China and Singapore, resulting in results. Nodes of power and influence among the improvements in surveillance, hospital urban poor, local governments and the public infection control, public hygiene, health sector are growing and cross-linkages quarantine and risk communication; between geopolitical regions are being healthy marketplace initiatives in Viet discovered. In Asian cities, as in other cities Nam; health promotion and public around the world, there are countless examples of education on HIV/AIDS in train living networks of people, communities, stations in Beijing; compassionate care organizations and institutions that have the for survivors of HIV/AIDS in Thailand). knowledge, skills and resources for scaling up change. They could certainly benefit from a more 4) Improving efficiency in health supportive and enabling environment for promotion financing in cities achieving fairer health opportunities for all. (Examples: Social insurance coverage Rendering visibility to the health vulnerabilities for prevention and health promotion in of the urban poor through the skilful framing of Japan; tobacco and alcohol taxes used public policy issues seems to be an effective for health promotion by Thai Health; starting point. the Korean Health Promotion Fund).

5) Applying information technology to population health activities (Examples: Village phone systems in Bangladesh peri-urban areas; strategic communication and use of mass media entertainment to deliver family planning and reproductive health messages in urban and rural Indonesia, Bangladesh and the Philippines; use of geographic information systems for health planning, mapping and programme monitoring, Cebu, Philippines).

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Table of Contents

I. Introduction……………………………………………………………………………………5

II. A model for understanding health vulnerability in new urban settings as “spheres of high socio-ecological stress”…..……………………………………………...8

III. Health in the “new urban settings” of Asia…………………………………...….……..……11

IV. Methodology…………………………..…………………………………………….……..…16

V. Innovations that respond to health vulnerabilities among the urban poor in Asia………………………….…………………………………….…………………...17

1. The urban poor as the key drivers and decision-makers in community upgrading……...………………………………………………...……….18

2. Local governments holding themselves accountable for healthy urban settings...…………………………………………………………….…..……..18

3. Using infectious disease outbreaks as opportunities for strengthening public health infrastructure……………………………….……….....19

4. Improving the efficiency of financing of health promotion in cities………………………………………………………….………………...... 20

5. Applying information technology to population health activities...... 20

6. Optimizing social determinants of health in urban settings.………………….……..21

VI. Synthesis, strategic entry points for scaling up action and conclusions………………….….37

References...……………………………………………………………………………….....44

Annexes……………………………………………………………………………………...52

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I. Introduction century and has brought many positive benefits Asia is home to 60% of the world’s population. to the East Asian “tiger economies” as well as In the next few decades, estimates are that more many other countries in South and Southeast than 60% of the increase in the global urban Asia through higher incomes, better education, population will be in Asia, mostly in China and better health outcomes, declines in infant India, but also in Pakistan, Bangladesh, the mortality rates and longer life expectancies.7,8 Philippines and Viet Nam.4 Three major sources contribute to urban growth in Asia: natural The drawing power of Asian cities for rural growth (the excess of births over deaths) and net migrants seeking more economic opportunities is in-migration (where population inflow exceeds evident in that the per capita GDP of cities is outflow) as well as growth due to administrative often higher than the per capita national GDP.9 changes or the redrawing of boundaries due to In the future, this will continue to drive the sprawl from urban centres.5 In each country, rural-to-urban population shift as well as the high these sources of urban growth have different level of migration between countries. These implications for urban administration and migrations are an important part of the economic national policy. transformation of countries, but they demand a sharper focus on population and development Unlike other regions, usually the growth of Asian policies. cities and municipalities6 has been accompanied by economic prosperity. There is no doubt that Where urbanization has been unplanned and has the Asian economic miracle was one of the most progressed at an unmanageable pace,10 existing significant global developments of the twentieth public infrastructure, the urban environment and the traditional social fabric deteriorates and the growth and wealth of cities cease to translate into 11 12 4 Ooi Giok Ling and Kai Hong Phua. 2006. “an urban advantage”. , In the developing Urbanization and Slum Formation. Thematic paper for countries of Asia, where national and municipal the Knowledge Network on Urban Settings, WHO authorities have been unable to cope with the Centre for Health Development. speed of change, the net effect is failure of 5 Ness, Gayl D. & Prem P. Talwar (eds). 2005. Asian governance, increased and unabated inequity and Urbanization in the New Millennium. Marshall the urbanization of poverty. In developed Cavendish Academic, Singapore. 6 Cities and municipalities are used interchangeably in the paper to refer to local government jurisdictions in the urban setting. There are no universally accepted 7 Tao Liu. 2006. China's health challenges. British definition of what constitutes a city or an urban area. Medical Journal 333, no. 7564 (August 19): 365 A city implies a sizeable conglomeration and (accessed April 16, 2007). concentration of dwellings, businesses and their 8 Cornia GA. 2001. Globalization and health: results workplaces and infrastructure; it usually implies some and options. Bulletin of the World Health Organization administrative status, for instance as a district or 79, no. 9 (January 1), pp. 834-41. provincial capital. Of course, it implies urban status, 9 Laquian AA. 2005. Beyond Metropolis: the planning but in most nations, the definition of “urban areas” and governance of Asia’s mega-urban regions. Baltimore: means that there are many urban centres too small to Johns Hopkins University Press. be considered cities. Many national definitions of 10 Ness, Gayl D. & Prem P. Talwar (eds). 2005. Asian “urban” consider all settlements with 1,000, 1,500 or Urbanization in the New Millennium. Marshall 2,500 or more inhabitants as urban. A large Cavendish Academic, Singapore. proportion of the world’s “urban” population lives in 11 UN-HABITAT. 2003. Slums of the World: The urban centres that lack the size or economic or Face of Urban Poverty in the New Millennium? political importance to be considered cities. For [working paper]. Nairobi, Kenya: The Global Urban instance, many nations have more than a fifth of their Observatory; 33-38. population living in urban centres with fewer than a 12 Freudenberg N, Galea S and D. Vlahov. 2006. Cities fifth of their population living in urban centres, with and the Health of the Public. Nashville: Vanderbilt fewer than 50,000 inhabitants (Satterthwaite 2006). University Press.

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countries, inequities exist along other It has been pointed out by Wratten,16 Rakodi,17 determinants such as ethnicity, gender and age. Satterthwaithe,18 Sen,19 Kawachi and Wamala20 and the Knowledge Network on Urban Settings In a rapidly urbanizing environment, different of the WHO Commission on Social groups of people may be exposed to a wide range Determinants of Health21 that poverty is not only of risks and exhibit varying and extreme degrees a question of financial or material resources, but of vulnerability or exposure despite that fact that needs to be considered in other dimensions with they “live in the same city”. These different strong links to social conditions. In turn, these vulnerabilities are translated in unequal health social conditions determine health risks and risks and outcomes and may not be easily gleaned outcomes: from routine health statistics. In order to unmask these differences and develop relevant • lack of opportunities (for employment interventions to reduce health inequity, risks and and access to productive resources); vulnerabilities ,as well as to address underlying • lack of capabilities (access to education, drivers of these conditions, new ways of looking health and other public services); at and evaluating health vulnerability and • lack of security (vulnerability to creating fairer opportunities for health must be economic risks and violence); established. • lack of empowerment (absence of voice, power and participation); and the The most extreme end of the health inequity • lack of 2a health-supporting physical gradient in cities includes the people in low- living environment (poor housing, unsafe income and informal settlements (“slums”13).14 working conditions, unnecessary To date, it is estimated that 60% of the world’s exposure to biological, chemical and informal settlers and slum dwellers are in Asian physical threats to health). cities. In South Asia, slums and squatter settlements constitute 58% of the total urban This applies to both the rural and urban settings, population, compared to 36.4% in East Asia and but may tend to be severe in the urban living 28% in Southeast Asia. In absolute figures this environment.22 translates to more than 550 million people.15

the Knowledge Network on Urban Settings, WHO Centre for Health Development 13 There is no universal agreement on the definition of 16 Wratten, Ellen 1995. “Conceptualizing urban what a “slum” is, but for purposes of this paper, the poverty”, Environment and Urbanization, Vol. 7, No.1, general definition used by UN-HABITAT denotes “a April, pp. 11-36. wide range of low-income settlements and/or poor 17 Rakodi, Carole 1995. “Poverty lines or household human living conditions.” (UN-HABITAT, 2003). strategies? A review of conceptual issues in the study These deprived areas are further characterized by the of urban poverty”, Habitat International, Vol. 19, following attributes: a) lack of basic services; b) No.4, pp. 407-426. substandard housing or illegal and inadequate building 18 Satterthwaite, David 1997. Urban Poverty: structures; c) overcrowding and high density; d) Reconsidering Its Scale and Nature, IDS Bulletin, Vol. unhealthy living conditions and hazardous locations; 28, No. 2. April, pp. 9-23. e) insecure tenure, irregular or informal settlements; 19 Sen, Amartya. 1999. Development as freedom. New and f) poverty and social exclusion. York, Alfred A Knopf Publ. 14 WHO Centre for Health Development 2005, “A 20 Kawachi Ichiro and Wamala S. 2007. Globalization Billion Voices: Responding to the Health Needs of and health. New York, Oxford University Press. Slum Dwellers and Informal Settlers in the Urban 21 WHO Centre for Health Development. 2007. Setting” Strategic and analytic paper for the Report of the Knowledge Network on Urban Settings Knowledge Network on Urban Settings, WHO to the WHO Commission on Social Determinants of Commission on Social Determinants of Health. Health (unpublished). 15 Ooi Giok Ling and Kai Hong Phua. 2006. 22 WHO Centre for Health Development. 2007. Urbanization and Slum Formation. Thematic paper for Report of the Knowledge Network on Urban Settings

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The urban poor who live in deprived urban How can we change the urban conditions that settings, informal settlements and slums make people ill? constitute the single largest group of vulnerable Most governments recognize the benefits of populations in today’s Asian cities. Sub-groups urbanization but with this recognition often within this population include women, children, comes ambivalence about the process. It is widely the disabled, minority groups of different ethnic believed that the urban poor can fend for origins or countries, street children, commercial themselves and that better job opportunities will sex workers, survivors of HIV/AIDS, “dalits”, erase social inequity in cities. On the contrary, indigenous peoples, sexual minorities, transient despite economic prosperity in many Asian workers and hawkers among others. cities, slums and informal settlement growth has escalated. A key constraint to responding to the needs of these vulnerable populations is systematic social In Asia, as in other parts of the world, urban and political exclusion that renders them centres are the “engines of growth” as well as “invisible” and powerless. power and wealth, but they are also the centres of opposition and dissent. This has given rise to The knowledge and means to achieve fairer conflicting policies and hesitancy in addressing health opportunities for these vulnerable groups the underlying structural determinants of health are available. Overcoming the social and for the urban poor. The political reality is that political barriers to fairer health opportunity is uneven power structures, incomplete the more formidable challenge. The vulnerability decentralization and weak local government of these groups is related to place, people and capacity coupled with cultural bias and social time (or life course) events. In this context, discrimination against the urban poor remain health vulnerability per se is reversible. Hence, deeply embedded in health systems and the larger public health interventions need to address two governance systems. This needs to change if the problems: lack of access to health services and half-billion people who live in slums in Asia are information and social determinants or “the to have better lives in the near future. causes behind the causes of ill-health”23 in the urban setting. In relation to informal settlements This paper reviews the literature on health in the and health of the urban poor, a high priority urban settings of Asia and proposes a closer should be placed on stopping the development of examination of how unfair health opportunities new slums.24 This is aptly summarized by the can be overcome by addressing social challenge posed by Sir Michael Marmot, Chair of determinants of health and improving urban the WHO Commission on Social Determinants governance. of Health: “Why do we keep treating people, only to send them back to the conditions that Innovations that have been included in the made them ill in the first place?”25 paper were selected with a governance lens. The paper also attempts to show how the actors in innovations in population health are using a to the WHO Commission on Social Determinants of wide range of indicators of upstream (socio- Health (unpublished). ecological drivers such as poverty, education, 23 WHO Commission on Social Determinants of employment, poor housing, unsafe Health. “The President of Chile and the WHO Director-General launch global commission to tackle environments) and downstream (access to the “causes behind the causes of ill-health.” Press quality health care, quality services, social release by the CSDH, 18 March 2005. insurance coverage) determinants of health to 24 Garau, P., Sclar, E.D., and Carolini, G.Y. 2005. A home in the city. Report from the UN Millennium on Health Promotion, Bangkok, 8 August 2005. Project. London, Earthscan Publ. http://www.anamai.moph.go.th/6thglobal/08_1100_A 25 Marmot, Michael. “Addressing social determinants ddressing_H_determinants-_Marmot- of health.” Presentation to the 6th Global Conference ESCCAP_Hall.pdf.

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advance action on health in cities in general and We therefore propose that a platform for the of the urban poor in particular. evolving notion of “healthy urban governance”26 seeking to improve the social, political, physical Throughout this paper, evidence of improvement and economic environment in cities is crucial to of health outcome (using health or and disease improving the health of the urban poor and may indicators) is considered as only one of several be considered as a strategic pathway for healthy sources of information on effectiveness of urbanization27. innovations. Using a social and development framework, we have considered a wide range of other health-related indicators, such as governance indicators (participation, political commitment, enforcement of laws, protection of human rights, decency and fairness), health

Healthy urban governance: the critical pathway for equity

Urban factors Economic, Globalization +/- Spheres of social and aspects of high socio- Health and ecological political the urban social development system stress outcomes Urbanization and differentials

Well-being and quality of life

Speed of change

Figure 1. Healthy urban governance as a critical pathway for equity in new urban settings. (Modified from a model for “Health in New Urban Settings” developed by Ilona Kickbusch for the WHO Kobe Centre, 2005.)

26 systems indicators (efficiency, capacity and WHO Centre for Health Development. 2007. institution-building, sources and uses of funds for Report of the Knowledge Network on Urban Settings to the WHO Commission on Social Determinants of health), environmental health indicators (better Health (unpublished). quality of housing, cleaner indoor air, less 27 “Healthy urbanization”, as defined by the WHO pollution), and political and community Centre for Health Development, refers to the process indicators ( public perception, community of enabling cities to achieve health and equity through participation, social cohesion, support for policy, eight key principles, the “8Es”: environmental adherence to public health policies, e.g., sustainability, empowerment of communities, quarantine measures), as equally valid evidence engagement of all sectors, energy efficiency, of the impact of innovations in urban health. elimination of extreme urban poverty, enforcement of security and safety, equity-based health systems and expression of cultural diversity.

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II. A model for understanding health A syndemic approach28 helps us to appreciate vulnerability in new urban settings as how multiple causalities converge to create “spheres of high socio-ecological stress” disease patterns that may be linked to unequal health opportunities: 1) place-related: high stress Ill-health is brought about by the interaction of and vulnerability is related to the confluence of humans with their environment within “socio- biological, chemical, physical or psycho-social ecological spheres” and behavioral risks linked to characteristics of A model for understanding different outcomes in the place of residence, work, learning or play, urban settings is presented to characterize e.g., children living in a squatter area in Manila, linkages and pathways that result in “spheres of Philippines are nine times more likely to have high socio-ecological stress” resulting in the tuberculosis than non-squatter children in the vulnerability of population groups in new urban city;29 2) people-related: high stress and settings. (Figure 1) vulnerability related to discrimination based on gender, race, ethnicity or socio-economic status, Country specific contexts, e.g., economic, social e.g., in China, the “floating population” (liudong and political factors interact with the forces of renkou) is considered to be at high risk of globalization and rapid and unplanned contracting HIV/AIDS because of higher urbanization in countries to affect human mobility rates, transient residence and limited communities. The intersection between the access to knowledge of the disease or how global and the local may produce both positive condom use prevents infection;30 and 3) time- and negative effects. In cities, an aggregate of related: high stress and vulnerability related to attributes of urban living or “the urban factor” – changes during the developmental stages of the mobility, density, connectivity, opportunity, life cycle and the inability to cope with rapid anonymity, viability, privacy, proximity and social change, such as the rise in solitary deaths diversity – determine lifestyles and social (kodoku-shi in Japanese) among elderly and environments and affect the way in which people relatively poor individuals who survived the live, work, learn and play. Great Hanshin Awaji earthquake in Kobe, were relocated, and lived alone with almost no social Where social and political institutions are unable contact with neighbours or family, and whose to adapt, manage and contain the tensions created by urban living, spheres of high socio- ecological stress emerge. High socio-ecological stress gives rise to health vulnerabilities that 28 “Syndemic” is a term invented to describe a set of manifest in a range of health and social linked health problems. The first syndemic to have outcomes, differentials and inequities. Some of been named and analysed in professional public health these are context-specific, but in some cases, literature was reported by Merrill Singer. Comprised of cross-national trends may be noted. substance abuse, violence, and AIDS, the “SAVA” syndemic conveyed what he saw as inextricable and Within this model, the well-being and quality of mutually reinforcing connections between three life of human communities in turn affect conditions that disproportionately afflict those living urbanization and globalization; the cycle in poverty in U.S. cities. http://www.cdc.gov/syndemics/overview- continues and may be mediated by the speed of definition.htm (accessed on 27 April 2007). change. The types of health problems that arise 29 Fry S, Cousins B, Olivola K. 2002. Health of in spheres of high socio-ecological stress are Children Living in Urban Slums in Asia and the Near characterized by disempowerment and the East: Review of Existing Literature and Data. accompanying loss of control, choice and Washington, D.C.: Environmental Health Project, autonomy over circumstances, situations and U.S. Agency for International Development. conditions that normally help individuals, 30 Adapted from Christian Delsol and Patricia Chan. families and communities protect themselves 2006. UNFPA Supports China to Spread HIV/AIDS when faced with threats or hazards. Message. http://www.un.org/webcast/pdfs/unia1028.pdf (accessed on 22 April 2007).

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bodies have gone unnoticed for as long as a is underscored. Some key principles that are used month after dying alone at home.31 to characterize good governance in the urban setting include: A framework for better urban governance is needed to change the socio-ecological 1) participation, the degree of ownership phenomena in the urban setting that cause and involvement that stakeholders have health inequity and unnecessary vulnerability in the political system; Using the WHO definition of health as a “state 2) fairness, the degree to which rules are of complete mental and physical well-being and applied equally to everyone; not just the absence of disease” and the notion of 3) decency, the degree to which rules are health as a “resource for living” as stated in the formed and implemented without Ottawa Charter on health promotion, a humiliating or harming particular groups governance perspective helps locate nodes of of people; influence and power that can be mobilized and 4) accountability, the extent to which engaged to effect changes in the social, political those with governing power are and economic environments of the urban poor to responsible and responsive to those who enable them to gain greater control of their life are affected by their actions; circumstances and the determinants of their 5) sustainability, the extent to which health.32, 33 current needs are balanced with those of future generations; and In this paper, governance is defined as “the 6) transparency, the extent to which management of the course of events within a decisions are made in a clear and open social system”34 and involves a wide range of manner.35 actors beyond those who are in positions of authority in government. In the previous section, We refer to “healthy urban governance” as the the proliferation of informal settlements and systems, institutions and processes that promote a slum growth has been attributed to “failure of higher level and fairer distribution of health in governance”, meaning current governance urban settings as a critical pathway for improving systems may be inefficient, corrupt or population health in cities. Key features of unresponsive and irrelevant to the needs of the healthy urban governance36 include: governed. The importance of “good governance” in achieving better health for vulnerable groups • Putting health and human development at the centre of government policies and actions in relation to urbanization; 31 WHO Centre for Health Development 2006. • Recognizing the critical and pivotal role Scoping paper for Japan Healthy Urbanization Field of local governments in ensuring Research Site, Healthy Urbanization Project 32 adequate basic services, housing and Barten, Francoise, Catherine Mulholland et al. access to health care as well as healthier 2006. Healthy governance/ Participatory governance: and safer urban environments and towards settings where people live, work, learn an integrated approach of social determinants of and play; health for reducing health inequity. Thematic paper for the Knowledge Network on Urban Settings, WHO Centre for Health Development 33 Burris, Scott, Vivian Lin, Andrew Herzog and 35 Hyden, Goran, Julius Court and Kenneth Mease. Trevor Hancock. 2006. Emerging Principles of 2003. Making Sense of Governance: The Need for Healthy Urban Governance. Thematic paper for the Involving Local Stakeholders. Overseas Development Knowledge Network on Urban Settings, WHO Centre Institute, London for Health Development 36 WHO Centre for Health Development. 2007. 34 Burris, Scott, Peter Drahos and Clifford Shearing. Report of the Knowledge Network on Urban Settings 2005. Nodal Governance. Australian Journal of Legal to the WHO Commission on Social Determinants of Philosophy. 30:30-58. Health (unpublished)

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• Building on and supporting community Railway linking Japan with Eurasia through the grassroots efforts of the urban poor to Korean peninsula37. In the near future, gain control over their circumstances Bangladesh may become the transport hub of and the resources they need to develop South Asia and the Southeast Asian region and better living environments; also may become the gateway for countries like • Developing mechanisms for bringing Nepal, Bhutan, India and Myanmar through the together private, public and civil society Bangla Bandha land port and the Chittagong sectors, and defining roles and seaport.38 Recently, Malaysia has positioned itself mechanisms for international and to compete with Singapore as the key Southeast national actors to support local Asian shipping hub for the region through the governance capacity. Port of Tanjung Pelepas on the southern tip of • Winning and using resources – aid, the Malay Peninsula facing the Strait of Malacca, investment, loans – from upstream one of the world’s most important international actors to ensure a balance between shipping channels.39 economic, social, political and cultural development and establishing Then as now, these lines of connectedness governance support mechanisms that generate great potential for economic growth and enable communities and local prosperity. But as recent history has shown, high governments to partner in building city-to-city connectedness also present risks for healthier and safer human settlements the spread of infectious diseases, harmful in cities. products and social tensions across highly dense populations elsewhere in the world. III. Health in the “new urban settings” of Asia So what is different about Asian cities today? As early as 300 BC, the development of cities in Five interrelated conditions of the current Asian Asia was linked to the development of trade. urban context make it different from any other Cities on both ends of the Silk Road flourished as point in history: 1) the unprecedented rate of gold, silver, ivory, silk, precious stones and exotic urban growth and its effect on municipal animals and plants were traded across the area governments; 2) faster and continuing growth of that once separated the East from the West. In market economies in “primate cities”40 those days, the largest Asian cities were the accompanied by both marked improvement in capitals of the medieval empires: Pataliputra (India), Constantinople (later Istanbul) and Chang-An (now Xian, China). In the 1300s, the 37 Valencia, Mark J. 2002. Regional Development same Silk Road that fostered trade, commerce Planning for Northeast Asia: Possibilities and Politics. and cultural exchange along its eastern and Paper contributed to NIRA Policy Research, Vol. 15, No. 11. East-West Center, Hawaii. western borders also brought one of the most 38 devastating epidemics in human history: the http://english.people.com.cn/200512/20/eng2005122 0_229510.html (accessed on 27 April 2007). plague or “black death” that spread across Europe 39 from China, killing what some historians claim as http://www.iht.com/articles/2002/02/01/port_ed3_.ph a third of the entire population of the continent, p (accessed on 27 April 2007). 40 Mark Jefferson in 1939 described the primate city in an estimated 20 million people. a country as one that is four to ten times as large as the

second city and dominates all urban life. This is Then as now, the connectedness of Asian cities especially true in the smaller developing countries. In to the rest of the world through trade and Laos, for example, half the urban population resides in commerce makes them strategic hubs for the capital of Vientiane. That city has been 3–10 economic growth across the continents. Recent times the size of the next two cities. Rangoon has a developments point to how this trend will third (29%) of all Myanmar’s urban population and is continue through proposed land bridges to five times the size of the next city, Mandalay. connect Europe through China (Tianjin-Beijing- Kathmandu in Nepal has 18% of the country’s urban Ulaanbaatar-Ulan-Irkutsk) or a Trans-Korean population.

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quality of life and living conditions in some increasing inability to co-exist harmoniously. In places but with an upsurge in poverty, slums, Mumbai for example, street violence and informal settlements and inequity in others; 3) “winning back the street” or control over certain regrouping of marginalized and socially excluded parts of a neighborhood is divided by lines of groups along ethnic, cultural and religious lines distrust drawn along socio-economic and within cities, e.g., sub-communities of Nepalese religious differences between Hindus and refugees in the slums of New Delhi; 4) sustained Muslims.42 Extremism is created when citizens city-to-city interconnectedness through trade, are not invited into and have not grown to trust commerce, industry and international travel; and in institutions but rather rely on the ties of blood 5) new and emerging health vulnerabilities or religion or systems of patronage to gain a sense brought about by a confluence of biological, of control over their circumstances. 43 High social, political and environmental tensions and levels of inequity result in the fragmentation of risks. cities, with certain areas attracting businesses and high-income earners at the expense of others Combined, these give rise to what the WHO who have none and suffer from high Centre for Health Development refers to as “new unemployment, little or no access to essential urban settings”41 or urban areas characterized by a services, and infrastructure in need of radical process of change with positive and maintenance or repair.44 The multifaceted effects negative effects, increased inequities, greater of globalization on the health of poor and low- environmental impacts, expanding metropolitan income populations in all cities need to be better area, the proliferation of slums and informal understood in this context, both at the individual settlements and new and increasing health level and within the city and community45, 46. vulnerability across the social gradient. What is reported in the next section is by no Understanding the social pathways of health means an exhaustive survey of evidence and inequity and vulnerability of the urban poor knowledge on health in new urban settings in The inequities of 21st century globalization play Asia. Instead we attempt merely to highlight out vividly in the cities of Asia. In relation to the strategic issues and offer illustrative examples. It urban poor, health vulnerability may be linked to must be stated up front that there is an overall place, people and time, though cross-linkages are paucity of data on informal settlers, slums and obvious. The places where people live, work, health conditions of the urban poor.47 The lack learn and play; the people and their socioeconomic status, and specific conditions in relation to time, developmental stages of the life 42 Carla Power and Joe Cohcrane. “The Urban cycle or life course events define how inequities Extreme” Newsweek magazine, Oct.-December, 2003, are heightened. In all instances, inequity is pp. 63-64. 43 compounded by disempowerment and the Sudip Mazumdar. “The City Solution” Newsweek magazine, Oct,-December, 2003, pp. 12-23. inability to gain access to nodes of power or 44 influence. At the level of the individual, this is International Institute for Environment and Development (IIED) (2002:1). manifest in loss of control, choice or autonomy 45 over one’s life circumstances. At the social level, Saskia Sassen, one of the preeminent scholars on globalization and urbanization, underlines that the rapid changes such as overnight economic “decoding of globalization” can only be undertaken at opportunities in boom cities may create income a local level (Sassen, 2001). inequalities that drive deeper wedges into 46 Sassen (2005:30) states that MDG 7 strongly communities and result in the loss of trust and influences many of the other MDGs, and the need for respect between sub-groups, and may result in international coordination to realize environmental sustainability is an important factor in the realization of other development objectives. 41 WHO Centre for Health Development. 2004. 47 David, Annette, Susan Mercado, David Becker, Report of the Ad hoc Research Advisory Committee Katia Edmundo, Fredrich Mugisha. 2006. The to the WHO Kobe Centre. Background paper. prevention and control of HIV/AIDS, TB and vector-

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of disaggregated urban data (such as from intra- as near traffic hubs, dumpsites and polluting urban health differential studies, urban surveys, industries.50 or routinely reported data on urban health) is a key constraint and limitation of this paper and is Unequal access to water and sanitation needs to a challenge that must be overcome if future be highlighted as a persistent and major action and policy change is to be meaningful. In preventable underlying pathway for many the future, investments in developing capacity diseases and conditions in Asian cities. These and systems to generate and analyse urban health pathways may be further classified as being data specifically intra-urban differentials, will be waterborne, water-washed (or water scarce), critical for leveraging policy, action and research water-based or linked to water-related insect to unmask health vulnerability across the social vectors.51 Privatization of water in cities has been gradient. shown to heighten inequity in access and has led to disease outbreaks.52 In many instances, the Places urban poor pay much more for water as they rely Unsound living conditions (e.g., unsafe water, on informal vendors, compared to the better off unsanitary conditions, poor housing, who have house connections. In Vientiane, these overcrowding and high density, hazardous vendors charge US$ 14.6.8/m3 compared to locations and exposure to extremes of 11 cents/m3; in Mandalay $11.33/m3 compared temperature) are a major intermediate to 81 cents/m3; in Phnom Penh $1.64/m3 determinant of health inequity in Asian urban compared to 9 cents/m3.53 settings and invariably linked to poverty both in developed and developing countries.48 Industrialization and the proximity of the urban poor to factories and manufacturing zones and The lack of shelter and the poor quality of further compounded by weak regulatory and housing are major threats to health in urban pollution control measures and enforcement at slums and more than half a billion people in national and municipal levels, result in a wide Asia.49 There is compelling evidence to link range of other types of environmental risks to different communicable and noncommunicable, health. These include exposure to chemicals and injuries and psychosocial disorders to risk factors biological agents that pollute the ambient air, as related to unhealthy living conditions, such as well as indoor air pollution,54 extremes of noise faulty building, defective water supplies, and temperatures, and industrial pollution of substandard sanitation, poor fuel quality and land and water.55 For example, Minamata ventilation, non-existent refuse storage and disease56, caused by methyl mercury poisoning collection, improper food and storage from eating shellfish and fish where the toxic preparation, as well as poor/unsafe location, such

50 World Health Organization. 1997. Indicators of unhealthy living conditions. Report of the WHO Commission on Sustainable Development and Health. 51 Gordon McGranahan et al. 2001. The Citizens at borne diseases in informal settlements: challenges, Risk: from urban sanitation to sustainable cities. Earthscan opportunities and insights. Thematic paper for the Publications, London. Knowledge Network on Urban Settings, WHO Centre 52http://www.citizen.org/cmep/Water/cmep_Water/rep for Health Development orts/southafrica/( accessed on 25 May 2007). 48 Kjellstrom T et al. 2006. Improving the Living 53http://www.unescap.org/huset/urban_poverty/poorpay Environment. Thematic paper for the Knowledge more.htm (accessed on 2 May 2007). Network on Urban Settings, WHO Centre for Health 54http://www.who.int/indoorair/publications/national_ Development burden_of_disease.pdf (accessed on 2 May 2007). 49 Sheuya et al. 2006. The Design of Housing and 55 Kirdar U (ed). 1997. Cities fit for people. UNDP, New Shelter Programmes. Thematic paper for the York. Knowledge Network on Urban Settings, WHO Centre 56http://www.unu.edu/unupress/unupbooks/uu35ie/uu3 for Health Development 5ie0c.htm (accessed on 21 May 2007).

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chemical bioaccumulated, affected more than multi-drug-resistant strains of tuberculosis that 2,000 city residents in Minamata, Kumamoto place the urban poor at a higher risk India, Prefecture, Japan and resulted in 1,784 deaths Indonesia, Nepal and Myanmar.62 Vector-borne and more than 10,000 claims for financial diseases such as dengue and urban malaria63 have compensation since 1956. More recently, official also been found to be increasing in many towns reports from China state that there are now more and cities due to migration, climate change, than 200,000 enterprises engaged in the stagnant water, insufficient drainage, flooding production, transportation and treatment of and improper disposal of solid waste.64 hazardous chemicals. Many of these are located in urban areas. Last year, China reported 142 People chemical accidents, resulting in 229 deaths. In Stigma and social exclusion must be cited as the biggest disaster yet, a spill of nitrobenzene important intermediate determinants of health.65 and other chemicals into the Songhua River in Slum dwellers and informal settlers suffer from 2006 forced Harbin, the biggest city in the the stigma associated with not having a street northeast, to suspend running water to 3.8 address66 – just one example of how they are million people for five days.57 excluded from “full citizenship” within cities. Slum dwellers and informal settlers are usually Cities can become both breeding grounds and not counted in regular municipal census gateways for emerging and reemerging infectious activities. These are key social determinants that diseases. Migration and increased mobility bring limit slum dwellers’ ability to take action to new opportunities for otherwise marginal and improve their living environment. Other factors obscure microbes.58 Other contributory factors with detrimental impacts on slum dwellers’ include changes in the ecology of urban health are lack of transportation, exposure to environments, crowding and high population crime and violence and the stress created by density, international travel and commerce, living in constant fear of one’s safety. This technology and industry, microbial adaptation to creates high levels of mistrust and low social changes and breakdowns in public health capital. measures59. The recent outbreak of severe acute respiratory syndrome (SARS) that was spread globally from city to city by airline passengers is a case in point.60 Other examples are the threat of Pridmore et al. “Social Capital and Healthy a global pandemic of H5N1, the resurgence of Urbanization in a Globalized World”, thematic paper tuberculosis through homeless populations and for the Knowledge Network on Urban Settings, WHO transients in cities like Osaka61 and the spread of Centre for Health Development, 2007 (http://www.who.or.jp/knusp/docs/00_12KNUS_Case_ Studies_130307ed.pdf). 57 http://english.gov.cn/2006-07/12/content 62http://www.wpro.who.int/media_centre/press_release _334287.htm (accessed on 21 May 2007). s/pr_20070322.htm (accessed on 2 May 2007). 58 Wilson ME. 1995. Infectious diseases: an ecological 63 http://www.rbm.who.int/wmr2005/html/2-2.htm#sea perspective. British Medical Journal, 1995, 311: 1681– (accessed on 2 May 2007). 1684. 64 McMichael AJ. The urban environment and health 59 Morse, Stephen. Factors in the Emergence of in a world of increasing globalization: issues for Infectious Diseases, developing countries. Bulletin of the World Health http://www.cdc.gov/ncidod/eid/vol1no1/morse.htm Organization. 2000;78(9):1117-26. (accessed on 2 May 2007). 65 WHO Centre for Health Development. A Billion 60 WHO Western Pacific Regional Office. 2003. Voices: Listening and Responding to the Voices of a Healthy Cities and SARS. A presentation made at the Slum-Dwellers and Informal Settlers: a strategic and Meeting on a Regional Mechanism for Healthy Cities, analytic paper. Knowledge Network on Urban Western Pacific Region. Settings, WHO CSDH (July, 2005). 61 Bradford, Richard and Makie Kawabata. 2006. From 66 Garau P, Sclar ED, and Carolini GY. 2005. A home exclusion to participation: activities of the Kamagasaki in the city. Report from the UN Millennium Project. Community Regeneration Forum. Case study for London, Earthscan Publications.

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It is reported that the “floating population” of and mortality rates from noncommunicable China now numbers 140 million. These are diseases, obesity and injuries even among migrants who are not counted as part of the vulnerable groups and the urban poor.72, 73 population of the cities where they work, but who may spend several months in the city in Tobacco use is a major risk factor for deprived living conditions67, 68 and suffer from a cardiovascular disease and cancer in Asian cities wide range of disparities, including unequal and is an underlying factor that contributes to treatment in relation to crime and punishment in household level poverty in cities.74 Alcohol and Beijing as well as other cities.69 other forms of substance abuse are also a leading public health challenge.75 Marketing and It is important to point out that among the urban promotion of harmful products usually target poor in Asia, gradients of disadvantage exist. adolescents and youth. Gender is a major cross-cutting structural determinant. For example, tuberculosis causes Road injuries and violence also contribute to a more deaths among women of reproductive age high burden of disease in Asian cities and youth than any other infectious disease,70 yet for are at higher risk.76 The total mortality from road example, all factors being equal, the health care traffic injuries of the regions of Southeast Asia77 system in Viet Nam is less likely to test and treat and the Western Pacific78 account for more than women for TB than men.71 half of the world deaths (50.7%) and about half of the disability adjusted life years (DALYS) lost: Time China has a high country rate at 15.6 road deaths Globalization and urbanization have profound per 100,000. Thailand and the Republic of Korea effects on lifestyles in cities and thereby the have worse rates still, at 20.9 and 22.7 deaths per health of urban populations. Modernization, the 100,000, respectively. While these figures are not globalization of food culture, unhealthy diets, disaggregated as rural or urban, increasing easier access to harmful products, increasing motorization and the inability to cope with dependence on motorized vehicles for transport, less physical activity and stress from the speed of change affect all age groups in urban settings. Some of these factors have been linked to risks to 72 Campbell, Tim and A Campbell. 2006. Emerging health that contribute to increasing morbidity health challenges in cities of developing countries. Thematic paper for the Knowledge Network on Urban Settings, WHO Centre for Health Development. 67 Goldestein A, Guo S. Temporary Migration in 73 World Health Organization. The World Health Report Shanghai and Beijing. Stud Comp Int Dev.1992 2002: Reducing Risks, Promoting Healthy Life. Geneva, Summer; 27(2):39-56. 2002. 68http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?itool= 74http://www.searo.who.int/EN/Section1174/section14 abstractplus&db=pubmed&cmd=Retrieve&dopt=abstr 62/default.asp (accessed on 2 May 2007). actplus&list_uids=12319798 (accessed on 27 April 75http://www.searo.who.int/LinkFiles/Alcohol_and_Su 2007). bstance_abuse_7-Gaining.pdf (accessed on 2 May 69Lei Guang. 2002. Strangers in the City: 2007). Reconfigurations of Space, Power, and Social 76 Campbell, Tim and A Campbell. 2006. Emerging Networks within China's Floating Population. Review health challenges in cities of developing countries. in Journal of Asian Studies 61, no. 4 (November 1): Thematic paper for the Knowledge Network on Urban 1364-1366 (accessed May 2, 2007). Settings, WHO Centre for Health Development. 70 World Health Organization. 2001. A Human Rights 77http://www.searo.who.int/EN/Section1243/Section13 Approach to Tuberculosis. Geneva, Switzerland: World 10/Section1343/Section1344/Section1836/Section183 Health Organization. 7.htm (accessed on 22 May 2007). 71 Long NH, Johansson E, Lonnroth K, Erikkson B, 78 http://www.wpro.who.int/NR/rdonlyres/3862AC72- Winkvist A, Diwan VK. 1999. Longer delays in CDAE-4BE6-8DE1- tuberculosis diagnosis among women in Viet Nam. Int 3EF2B778BEF8/0/RegionalDataFactSheets.pdf J Tuberc Lung Dis. 3(5): 388-393. (accessed on 22 May 2007).

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higher levels of mobility have been identified as IV. Methodology underlying factors. Examples of innovations were identified by the authors based on their work related to Healthy At the extremes of age, infants and very young Cities in the WHO Western Pacific Region and children along with older persons are particularly the South-East Asian Region, the Alliance for vulnerable to social and environmental change Healthy Cities, and the Knowledge Network on in urban settings. And with slums and informal Urban Settings of the WHO Commission on the settlements often hives of informal economic Social Determinants of Health, of which the activity, working conditions also constitute major WHO Kobe Centre is the hub. More than a intermediate determinants of health for men, hundred case studies and reports were reviewed. women and children (child labourers, street Where documentation was insufficient or children).79 Globalization and urbanization may outdated, the authors commissioned the writing also affect child health in an indirect, generally of case reports through the Southeast Asian Press ignored, manner: through an increase in women’s Alliance, an independent network of Asian participation in the labour force. In East and journalists.82 Southeast Asia, up to 80% of the workforce in export-processing zones is female.80 In The authors decided to review and consider Bangladesh, the number of garment factories innovations that tackle upstream (socio- increased from four in 1978 to 2400 in 1995, ecological drivers) as well as downstream (access when they employed 1.2 million workers, 90% of to quality health care, information, services and whom were women below 25 years of age. While programmes) determinants of health. We are female employment results in better family mindful of how inequitable access to research incomes and more bargaining power for women funds in the developing world may skew the in the family, if economic activity by women is results in favor of reports that have been not accompanied by the development of published, i.e., innovations that are funded adequate child care institutions, there may be an externally by players who are interested in increase in injury and malnutrition among capturing immediate impact on specific diseases children despite a rise in family incomes.81 or groups at risk, rather than addressing intermediate and structural determinants as they It is evidence that multiple and multi-leveled give rise to syndemics in the urban setting. policy and action interventions on social determinants of health in the urban settings of As mentioned previously, we have cast a wide Asia are needed to address a wide range of issues, net on evidence effectiveness on health and structures and value systems that influence health determinants of the urban poor and did population health. Though the challenges seem not limit ourselves to health indicators. Using a daunting, there is strong evidence to show how social determinants of health approach, we Asia is mustering political will at many levels to considered a wider data set including social, confront the issues of inequity. political and economic indicators on how innovations brought about changes in the enabling and reinforcing conditions for action to shape political space, advance health agendas, mobilize support for health, and modify power 79 Stellman, J (ed). 1998. ILO Encyclopedia on relationships and governance mechanisms over Occupational Safety and Health. Geneva, the resources and requisites for health and decent International Labour Office. living. To further validate the results, 80 Cornia GA. 2001. Globalization and health: results triangulation was achieved through informal and options. Bulletin of the World Health interviews that provided insight into the values Organization 79, no. 9 (January 1): 834-41. 81 Cornia GA. 2001. Globalization and health: results and options. Bulletin of the World Health 82 http://www.seapabkk.org/home.html (accessed on 2 Organization 79, no. 9 (January 1): 834-41. May 2007).

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of the stakeholders as reported in the case studies that were developed by the Southeast Asian Press Alliance.83

The following criteria for selection were used: a) effectiveness in reducing the health vulnerability of the urban poor (although in some examples gradient approaches do not target the urban poor per se but the poor in general84) in relation to place, person or time; b) attention paid to overcoming social barriers to health through interventions that are clearly consistent with principles of good governance, i.e., participation, fairness, decency, accountability, sustainability, transparency in the urban setting; and 3) reasonably sufficient documentation to derive lessons learned but preferably with availability of tools, guidelines and methodology for cross- national application of the innovations.

V. Innovations responding to health vulnerabilities of the urban poor in Asia The following is a summary table of innovations that address and respond to health vulnerabilities of the urban poor in Asia. These are described in greater detail in the succeeding part of the report and in the annex as case studies. The governance principles that these innovations demonstrate are mentioned. The types of vulnerabilities addressed are also cited. Types and examples of indicators that are used by the actors and stakeholders are included.

83 Refer to Case Studies in Annex 1. 84 In the cases of the Village Phone Operators and Grameen Bank, the use of information technology and microfinancing for health is basically rural; however it is clear that these types of measures prevent further migration to cities and the urbanization of poverty.

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SUMMARY TABLE OF INNOVATIONS AND INDICATORS USED IN ASIA

Innovations Examples Analysis of health Types of indicators vulnerabilities currently used by players addressed and stakeholders 1. The urban Society for the Promotion of Lack of security Rights to secure tenure, poor as key Area Resources Centre housing and property drivers and (SPARC), India Lack of decision- opportunities Better homes and living makers in Asian Coalition for Housing conditions, e.g., stronger community and Rights (ACHR) Lack of capabilities construction materials in upgrading homes, efficient drainage Slum Dwellers and its Lack of systems, less flooding, more Relevant members, the Women’s empowerment footpaths governance Development Bank principles: Federation, Nepalese Lack of a safe living Community process participation, National Squatters environment indicators, i.e., participation, fairness, Federation, Philippines empowerment of women, decency, Homeless People’s viable local organizations, accountability Federation, National Slum skilled local leaders, social Dwellers Federation/Mahila cohesion Milan and Homeless International Access to resources, e.g., microfinancing, water, Community Organization health services, electricity Development Institute (CODI), Thailand Self-reported health and well-being Self-Employed Women’s Association (SEWA), India Health outcome indicators – e.g., decrease in morbidity Oranji Pilot Project, Pakistan from diarrhoeal diseases after water supply is introduced.

2. Local Alliance for Healthy Cities Lack of General good local governments – “Twinning” of Marikina opportunities governance indicators, e.g., holding City and Ichikawa City commitment of mayors and themselves Lack of a safe living other political leaders to put accountable for Asian Network of Major environment health high on the city healthy urban Cities, “Asian Infectious agenda, better city policies settings Disease Project “ – New Lack of capabilities on health, willingness of Delhi, Hanoi, Jakarta, business and industry to Relevant Singapore, Taipei, Tokyo Lack of comply with health, governance and Yangon empowerment occupational and safety principles: regulations, business-led accountability, WHO Collaborating Centre community projects on transparency, on Healthy Cities and Urban health and environment participation, Health, Tokyo Medical and

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fairness, Dental University, Japan – Improvements in municipal sustainability Community participation services, city planning and research project on public infrastructure – better communities living in boats, sanitation, waste Hue City, Viet Nam and management, cleaner and research on drug abuse, safer marketplaces, well-lit Vientiane, Laos streets

WHO Centre for Health Healthy city Development – Action – process/governance research on Healthy indicators, e.g., multi- Urbanization – Bangalore, sectoral participation, India; Suzhou, China and investments and support Kobe, Japan from the private sector, community participation in Healthy Cities, Kuching health projects, strong Malaysia community interest in health activities, sustained action, Mongolian Association of social cohesion Urban Centres, Ulaanbaatar City Mongolia

Confederation of Indian Industry (CII) and the Indian Business Coalition on AIDS (IBCA) in India, the Thailand Business Coalition, an alliance of more than 100 companies.

Corporate Social Responsibility Asia Magazine

Asian Institute of Management 3. Using Coordinated city and Lack of security Health systems improvement infectious national action on SARS and indicators, e.g., capacity of disease avian flu in Hong Kong, Lack of health workers and hospitals outbreaks as Viet Nam, China, Singapore, opportunities improved through training, opportunities resulting in improvements in activation of infection for surveillance, hospital Lack of capabilities control committees strengthening infection control, public public health hygiene, quarantine and risk Lack of a safe living Updated public health infrastructure communication. environment policies for infectious disease prevention, control and Relevant Healthy marketplace response, e.g., quarantine governance initiatives in Viet Nam ordinances principles: transparency, Health promotion and public Enforcement of health accountability, education on HIV/AIDS in protection laws and food decency, fairness train stations in Beijing safety regulations

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Compassionate care for Perceived improvements in survivors of HIV/AIDS in environments and conditions Thailand that are conducive to business and trade

Higher awareness about disease transmission, e.g., HIV/AIDS and condom use; social support systems for survivors of HIV/AIDS

4. Improving Social insurance coverage for Lack of Health financing indicators, efficiency in prevention and health opportunities e.g., increase in coverage of health promotion in Japan benefits of health financing, promotion Lack of capabilities i.e., health promotion; new financing in Tobacco and alcohol taxes sources of finance, increase cities used for health promotion by Lack of in levels of financing for Thai Health, Thailand and empowerment health promotion Relevant the Korean Health governance Promotion Fund Lack of a safe living Health sector reform principles: environment indicators, e.g., more participation, efficient mechanisms for fairness, funding Healthy Cities decency, projects from tobacco taxes accountability 5. Applying Village phone systems in Lack of Health communication information Bangladesh peri-urban areas opportunities indicators, e.g., higher technology to awareness of health population Strategic communication and Lack of capabilities messages, endorsement of health using mass media healthy behaviours and activities entertainment to deliver Lack of practices by celebrities who family planning and empowerment influence youth and women Relevant reproductive health messages through popular culture, i.e., governance in urban and rural Indonesia, movie stars, athletes, artists principles: Bangladesh, Philippines participation, Behavioural change decency, Use of geographic indicators, e.g., increase in accountability, information systems for contraceptive prevalence sustainability health planning, mapping rates and programme monitoring, Cebu, Philippines Changes in social perceptions, social support systems and social cohesion

Health service utilization indicators, e.g., more women go for prenatal check-ups; teenagers seek counselling on

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STDs

More efficient implementation of public health programmes in urban areas 6. Optimizing Tobacco-free sports (World Lack of Changes in social norms and social Cup Series, Olympics and opportunities acceptance of regulations on determinants Southeast Asian Games) in harmful products – bans on of health in the host cities of Korea, Lack of capabilities advertising of tobacco at urban settings Japan, China and Viet Nam major sports events; bans on Lack of smoking in public places, Relevant Walking for health in empowerment higher visibility of anti- governance Singapore smoking messages principles: Lack of a safe living participation, Life skills and pre- environment Changes in social norms in fairness, employment training in relation to vulnerable groups, decency, Marikina City e.g., older persons accountability Fuel regulation policy on Decline in unemployment compressed natural gas in rates among the urban poor India Air quality improvement

Descriptions of innovations 1) The urban poor as key drivers and decision- At the forefront of this social movement are makers in community-upgrading organizations and groups that have steadily Linking the right to health of the urban poor to reshaped perceptions about the role of the urban the requisites of a decent life85 – secure housing, poor in the process of community-upgrading, land rights and micro-financing – is the most from “targets” and “beneficiaries” to “key drivers” important innovation in population health for and ”decision-makers”. These organizations and Asia. groups demonstrate how incremental and hard- won gains in participation, decency, fairness and Progress in advancing these issues to the arena of accountability result in meaningful change in healthy public policy has not been due to actions their day-to-day existence. Examples of of ministries of health or housing, but by the organizational nodes that have enabled this urban poor themselves who have the desire, the process include the Society for the Promotion of political will and the capacity to negotiate, Area Resources Centres (SPARC), India, the dialogue and manage funds and projects for Asian Coalition for Housing and Rights community-upgrading,86 as an issue of social (ACHR), Slum Dwellers International and its justice. member groups, the Women’s Development Bank Federation, Nepalese National Squatters 85 WHO. 1986. The Ottawa Charter on Health Federation, Philippines Homeless People’s Promotion. Federation, National Slum Dwellers 86 CODI prefer to use the phrase “community- Federation/Mahila Milan, and Homeless upgrading” instead of “slum-upgrading” to denote International. continuing improvements in the community in relation to the social, economic and political environment and not just improving the “slum” as a physical entity.

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Power relations need to change they find that they are no longer isolated within their individual settlement – they have allies, What the urban poor federations have done friends with similar difficulties, similar fates, and is to show that an effective housing policy similar ways of doing things. They are not alone for low-income groups is actually about – instead they are building links dozens of changing the relationships of “slum shack” communities facing similar problems in the same and “pavement” dwellers with official city. When communities expand, the fora for agencies – not about physical improvements. negotiating change also grow. Thus communities The physical improvements – in housing, gain access to more responsive audiences. Forum- housing tenure and basic services – come shifting leads to better information and from these changing relationships. opportunities to enlist support for structural changes. However, linkages in themselves are Such was the conclusion of David Satterthwaite not sufficient for sustained change. Almost all in a recent paper87 presented at a social policy political systems have vertical structures linked conference in Arusha, Tanzania. Together with to status, power and wealth that influence key five other organizations, he singled out the decisions affecting all people in society. Community Organization Development Institute Therefore, the emergence of horizontal platforms (CODI) in Thailand as one organization that or networks to balance and tap into those demonstrates change for slum and squatter vertical strings (linking social capital) are very settlers through upgrading using participatory important. Communities and development actors and inclusive processes that ensure good services, in the city can work together and start processes including health, through enforcing good that provide a chance to think and understand governance. The “network of networks” their own situation and harness their power and approach used by CODI was able to mobilize support to engage and gain greater access to neighbourhood groups of slum dwellers, networks power and influence decision-making. This of sectors and networks of important stakeholders process can result in the creation of new and leaders able to make a difference. This “nodes”90 of governance and power structures initiative has now reached 415 communities and that can be fairer, more responsive, accountable 30,000 households in 140 Thai cities.88 and transparent.

What has been the backbone of this success? Confronting patronage politics and moving Somsook Boonyabancha,89 Director of CODI, toward democratization explains that the horizontal linkages between Municipalities – and municipal politicians from individuals (bonding social capital) and peer various parties – always have their own groups (bridging social capital) are key factors in intermediaries that link with urban poor the development of new power bases (nodes). communities. Urban poor communities in any When urban poor communities have the given city tend to be divided into camps – for possibility of looking at their city in its entirety, instance, one community might “belong” to the ruling party while another might belong to the 87 opposition. Politicians like to have bilateral Satterthwaite D. 2005. Housing as an asset and as an relationships with community leaders and often arena for developing social policy: the role of lead with a “divide and rule” mentality in order federations formed by the urban poor. New frontiers of to control their constituents and maintain power. Social Policy: Development in a Globalized World. Arusha, Tanzania: The World Bank; 2005. But if this kind of patron-client relationship and 88 Boonyabancha S. 2004. Scaling up slums and its division between the “benefactor” and the squatter settlements upgrading in Thailand leading “petitioner” is to be changed, such bilateral ties community-driven integrated social development at city-wide level. New Frontiers of Social Policy: development in a globalized world. Arusha, Tanzania: 90 Burris, Scott, Peter Drahos and Clifford Shearing. The World Bank. 2005. Nodal Governance. Australian Journal of Legal 89 Boonyabancha S. 2004. Philosophy 30:30-58.

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have to be challenged by development Association (SEWA)91 in Gujarat, India. Not interventions that encourage poor communities only was SEWA successful in its own right, but in a city to work together. Such city-wide the Association joined other like-minded processes enable communities to gain both organizations to form a trust specifically independence from and to tap into these vertical dedicated to promoting housing for self-employed strings of patronage which control them. women. The trust aims to provide technical support, research and advocacy to its members. A sharper focus on social cohesion: These services enable the members to access “community-upgrading” vs. “slum-upgrading” better housing and have demonstrated Communities, even poor communities, always improvements in health and declines in have a mix of rich and poor, helpless and super- morbidity as a result.92 active people, people with particular problems such as disabled, unemployed, elderly, orphans, The Orangi Pilot Project93 in Pakistan is another drug addicts, the sick and people in crisis or organization that has used networking for emergency. In the market system, only those who improving water and sanitation for the urban can afford to pay can fully enjoy society’s poor through “networks of networks” of benefits. But in a collective community process, community organizations that manage and everybody can be taken care of if the process is supervise the water and sanitation systems. sufficiently inclusive and if social cohesion- Begun in Karachi’s Orangi squatter community building has been adequate. in the 1980s, one “lane manager” would represent 15 households on a “lane committee” Community processes must also seek to work at representing a total of 600 households. These scale, finding solutions for all urban poor groups, networks or organizations gradually gained including those with very low incomes and very control and applied pressure to hold their limited capacity to pay. If reconceived in this municipalities’ policy-makers to account. This way, “community-upgrading” (as opposed to resulted in the release of municipal funds for “slum-upgrading”) upholds the processes of construction of primary and secondary sewers participation, engagement, decency, fairness and servicing over 600,000 people in Karachi. accountability through social processes that are inclusive. Community-upgrading refers to These network processes require social cohesion. restoring the notion of shared space, resources If cohesion is absent, it has to be created, and if it and public goods. This can be a powerful exists, it has to be strengthened. All communities intervention for rebuilding or reinforcing social have a need for social cohesion, but in the urban cohesion and capital from bonding via bridging setting this need is greater than ever due to the to linking, thus addressing structural increased pressure of globalization and the rapid determinants of health and establishing a basic and radical changes that result in the unraveling safety net for the urban poor. These processes of the traditional social fabric and the breakdown may further reduce poverty and support of social bonds. The caveat is that there are two decentralization processes. CODI has done all sides to the coin. Whereas social cohesion can this by having cross-subsidiaries and financial have a positive effect on health if the processes incentives built into the project through a are inclusive and participatory, some cities have communal welfare fund and communal welfare sought cohesion in negative ways, classically by facilities and called it “collective equalizing”. glorifying the sense of belonging as citizens and

CODI is just one of several community organizations that have worked through 91 WHO Centre for Health Development 2006. Report networks. Another success story has been of the Second Meeting of the Knowledge Network on documented by the Self Employed Women’s Urban Settings. 92 Ibid. 93www.siteresources.worldbank.org/INTGENDER?reso urces/toolkit.pdf (accessed on 21 April 2007).

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inciting mistrust of foreigners, immigrants and health as an outcome with both social and floating populations. political value, the achievement of better health is more likely to be linked to democratization 2) Local governments holding themselves processes. accountable for healthy urban settings Many countries in Asia are decentralizing, Local government support for health goals builds meaning they are transferring decision-making social cohesion and helps mobilize different and spending powers from national to local sectors for health. Local leaders are also in a governments. This entails a transformation of better position to articulate health goals as social political power, increasing the importance of goals, as opposed to narrow health sector goals. cities in the conduct of public business. In public However, many local and municipal institutions health, the drama is one of balancing priorities, are ill-equipped to respond to population health allocation of resources, and personnel issues challenges, especially where decentralization is between central governments and local recent and, more often than not, incomplete.97 communities,94 as city and community leadership – mayors, elected officials, health sector Democratization is relatively new in some parts professionals and administrators – play a growing of Asia. Coupled with decentralization, it is a role in health care.95 process that poses daunting challenges for the unprepared. Popular elections in scores of Local government officials (in what were highly countries around the world subject public sector centralized systems) holding themselves decision-makers to a scrutiny and a clamour for accountable for healthier cities has been a major participation with which they have limited or no innovation in population health for Asian cities. experience and poor or underdeveloped tools. When empowered mayors and governors Participatory democracy requires new levels of encounter WHO’s concept of health, referring to sophistication in structuring decisions, informing a state of “complete physical, mental, and social the public, and channeling feedback on the well-being and not merely the absence of implementation of programmes in the public disease”, and see evidence that a wide range of sector.98 their actions influence health outcomes in the population, they too can play more active roles as Capacity building, therefore, is critical for effective health governors. enabling local governments to hold themselves accountable for healthier cities. Rathor99 An understanding of how health is a requisite of addressed capacity building in urban public productivity and economic development can be a health programmes as: strong motivator for putting health on the agenda of local governments. WHO’s Healthy …a health and welfare promotion system Cities movement over the past 25 years has applied with a ‘bottom up and inside out’ produced countless examples of how this has approach; as a continuous process of 96 happened. And once local governments see of health for reducing health inequity. Thematic paper 94 Campbell, Tim and A Campbell. 2006. Emerging for the Knowledge Network on Urban Settings, WHO health challenges in cities of developing countries. Centre for Health Development. Thematic paper for the Knowledge Network on Urban 97 Campbell, Tim and A Campbell. 2006. Emerging Settings, WHO Centre for Health Development. health challenges in cities of developing countries. 95 Bossert T and J Beauvais. 2002. Decentralization of Thematic paper for the Knowledge Network on Urban health systems and Ghana, Zambia, Uganda and the Settings, WHO Centre for Health Development. Philippines: a comparative analysis and decision space. 98 Ibid. Health Policy and Planning. 17 (1): 14-31. 99 Rathor HR. 2004. Capacity building for effective 96 Barten, Francoise, Catherine Mulholland et al. 2006 evidence-based and responsive public health. “Healthy governance/ Participatory governance: Presentation at the Inaugural Conference of the towards an integrated approach of social determinants Alliance for Healthy Cities. Kuching, Malaysia.

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enhancing the ability (capability) of all the Singapore and Vietnam, and it has a close key stakeholders to perform their core relationship with WHO. It started with 26 functions to reach the ultimate goal of members in 2004 and the steady growth of its overall health and quality of life in a city, membership indicates how cities themselves where its environment is suitable and value city-to-city learning through international sustainable for present and future networks. Evaluation of impact of Healthy City generations. projects are on-going and part of the work of the individual cities as well as the network itself.104 City-to-city learning As emerging health issues take on distinctly The network provides many processes for urban features, cities themselves have much to learning and capacity building. Cities receive offer each other as they develop approaches and practical advice on programmes for health. Sub- solutions to reduce health risks. Many cities have networks or “national chapters” have been already engaged in city-to-city exchanges in areas initiated in some countries to help promote a such as trade, economic development, country level understanding of geo-culturally environmental sustainability and finance. relevant programmes in the local language. “Horizontal assistance” is a phenomenon that Exposure to a wide range of interventions across already likely amounts to a shadow economy of the diverse cultures of Asia stimulates creativity knowledge.100 UNDP asserts that links between in approaches to health and helps expand the cities over the past several decades number in the understanding of health determinants in a global range of 15,000 to 20,000.101 City-to-city world. cooperation has become a recognized field of development assistance.102 Anecdotes and “Twinning activities” have been pursued through systemic hard data for specific cities suggest a the network. For example, since 2005, Marikina very large latent demand and a strong willingness City, Philippines and Ichikawa City, Japan have to pay: it is clear that the formation of knowledge worked together for the promotion of healthy markets could be of great utility for cities as they diets and physical activity through urban invent or look for ways to solve emerging health planning. WHO supported a one-week study visit problems. of four Marikina City officers to Ichikawa and another week-long study visit by four Ichikawa Learning through international networks of City officers to Marikina to encourage cities understanding of the diverse contexts of these The Alliance for Healthy Cities103 is an two cities. City officials reaffirmed the value of international organization aiming to protect and health in cities and the relevance of local social enhance the health and quality of life of city dwellers through the Healthy Cities approach. It 104 is an autonomous organization with, as of April As studies on urban health determinants indicate 2007, 67 members from Cambodia, China, Japan, (Takano, 2001a), there are wide-range factors Republic of Korea, Malaysia, Mongolia, influencing on health of urban dwellers. Frameworks of participatory-style research using quantitative and qualitative methods were proposed to evaluate 100 Blanco H and Campbell T. 2006. Social Capital of comprehensive programs aiming better health of the Cities: Emerging Networks of Horizontal Assistance. urban population (Takano, 2001b, Baum, 2003, Technology in Society. Vol. 28, no. 1-2 Special Issue on Nakamura 2003). An example of more practical Sustainable Cities. Elsevier. guideline for evaluation is also available (Technical 101 UNDP. 2001. Linkages in Cities. UN Report on Secretariat, 2003). There are some qualitative City to City Cooperation. New York. evaluations (Harpham, 2001; Kiyu, 2006), results of 102 UN-HABITAT. 2002. City to City Cooperation: needs assessments (Hashim, 1996), and baseline Issues Arising from Experience. Draft Second Interim quantitative evaluations of health of urban dwellers Report. Processed. Nairobi. (Quang, 2005) from initiatives related to Healthy 103 http://www.alliance-healthycities.com/ (accessed on Cities and Villages in Asia. 27 April 2007).

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health determinants. Study visits provided these communities is essential. Health inequity different sectors of both cities a chance to share may be recognized within cities, but the potential their respective visions through participation in entry points for improving health opportunities meetings, discussions and presentations on vary from place to place. The participation of the Healthy Cities activities in both sites. City senior community and local research practitioners is officers, technical officers, practitioners, crucial in identifying these highly localized entry community group leaders, teachers and children points and opportunities and in developing in the cities also gained a greater understanding approaches that are socially and culturally of the challenges of urban public health. acceptable and appropriate. In particular, participatory action research encourages the The “Asian Infectious Disease Project” is another production of evidence reflecting locally example of how city-to-city learning has taken perceived needs, felt needs and perceived place through an international network of cities. solutions. Participatory action research also This project was launched in November 2004 promotes communication and management skills with the participation of 11 megacities in Asia as among particular communities and stakeholders a health project of the Asian Network of Major including local authorities and research Cities 21.105 New Delhi, Hanoi, Jakarta, institutions.106 Community participation in a Singapore, Taipei, Tokyo, and Yangon are research project on the health of communities among the network members. These cities share living on boats in Hue, Viet Nam, and research the view that the rapid spread of infectious on drug abuse in Vientiane, Laos shows diseases including SARS and avian influenza importance of community capacity.107, 108 Within have had serious effects on Asian economies and the WHO Centre for Health Development’s national livelihoods. This project directly links Healthy Urbanization Project, participatory health information among participating cities action research is a key strategy for mapping without necessarily passing through the channels health inequities in six urban sites, three of of individual cities’ central governments. which are in Asia, namely Bangalore, Suzhou, Participating cities also accept clinicians and and Kobe.109 Through “Healthy Urbanization researchers for study visits and training. The Learning Circles” at each site, learning establishment of a mechanism of formal and environments are created where social informal information networking allows the accountability is put into practice. Since the prompt exchange of information and skills. Such project started in 2006, documentation of results a mechanism further allows technical are still on-going. collaboration between cities. This project represents fairer opportunity for local governments to access strategic information for emergencies without having to be at the mercy of national bureaucratic processes. The project 106 provides capacity building for technical and Takano T . 2007. Health and environment in the management personnel who are at the frontline context of urbanization. Environmental Health and Preventive Medicine, 12: 51-55. of infectious disease control in major cities. 107 Quang NKL, Takano T, Nakamura K, et al. 2005. Variation of health status among people living on boats in Using participatory action research to derive Hue, Vietnam. Journal of Epidemiology and local knowledge Community Health 59: 941-947. To develop effective heath programmes for 108 Fujiwara T, Takano T, Nakamura K et al. 2005. vulnerable urban communities, evidence from The spread of drug abuse in rapidly urbanizing communities in Vientiane, Lao People’s Democratic Republic. Health Promotion International 20: 61-68. 105 Asian Network of Major Cities 21. Report of 109 WHO Centre for Health Development. 2006. The Conference on Countermeasures to Combat Infectious Core Project: Optimizing the impact of social Diseases in Asia. 1–3 September 2005, Tokyo. determinants of health on exposed populations in urban settings. Information brochure.

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Benchmarking against a Healthy City services and environmental issues. Within- demonstration site country study visits by groups of mayors and Kuching City in Sarawak, Malaysia, is a Healthy governors have also created learning City demonstration site that first applied the opportunities for decision-makers. Through this Healthy City concept to its communities in 1994 process for example, a plan to encourage sanitary and has since received more than 800 visitors practices in ger (traditional tents for living) areas from around the world, each keen to study how it has been developed. became a “Healthy City”. Process indicators and improvements in local living conditions as well The hub of the network is Ulaanbaatar City as the establishment of elemental settings Office, where the Association secretariat is based; (healthy marketplaces, health promoting a full-time coordinator facilitates information schools) demonstrate the effectiveness of this dissemination and capacity building.110 approach. The city also sends out senior officers to other cities to attend seminars, meetings, and Working with the private sector to promote consultations on healthy settings including health in cities Healthy Cities. All of these opportunities have In the Asia-Pacific region, corporate social strengthened Kuching’s local resolve to be a responsibility efforts directed toward improving model for health- and environment-centred health and reducing the vulnerability of groups urban development. City-to-city learning in the urban setting is on the rise. Some activities with Kuching have stimulated Healthy examples of corporate social responsibility, City projects in southeast Asian countries and public-private partnerships and the private and beyond. corporate sector sponsorships have been applied to the prevention, care and support activities for National city-to-city learning mechanisms HIV/AIDS, such as the initiatives by the bridge language barriers Confederation of Indian Industry (CII) and the While international networking and exchange Indian Business Coalition on AIDS (IBCA) in has many benefits, in some countries, local India, and the work of the Thailand Business officials may be unable to learn from cities in Coalition, an alliance of more than 100 other countries because of language barriers. companies.111 National city-to-city mechanisms can help bridge such gaps. In small countries, primary cities may In response to public protest in the early 1990s be the sole beneficiaries of international against sweatshops in Asia operated by big exchange and while this creates a starting point foreign firms, labour compliance has become a within a country, it may also create new mainstay on the agenda of many corporate inequities between the primary city and other boardrooms. Independent media groups such as cities that do not have the same level of access to the Corporate Social Responsibility Asia international knowledge. Domestic networks of Magazine provide a clearing house of healthy cities give secondary and smaller cities information, news and reports that are relevant and municipalities a fairer chance at gaining to business-initiated and supported projects on access to knowledge on healthy urban labor law compliance, occupational health, governance. For example, the Mongolian environment, health and poverty alleviation. In Association of Urban Centres (MAUC) China, for example, a partnership between established in 2003 is a nongovernmental academics and NGOs, and a consortium of organization that demonstrates how cities can export-processing companies including Ford learn from each other within Mongolia. Motor, Gap, HP, Liz Claiborne, Pfizer, Emerging from an agreement made at the first meeting of mayors in the capital, Ulaanbaatar, 110 Mongolian Association of Urban Centres the vision of MAUC is to support exchanges of http://www.mauc.org.mn/ (accessed on 27 April 2007). experiences in urban planning and good 111http://www.youandaids.org/Themes/Corporate%20S governance and has made decentralization a key ocial%20Responsibility%20(CSR)/index.asp. concern. MAUC covers urban planning, urban

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MeadWestvaco, Motorola and Target launched SARS shook the world. By some standards, the Global Supplier Institute to offer training on the first emerging and readily transmissible management, health and safety, and HIV/AIDS, disease of the 21st century was not a big amongst other compliance curricula.112 killer, but it caused more fear and social disruption than any other outbreak of our In 2002, the first Asian Forum on Corporate time. … More than 95% of the SARS cases Responsibility (AFCR) was convened by the took place in the WHO’s Western Pacific Asian Institute of Management-Ramon del Region. ... I don’t know if one can decently Rosario, Sr. Center for Corporate Responsibility say that SARS had a silver lining, but if it and included presentations from groups like did, it was that it awakened the global Koalisi Indonesia Setasi (Coalition for a Healthy public-health community from a kind of Indonesia) and discussions on corporate giving as slumber. … since those days many countries social investment, corporate responses in the and cities have invested extensively in delivery of low-income housing, public health. … Health care workers have corporate/sectoral partnerships with health been drilled in infection-control measures. professionals and corporate partnerships in Better surveillance systems are in place. And delivering health services.113 research has been intensified. SARS, for all the fear and suffering it caused, has left public-health systems greatly improved. 3. Using infectious disease outbreaks as opportunities for strengthening public The role of communication and media in health infrastructure achieving transparency “Seizing opportunity in crisis” best describes how Surveillance (defined as “close observation, Asian national and local governments have especially of suspected persons”115) during the responded to the outbreaks of SARS, avian SARS outbreak went beyond the usual influenza and HIV/AIDS in their jurisdictions. mechanisms of public health in terms of the level These crises have served as triggers for of detail and the speed of information gathering refurbishing failing public health infrastructure. and dissemination. Early in the outbreak, when Effective and sophisticated management of little was known about the disease, rumours information, skill in risk communication and spread through the news and Internet. During engagement with global media to control the the outbreak, in-country teams, usually in the outbreak and mobilize governments and society Asian capital cities, gathered information to take action are highlighted. through both “official” (reports sent to WHO by ministries of health) and “unofficial” channels SARS, a wake-up call for governments to pay (unconfirmed rumours). WHO handled these attention to public health and hygiene two types of information differently. In his overview in the book SARS: How an global Interestingly, two thirds of rumours were later epidemic was stopped,114 Dr Shigeru Omi, confirmed.116 Regional Director of the WHO Western Pacific Region, notes: Global electronic media played a critical role in providing the public with timely information and sounding the alarm to restrict movement in high- risk areas through 24-hour news coverage of 112 Stephanie Yan 2005. Corporate social responsibility WHO travel advisories. WHO, by talking in China. China Daily, May 13, North American Ed.. directly to the global public through global http://www.proquest.com/ (accessed May 22, 2007). electronic media, held governments accountable 113 AIM hosts forum on corporate responsibility. for controlling the epidemic and heightened 2002. BusinessWorld, July 1, 1. http://www.proquest.com/ (accessed May 22, 2007). 114 WHO WPRO. 2006. SARS: how a global epidemic 115 Ibid. was stopped. World Health Organization. 116 Ibid.

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awareness on the need for transparency in Avian influenza prevention: a rallying point for reporting cases at all levels. Healthy Marketplaces and safer food systems The lessons learned from SARS are currently National and local officials closed ranks to helping countries in the region to deal with the control the SARS outbreak ongoing epidemic of H5N1 avian influenza. Both National governments and affected cities diseases have drawn attention to how traditional throughout Asia, despite tremendous political cultural practices, higher population density and pressure and often adverse public opinion, increased mobility of human beings have created mustered the political will to enforce stronger contexts for animal viruses to cross over and surveillance, quarantine and isolation measures attack humans. In particular, Dr Shigeru Omi to control SARS. In Beijing, for example, at least cites the risks that come from: 30,000 people were quarantined and 20–30% of the population isolated themselves. In Guangxi, …the way animals are raised for food in gatherings of more than 50 people were banned. Asia, where increasing prosperity has led to a greater demand for meat, and , in some In Hong Kong, the designation of the Princess cultures, a taste for the flesh of exotic Margaret Hospital as the SARS hospital was a animals. In markets where wild animals are difficult yet crucial decision. At the end of the sold for the table, creates that would never epidemic, 62 staff were infected, 25 from the meet in their natural habitat are kept in intensive care unit. In late March 2003, Hong proximity to one another, setting the Kong’s Quarantine and Prevention of Disease conditions for the emergence of new viruses. Ordinance of 1936 was revised to include SARS A similar threat lies in the ways that and required medical practitioners to report chickens, ducks, and pigs are raised together, SARS to the Ministry of Health. This ordinance often in unhygienic conditions and usually required SARS contacts to report to medical with no barriers between them and humans. authorities within 10 days of exposure. The Such husbandry practices must change, or ordinance also enabled quarantine and later more viruses are likely to emerge from the evacuation of the residents of Block E, Amoy animal world.118 Gardens when evidence increasingly pointed to an environmental source of spread. Hong Kong’s Furthermore, the spread of the H5N1 virus in health promotion sector immediately seized the Viet Nam and Hong Kong was linked to opportunity to launch a Hygiene Charter that unrestricted poultry movement within and put forward suggestions and guidelines on hygiene between countries119 and the role of wet markets practices for more than 10 sectors: the personal in this process was highlighted.120 Because and family, management, buildings, catering, marketplaces in Asia have multiple economic, education, finance and commercial, industrial, cultural, social, religious and political functions, medical and health, public transportation, social closure of marketplaces was not an option. welfare, sports and culture and tourism.117 Countries such as Viet Nam managed to use the

In Singapore, cases were identified and isolated 118 promptly at Tan Tock Seng Hospital. Hospitals WHO WPRO. 2006. SARS: how a global epidemic was stopped. World Health Organization. improved infection control measures. Contact 119 Chen H et al. Establishment of multiple sublineages tracing was intensified. The Infectious Disease of H5N1 influenza virus in Asia: Implications for Act was amended to allow the Government to pandemic control. Proceedings of the National Academy compel contacts of suspected SARS cases to be of Sciences, 21 February 2006. quarantined at home and mandated fines for 120 FAO/OIE/WHO. 2005. Proceedings of the those who refused to comply. Consultation on Avian Influenza and Human Health: risk reduction measures in producing, marketing, and 117 http://www.hygienecharter.org.hk (accessed on 27 living with animals in Asia. Kuala Lumpur, Malaysia. April 2007). July 2005.

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avian influenza epidemic as a rallying point to Saharan Africa remains the region with the implement a Healthy Marketplaces initiative and greatest HIV prevalence. Of the 4.8 million new safer food systems. Prior to the avian influenza HIV infections worldwide in 2003, Asia outbreak, most Vietnamese markets did not have accounted for one in four. UNAIDS estimates separate areas for different types of food. Fresh that more than seven million Asians are living meat and poultry and cooked food were often with HIV, and that high-risk behaviors fuel the sold in the same stall. Sellers’ hands tended to be spread of the virus. Unsafe drug injections and unclean due to the lack of basic infrastructure for unprotected commercial sex are reported to be hygiene. responsible for most of the new infections in Asia. HIV/AIDS is predominantly urban in Asia, Under the Healthy Marketplaces initiative with though there is a paucity of data on intra-urban WHO, poultry sellers were given gloves, boots, differentials. and aprons to protect them from the virus and prevent them from handling live chickens with Every year, one billion people ride on China’s their bare hands as they had done before. They gigantic railway system. Beijing’s West Station also underwent monthly health checkups as a alone services 70,000 passengers daily and up to preventive measure. More importantly, they were 300,000 a day in peak holiday seasons. Many are told to keep the sick poultry out of the stalls; it migrant workers seeking jobs and considered to was well known that sick or dead poultry were be at high risk of contracting HIV/AIDS but who often secretly sold for a profit. Since the opening have little knowledge of the disease or of how of the new stalls, no poultry can be sold without condom use prevents infection. On average, a stamp of approval by food safety officials. Local passengers spend two hours in the station and 20 veterinarians have also been closely monitoring hours on trains. poultry suppliers in an effort to stop any smuggling or other illegal means of selling Since 2003, Beijing’s West Station has run an poultry from bird flu-infected areas. information campaign on HIV prevention.122 The organizers target waiting and traveling times, Both the sellers and consumers accepted the during which they believe passengers are changes (no live chicken sales at the market, receptive to hearing and accepting information among other new regulations) when it became about HIV prevention. The Beijing West Station obvious that cleaner markets and improved is one of nine stations participating in a market practices were absolutely necessary. groundbreaking project initiated by the Ministry of Railways, supported by UNFPA. The After the success in setting up Healthy programme taps into the railway’s massive Marketplaces in the famous tourist area of networks in reaching out to a vast audience, Ha Long, officials from Quang Ninh and Thai especially the floating population of migrants. Binh provinces have publicly stated their Evaluation on knowledge, attitudes and skills is admiration of the initiative and are considering on-going. duplicating the measures when they build new markets. The Ministry of Railways hopes to scale up the HIV/AIDS prevention efforts and expand the programme to its 5,700 railway stations across the Reaching out to migrants and floating country, a challenge that would require populations at risk for HIV/AIDS in Asian cities continued political and economic support. Asia121 is one of two regions with the most rapid growth in new HIV infections, even though sub- 122 Adapted from Christian Delsol and Patricia Chan. 121 Thompson, Drew. China confronts HIV/AIDS. 2006. UNFPA supports China to spread HIV/AIDS 6 June 2005. Population Reference Bureau. message. http://www.un.org/webcast/pdfs/unia1028.pdf www.synergyaids.com/documents/ChinaConfrontsHIV (accessed 22 April 2007). AIDS.pdf (accessed on 23 April 2007).

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Cultivating social solidarity and compassion for local people are accustomed to telling monks survivors of HIV/AIDS their troubles, the latter have become a conduit In predominantly Buddhist Thailand, the for identifying many undocumented HIV- application of the Four Noble Truths: Dukkha positive people who…can be referred to support (suffering); Samudaya (the origin of suffering); groups and public assistance programs. ‘HIV- Nirodha (the cessation of suffering); and Magga friendly’ temples encourage these people to (the path leading to the cessation of suffering) in participate in community activities.” HIV/AIDS education and intervention has profoundly improved communities’ ability to mitigate the suffering caused by the disease and 4. Improving efficiency in financing health raised people’s awareness about their power in promotion in cities face of the scourge. In Asia and the Pacific, it is estimated that less than 10% of national health expenditures go Since 2002, monks under the Sangha Metta to public health services that carry out both Project have been conducting community prevention and promotion.123 Considering the HIV/AIDS workshops that begin with one basic magnitude of public health challenges that could exercise: a reflection on the Four Noble Truths benefit from prevention and promotion, the that replaces “Dukkha” – suffering – with funds available for population health are a “HIV/AIDS”. pittance compared to what is spent on hospital services, treatment and cure. Initiated by monks themselves, the project was a direct response to inadequacies in the formal In this section, innovations in national financing health response and resources of the national mechanisms that enable the promotion and government. Thai leaders were quick to protection of health across the social gradient acknowledge that the formal structure was including cities are highlighted. insufficient and that they needed community leaders from various sectors to step forward. Preventive health check-ups for all as part of social health insurance coverage in Japan It was in this context that community-based Health inequity studies in a predominantly urban interventions such as the Sangha Metta Project country like Japan clearly indicate that provided a breakthrough. The first workshops socioeconomically disadvantaged populations are were held by abbots of temples in northern less likely to attend health checkups124. Though Thailand. Those abbots then brought along this example comes from a developed country, it monks from their respective temples, who in turn demonstrates how social health insurance can extended invitations to lay community leaders, become more than a “sickness fund” for the poor, including village headmen, members of village the elderly, the disabled and other disadvantaged development committees, and representatives of groups and can be used to promote health and the Tambon Administrative Council. prevent disease among vulnerable groups.

The impact was immediate and has been Currently, almost all medical treatments are sustained, demonstrating the power of building included in social health insurance benefits in social cohesion for addressing the social dimensions of the HIV/AIDS epidemic. These 123 Email exchange with Dr D Bayarsaikhan, Regional interventions help survivors from urban centres Adviser for Health Financing, WHO Western Pacific who return to their villages and may be Region on 27 April 2007. ostracized. Using Buddhist ethics as their starting 124 Fukuda Y, Nakamura K, Takano T. 2005. point and guide, the community leaders teach Accumulation of health risk behaviours in associated about high-risk behavior, set up support groups, with lower socioeconomic status and women’s urban provide training for livelihood, and help to take residence: a multilevel analysis in Japan. BMC Public care of AIDS orphans. Meanwhile, notes the Health, 5: 53. Buddha Dharma Education Association, “because

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Japan. However, health promotion activities marketing restrictions and aggressive health such as health checkups and counseling are not. communication strategies helped to bring down In response to the growing health expenditure, smoking from 35% of the 15-and-over population following an increase in the burden of in 1981 to 22% in 2001. noncommunicable diseases, the Health Insurance Law and Medical Care for the Aged has been What truly sets the Thai model apart is its amended to incorporate a health checkup provisions for sustainability, by drawing revenue package programme into the social health and budgets from the targeted industries insurance system from April 2008. themselves. Two percent of annual state revenue from tobacco and liquor tariffs is deducted as a The plan obliges insurers to provide effective contribution to a national health promotion packages of health education, checkups and fund. counseling to their insured members aged between 40 and 74. Insurers are also obliged to Today ThaiHealth spends 6% of its budget on set specific targets to be achieved over five years raising awareness of health issues and conducting by measuring the health outcomes of their client an annual “Cigarettes vs. National Health” groups. Insurers who meet their targets will be seminar to facilitate regular exchanges among rewarded with a reduced contribution researchers, campaigners and the general public. requirement to the Medical Fee Payment Fund as It also encourages the formation of networks and a part of the joint payment system for medical an academic centre on smoking control will be fees for the elderly. established to undertake further training and research on cigarettes and health, and to support By initiating this obligatory health checkup legal and economic measures that will help programme, it is hoped that inequities in access expose unethical practices by the tobacco to health promoting services will reduce. industry. Financial incentives to the insurers would facilitate the development of effective and ThaiHealth’s breakthrough has been a source of efficient programmes and would lighten the inspiration for other countries in the region that burden for health promotion among are at different stages of setting up autonomous socioeconomically disadvantaged groups. While infrastructure and financing for the promotion of this is an example in a developed and high- health such as the Malaysian Health Promotion income country, there are many lessons and Board. Similar initiatives for securing tobacco insights that are useful for developing countries taxes for health have been seen in Mongolia, the that are undergoing health sector reform and Philippines and Tonga.125 looking for ways to achieve greater efficiency in social health insurance packages. Financing Healthy Cities projects from tobacco taxes in the Republic of Korea Upping the ante for tobacco and alcohol taxes to promote health in Thailand 125 In 2006, the Thai government approved a Bt5 A health promotion leadership and training billion (US$ 125 million) budget to support programme for strengthening infrastructure and financing for health using the health promotion sports and cultural events, but that was only half foundation models of Vic Health, Thai Health and the of the story. On the other side of this Swiss Health Promotion Foundation was first programmed spending for health, much of that established by the WHO Western Pacific Regional earmark was sourced from a 2% annual “sin tax” Office in 2002 under the name of “Prolead”. Prolead, on tobacco and alcohol. as a regional capacity-building template, continues in the Western Pacific Region as “Prolead plus”, and has Thailand already has one of the strictest tax and now been adapted by the Eastern Mediterranean anti-tobacco regimes in Asia, and is considering Region through the WHO Centre for Health enforcing new measures to address health issues Development and WHO Health Promotion Unit, related to alcohol consumption. High taxes, strict Geneva.

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Article 22 of the Korean Health Promotion Act, The macro-social environment in both urban 1995 specifies that tobacco taxes are to be and rural settings – specifically, new (relative) allocated to the Korea Health Promotion Fund affluence, technological innovation, and (KHPF), the primary funding organization for commercialization – can help create fairer health national and regional health promotion opportunities for vulnerable groups. programmes. It is estimated that the KHPF Technological advances and media reach both collected US$ 1.429 billion in 2005 from this rural and urban populations, but are nonetheless tax, and allocated 65% to national health influential among the urban poor. insurance, 5% to cover the administrative costs and 25% to fund projects specifically focused on Village phone systems improve health the health promotion topics of nutrition, opportunities in Bangladesh physical activity, tobacco and alcohol.126 In Bangladesh, the peri-urban “villages” maintain rural features but are slowly becoming more While total sales of cigarettes are decreasing, the concentrated and closely linked to government is gradually raising the tobacco tax communication infrastructure of the city. In this and successfully maintaining the health context, the degree of mobility was one of eight promotion fund. Utilization of tobacco taxes for indicators used in a study to assess the degree of health promotion projects exceeds its value over women’s empowerment.128 Having a telephone the social compensations of polluters – it is in the house may therefore be not only a helping smokers quit, protecting non-smokers profitable business opportunity for a woman from secondhand smoke and helping all the operator, but also make it a space that is citizens to promote their health. Moreover, this acceptable for other village women to access. large, secured fund is allowing close, continuous Findings indicate clearly that when women are attention to helping the poor in a predominantly Village Phone Operators, they are more likely to urban country – 82% of the Republic of Korea’s feel comfortable using a phone and are likely to population is urban and its slum to urban have more equitable access to population is 37%127. telecommunications. There is evidence of increased social status that Village Phone In addition to the national tobacco tax that Operators have gained in their villages. For accounts for 14.2% of the total package price, example, the fact that better-off villagers now local governments are allowed to further place come to a poorer woman’s house to use the taxes on tobacco (up to 25.6% per package) phone is significant.129 These factors, plus the under the Local Tax Law, another article of the added income, contribute to the increased status Health Promotion Act. Wonju City is one of the of women in the village.130 Women’s cities that has moved to enforce this law. In empowerment is closely related to maternal and 2005, the local tobacco tax accounted for 19.6% child health. In other words, this technological of all revenue, the second largest among all the advance could be a model for improving health local taxes of the city, and the money was used equity in village settings. for promoting housing supply, clean water supply, as well as free health care projects for low-income Empowerment through electronic media families.

5) Applying information technology to 128 Hashemi SM, Schuler SR, Riley AP. Rural Credit population health activities Programme and Women's Empowerment in Bangladesh. World Development. 1996; 24(4):635-653. 129 Bayes A, von Braum J, Akhter R. 1999. Village pay 126 Nam EW, Engelehardt K. 2007. Health promotion phones and poverty reduction: Insight from a Grameen capacity mapping: the Korean situation. Health Bank initiative in Bangladesh. Information and Promotion International (published online). Communication Technologies and Economic 127http://www.unhabitat.org/list.asp?typeid=44&catid= Development. 31 May-1 June. 65 (accessed on 3 May 2007). 130 Ibid.

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Another example of how technological transfer of telephones to provide health information and has improved women’s health comes from India, easier access to health services in Mongolia, and where the unmet need for reproductive health use of SMS text messages in the Philippines for care requires a wide demand net. In addition to national health campaigns. All of these have the supply of oral contraceptives, condoms and brought empowerment and strengthened social IUDs, a “non-supply” approach for increasing cohesion within those societies.136 contraceptive prevalence is recommended through education. The expansion of education Geographic Information Systems (GIS) for city through innovative technology in urban areas is health programmes partly responsible for the recent decline in In the Visayas region of the Philippines, a fertility in India. The community can – through number of local governments are leading the way technologies such as radio and television – in exploiting Geographic Information Systems become a key force in knowledge-sharing for (GIA) technology to improve urban centers. In greater contraceptive prevalence and also to the province of Capiz, for example, a “Backyard support its service sector. GIS” system – built on the backs of low-end computers and using existing data from previous In other countries, USAID has supported family government surveys – was used to help policy- planning programmes that utilize strategic makers and community members to take part in communication principles, including the what was billed a “Participatory Planning integration of entertainment and education Budgeting Workshop”. With leaders and their (“enter-educate”) to promote family planning, constituents looking at the same picture and increase social acceptance of artificial standing over the same page, GIS helped to contraceptives, and generate public demand for identify the community’s infrastructure and higher quality of reproductive services in the investment plans and projects, and helped public and private sector. These types of develop a list of priorities for funding. interventions have been documented by the Johns Hopkins Centre for Communication In the larger Visayan metropolis of Cebu City, Programmes131 and include success stories from GIS technology is used by the city government to Indonesia (“the Blue Circle”132), Bangladesh quickly identify “disparity areas” or to undertake (“the Green Umbrella”133) and the Philippines “poverty mapping” that can more compellingly (“Sentrong Sigla”134 – centres of vitality). call officials’ attention to problem areas. In health care, for example, GIS maps give city Other examples of using innovative technology planners the ability, in one glance, to monitor for health improvements in urban settings are: the spread and distribution of Cebu’s programmes promotion of literacy and health issues such as for maternal and child health. Through colour- HIV/AIDS awareness through radio soap operas coded representations of the city’s various in Cambodia; using bikes as innovative billboards barangays (villages), for example, they can and motorcycles for the disabled in China;135 use immediately see where there are too few health workers, or where there are higher or lower 131 incidences of infant mortality. This ability to http://www.jhuccp.org/quality/accredit.shtml quickly analyse in turn allows the local (accessed on 25 May 2007). government to formulate policies and/or direct its 132 http://www.constellafutures.com/abstract.cfm/219 limited resources. Cebu officials credit GIS (accessed on 25 May 2007). 133 http://www.green-umbrella.net/ technology with helping them to narrow the gap (accessed on 25 May 2007). between the health realities of “disparity areas” 134http://www.jhuccp.org/asia/philippines/sentrong.sht and that of the larger region and country. GIS, ml accessed on 25 May 2007). 135 Kohrman M. Motorcycles for the disabled: mobility, modernity and the transformation of experience in 136 WHO. Choosing the Channels of Communication: urban China. Cult Med Psychiatry. March 1999; a review of media resources for 11 countries in the 23(1):133-155. Western Pacific Region. Manila: WPRO; undated.

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for example, shortened the working time it took Olympics to ensure the games are smoke-free. for officials to check areas where immunization Smoking will also be banned at all hospitals was not being delivered and/or is still urgently serving the games by the end of 2007. The no- needed. smoking rule will also apply to public areas like public transport depots and offices. Places that So impressed and rewarded has Cebu been in its serve children will be a priority. experience with GIS that the city’s own GIS Center now assists local government departments Viet Nam’s laws already ban smoking in public on questions such as how to improve tax places. But getting people to respect the law collection and how to prevent fires in the remains a problem. Culture and lack of community. They also help the city’s Urban Poor knowledge about tobacco-related laws and health Division in seeking options for providing shelter issues prevent non-smokers from speaking up and tenure to the urban poor. The technology, in next to or in the face of smokers in public places. other words, has now become a standard support Nor is there widespread practice of tolerating service provided by the city government to all its such requests to stop smoking in this nation departments. where 52% of men (but just 1.8% of women) are still smokers. At the Hanoi railway station, some 6) Optimizing social determinants of guards reported having been threatened by health in urban settings smokers with a beating.

Changing the norm for citizens’ enforcement To introduce and promote the notion that of smoke-free policies smokers can and should be reminded not to light Since the Olympic Games were declared up in public places, Vietnam declared the 2003 tobacco-free in 1988, international tobacco-free Southeast Asian Games in Hanoi and Ho Chi sports events have helped boost host country and Minh City tobacco-free – then let volunteers set city efforts to curb tobacco use in other sports the example by stubbing out all cigarettes at the events as well. In 2002, the FIFA World Cup venues. Uniformed volunteers approached championship events held in the Republic of smokers in the stadiums and politely asked to put Korea and Japan were declared smoke-free. In the out their cigarettes. It was a simple act, repeated same year, FIFA received a tobacco control thousands of times throughout the days and award from the World Health Organization.137 venues of the games; Vietnamese officials believe it has had a lasting impact and support the long- Recently, Beijing has banned smoking in term efforts of the Vietnam Committee on restaurants and popular tourist spots in the lead- Smoking and Health (VINACOSH). “Anti- up to a smoke-free Olympic Games. Olympic smoking is not a priority for Vietnamese because venues, hotels and restaurants located inside the we are still facing a lot of other (economic) Olympic village will be smoke-free before June hardships,” said Do Thi Phi, who used to work 2008. The smoking ban was jointly issued by the for the International Development Enterprise city’s health bureau, tourism bureau and bureau NGO, a partner of the government and the of commerce. Beijing started working to reduce WHO in the anti-smoking push in Vietnam. smoking in public places a few years ago. As early “The SEA Games was the biggest event so far to as 2004, Chinese Premier Wen Jiabao said China attract people’s attention to the issue, and it would make creating a smoke-free Olympics a became an important venue to raise their priority in its preparations for a green Olympics, awareness.” and last year, Ministry of Health official Zhang Bin said the ministry was working with the Beijing Organizing Committee for the 2008 “Intergenerational” walking for health creates caring cities Statistics show the Asian population is ageing, 137http://www.paho.org/English/DPI/100/100feature22. presenting the challenge of how a smaller, htm (accessed 2 May 2007). younger generation will care for a much larger,

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older generation. The United Nations projects training programmes on how to budget a the number of Asians aged 65 and older will minimum wage for nutritious meals for a family increase more than 300% between the years 2000 of five, how to write a curriculum vitae, how to and 2050 – from 207 million to 857 million.138 In prepare for a job interview and so forth. Asia, governments’ long-term responses to Volunteers also receive health training and are demographic change and population ageing in able to serve as volunteer health workers. They urban centres are critical even at this stage. are also given job experience to rebuild confidence in their ability to take on productive Singapore has started to prepare for the future work – as clerks, community health workers or as through activities such as brisk walking and mass greeters for the local tourist programme. For four Qigong exercises initiated by its Health hours a day, individuals receive a wage of 100 Promotion Board (HPB) and implemented via pesos (roughly $2). the City’s five Community Development Councils (CDCs). To date, the five CDCs offer Through the programme, more than 4,000 37 programmes to assist special segments of the volunteer health workers have been added to the population, including the elderly, the young, and city’s health workforce. The impact on health the handicapped. Senior Minister Goh Chok systems was immediate. And while it is difficult Tong says CDCs have “touched the lives of to attribute reduction in diarrheal disease or 180,000 needy Singaporeans.” lower dengue prevalence rates to this single intervention, the approach demonstrates the The Brisk Walking Clubs represent just one importance of local government accountability outreach activity. The HPB and CDCs also for human resource development at the provide basic health screening in the community municipal level. But even beyond this, Mayor for people over 50, charging them a token S$2. Marides Fernando says the programme was also But it is the walking clubs, the organized about “creating opportunities for the people.” exercises, and the community activities that The volunteerism is just a start. After the reach people on any given day. Social cohesion, volunteers’ stints are over, their names and decency, respect and trust are built through these qualifications are added to an employment pool interventions. In Singapore, the elderly do not that where both private and public entities can walk alone. try to match organizational needs with individual skills. Mayor Fernando says the volunteer Life skills and pre-employment training program gives her constituents added capacity programmes provide a fairer chance for and capability to compete in the job market. The employment of the urban poor Marikina government allots some 15 million Marikina City, Philippines has been a Healthy pesos ($300 000) a year to maintain the City for more than 10 years and is recognized programme. From the perspective of the local locally and internationally. In 2004, it embarked government, the dividends, clearly, far outweigh on a human resource development project called the cost. “The Marikina City Volunteer Corps” that sought to overcome social barriers to formal Fuel regulation policy results in healthier city employment among the urban poor. Encouraging air for all the urban poor to participate in the network, the “New Delhi was choking to death,” says Sunita programme doubles as emergency employment as Narain, director of India's Center for Science and well as providing “transformation and Environment. “Air pollution was taking one life preparation of the poor for regular employment”. per hour.” Adds Bhure Lal, 63, then a senior The “volunteers” are engaged in life-skills government administrator: “The capital was one of the most polluted on earth. At the end of the day, your collar was black, and you had soot all 138 Brick, Gabrielle/Hong Kong. Asia - home to half the world population - is graying. Voice of America. 11 July 2006.

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over your face. Millions had bronchitis and Narain and Lal don’t claim to have slowed global asthma.”139 warming. But their efforts have attracted requests for advice from as far away as Kenya and For the past decade, local advocates and Indonesia.142 champions from civil society have worked toward regulations to force Delhi’s buses, taxis and rickshaws to convert to cleaner-burning VI. Synthesis, strategic entry points for compressed natural gas (CNG). In July 1998, the scaling up action and conclusions Supreme Court ruled largely in favor of the proposal and ordered a ban on leaded fuel, Synthesis of findings and some thoughts on conversion of all diesel-powered buses to CNG opportunities for building on current and the scrapping of old diesel taxis and innovations rickshaws. But the powerful lobbying of Innovations in population health that impact the busmakers and oil companies – supported by urban poor in Asia have been driven by players government ministers – created obstacles to and stakeholders who have been able to shape implementation. Bus companies took vehicles off the new political space created by globalization, the road, stranding angry commuters. Endless urbanization, decentralization, democratization queues of rickshaws formed at the handful of gas and advances in information technology to stations with CNG pumps. Oil companies trotted create opportunities, build capabilities, achieve out scientists who claimed that CNG was just as greater security, empower, engage and mobilize polluting as diesel. But Narain and Lal fought support for policy and action to improve the back. By December 2002, the last diesel bus had urban living environment for vulnerable left Delhi, 10,000 taxis, 12,000 buses and 80,000 populations. rickshaws were powered by CNG140, and now, the city stands as the world’s best test case for Within the set of examples used for this report, it CNG. is clear that a social movement exists to confront the stark inequities in cities that create and Narain estimates that Delhi’s air pollution would perpetuate inequity and vulnerability that result be 30% higher now but for the introduction of in poor health. CNG. Although air pollution in Delhi has stabilized, the fight for clean air is far from won. The primary stakeholders of this movement are Some 400 to 600 new private cars roll onto the organized groups of the urban poor prepared to city’s streets every day. Recent evaluation of the negotiate for the requisites of a decent life and impact of fuel-switching in New Delhi shows better health: secure housing, land rights and that the conversion of buses from diesel to CNG micro-financing. These groups have discovered has helped to reduce PM10, CO and SO2, but the power of their numbers and have shown how that conversely, no gains have been realized from networked and “asymmetric” governance nodes the conversion of three-wheelers from petrol to operate in a global environment. They CNG, possibly because of poor technology. The demonstrate how once-marginalized groups can gains are also being undermined by the increase bring powerful gatekeepers and interests to the in the proportion of diesel-fuel cars and rising negotiating table. distances traveled by all types of vehicles, pointing to the need for more aggressive City and municipal officials who must deal with promotion of public transport policy.141 the political implications of rising inequity in cities are feeling the heat and becoming 139 Alex Perry/New Delhi. Delhi Without Diesel. Time increasingly responsive to the needs of the urban International, April 3 2006: 48. http://www.proquest.com/ (accessed May 1, 2007). 140 Alex Perry/New Delhi. 07-08, Resources for the Future, Washington, D.C., 141 Urvashi Narain and Alan Krupnick. The impact of 2007. Delhi’s CNG program on air quality. Discussion paper 142 Alex Perry/New Delhi.

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poor. They are less threatened and more open to Asia is also showing how it can use its wealth for engaging with them to find solutions that will health. Innovations in the financing of health work as a means to achieving both economic and promotion (social health insurance and tobacco their political goals and the social goals of their and alcohol taxes) and the uptake of modern city. Increasingly, local governments of cities and information technology in health planning and municipalities (exemplified by the Healthy Cities public health education have been noted. champions) are holding themselves accountable Investments need to be made on healthy systems for health and its determinants and there are at all levels, but more so in urban areas. examples in every country of how local leaders Training, leadership development urban health are using intersectoral approaches and more information systems and new and innovative participatory approaches to governance over ways of financing health promotion, protection, health, the environment and social development. treatment, cure and emergency services are Local governments are also using city-to-city needed. connectedness (that has evolved through trade and business) as a means of learning and building Last but not least, interventions are needed that capacity for health. Partnership between the build social cohesion and address the social business sector and local governments within a determinants of health point to a growing framework of corporate social responsibility is on recognition of the links between social norms the rise. In order for healthy urban governance to and fairer health opportunities, as demonstrated flourish, enabling conditions need to be created by tobacco-free sports, pre-employment capacity and sustained at the national level. building for the urban poor and urban policies for Decentralization policies have enabled local cleaner air. Again, social health issues need to governments to break free from the stranglehold recognized and addressed in many different types of national bureaucracies and hierarchies, even if of urban activities. in many countries this process is incomplete and poorly supported. In this respect, national Strategic entry points for scaling up action governments need to develop clear policies and 1) Engage with the key actors of the strategies to manage rapid urbanization and existing social movements. As in any health, and human development should be at the social movement, there are political centre of this agenda. leaders at all levels (local, national, global) who are recognized and have Recent outbreaks of infectious disease in Asia gained credibility over many years of have prompted national authorities and staying focused on issues. Engagement ministries of health to pay closer attention to with these key actors requires an health risks and vulnerabilities created by the appreciation of the asymmetry of the urban dimensions of communities: density, movements and skill in maneuvering crowding, increased mobility, connectivity and through networked or nodal diversity. Promoting health and hygiene in the governance. One cannot go to the front different elemental settings of the city – of the parade and expect to lead it. marketplaces, restaurants, schools, ports, airports – is now higher on national health agendas and 2) Support the creation of “global creates a gateway of opportunity for public health knowledge markets” for healthier infrastructure development, be it surveillance, cities. In many instances, effective quarantine, isolation, hospital preparedness, sharing of knowledge of municipal emergency response, or outbreak regulations and policy options may be all that is needed laws. This should be sustained and must be to change what seem to be intractable extended gradually to pursue the unfinished problems. Previous work done by UN- agenda for water, sanitation and waste HABITAT and UNDP demonstrate management in urban informal settlements. how urban governance tools, systems for recognition for good practices and city- to-city learning mechanisms can bring

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about a critical level of change. Global between economic, social, political and cultural coalitions and alliances of cities such as development, and establish governance support UCLG, Metropolis and the Cities mechanisms that enable communities and local Alliance can strengthen their focus on governments to partner in building healthier and health as part of their current agenda. safer human settlements in cities. There is clearly a demand and willingness among cities to pay for Healthy urban governance, as an evolving understanding of how practical approach to reducing the health vulnerabilities of interventions can be applied to specific the urban poor in Asia, is achievable. Principles contexts. These knowledge markets of good governance need to be continuously need not be confined to Asia and could applied to the promotion and protection of have a global reach. health. There is no “one-size-fits-all” solution, and actors will need to continuously navigate a 3) Partner with global media to define fast-changing environment in order to achieve more “responsive fora” that can help results. Nodes of power and influence among the the actors reach a tipping point urban poor, local governments and the public together. Engaging with other health sector are growing and discovering their stakeholders who have a natural interest cross-linkages across geopolitical regions. In Asia, in transparency and accountability i.e. as in other cities in the world, there are countless global media, creates opportunities for examples of living networks of people, reaching a wider audience for political communities, organizations and institutions who mobilization. The SARS and avian flu have the knowledge, skills and resources for threats demonstrated the power of scaling up change. They could certainly benefit global media as a means of controlling from a more supportive and enabling an epidemic, albeit indirectly. environment for achieving fairer health opportunities for all. Rendering visibility to the Conclusions health vulnerabilities of the urban poor through We referred to “healthy urban governance” at skillful framing of public policy issues seems to be the start of this paper and reiterate the need for a an effective starting point. broad perspective on urban health in development:

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Cashin, Cheryl E, Michael Borowitz, Olga Dang, Anh, Sidney Goldstein, James Zuess. 2002. The gender gap in primary health McNally. Internal migration and development in care resource utilization in Central Asia. Health Vietnam. The International Migration Policy and Planning 17, no. 3 (September 1): Review 31, no. 2 (July 1997): 312-337. 264. David AM, Mercado SP, Becker D and Edmundo Celine D’Cruz and David Satterthwaite. Building K (2006): Approaches to prevention and control homes, changing official approaches: the work of of HIV/AIDS, TB and vector-borne diseases in the urban poor organizations and their slums and informal settlements. Thematic paper federations and their contributions to meeting for KNUS second meeting (a shorter paper is the Millennium Development Goals in urban published in the Journal of Urban Health in June areas. IIED Working paper 16, Poverty 2007 with similar title and the same authors). Reduction In Urban Areas Series, IIED, 2005. Dick, HW, Rimmer PJ. Beyond the third world Chatterjee, Patralekha, 2002. South Asia’s city: The new urban geography of South-east thirsty cities search for solutions. The Lancet 359, Asia. UrbanStudies 35, no. 12 (December 1998): no. 9322 (June 8): 2010. 2303-2321.

Chen, Bo, Zhiyi Bao, Zhujun Zhu. Assessing the Dixon J et al. (2006): The health equity Willingness of the Public to Pay to Conserve dimension of urban food systems. Thematic paper Urban Green Space: The Hangzhou City, China, for KNUS second meeting (a shorter paper is Case. Journal of Environmental Health 69, no. 5 published in the Journal of Urban Health in June (December 2006): 37-38. 2007, with similar title and the same authors.)

Cheng, Margaret Harris. China’s cities get a little Dong, Weizhen. Can health care financing healthier. The Lancet 368, no. 9550 (25 policy be emulated? The Singaporean medical November 2006): 1859-1860. savings accounts model and its Shanghai replica. Journal of Public Health 28, no. 3 Clark, David. Interdependent urbanization in an (September 15, 2006): 209. urban world: An historical overview. The Geographical Journal 1 164, (March 1998): 85- Donnelly CA, et al. Epidemiological 95. determinants of spread of causal agent of severe acute respiratory syndrome in Hong Kong. Lancet 361, no. 9371 (24 May 2003): 1761-6.

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WHO (2005d) CSDH, Towards a conceptual World Bank, (2006b). “The Social framework for analysis and action on the social Accountability Sourcebook.” vol. 2006: determinants of health. Draft discussion paper Washington, D.C., World Bank. 1.7.2005 (a later version from 2006 exists). Worldwatch Institute (2007) State of the world. WHO (2005e) Preventing chronic diseases – a Our urban future. Washington, D.C., vital investment. Geneva, World Health Worldwatch Institute. Organization. Xu F, Yin X, Zhang M, Shen H, Lu L, Xu WHO (2006) Guidelines for drinking water Y. Prevalence of Physician-Diagnosed COPD and quality. 3rd edition. Geneva, World Health Its Association With Smoking Among Urban Organization. and Rural Residents in Regional Mainland China. Chest 128, no. 4 (October 2005): 2818- WHO (2006a) Factsheet on overweight and 23. obesity online. www.who.int- dietphysicalactivity/ Xu X, Zhu F, O’campo P, Koenig MA, Mock media/en/gsfs_obesity.pdf. V, Campbell J. Prevalence of and risk factors for intimate partner violence in China. American WHO (2007) Scoping paper: Priority public Journal of Public Health 95, no. 1 (January health conditions. Version 3.1, January 4, 2007. 2005): 78-85. CSDH Knowledge Network on Priority Public Health Conditions. Geneva, World Health Youngblood, Robert L 1998. President Ramos, Organization. the Church, and population policy in the Philippines. Asian Affairs, an American WHO/FAO (2003). Diet, Nutrition and the Review 25, no. 1 (April 1): 3-19. Prevention of Chronic Diseases. Report of a Joint WHO/FAO Expert Consultation. Technical Yuen, Belinda. Urban Development and New Report Series 916. Geneva, World Health Towns in the Third World: Lessons from the Organisation. New Bombay Experience. Urban Studies 37, no. 11 (October 2000): 2126. WHO/WKC (1998) World Atlas on Ageing. Kobe, Japan: WHO Centre for Health Yusuf, S, Nabeshima K and Ha W (2006) What Development. makes cities healthy. Thematic paper for KNUS second meeting (a shorter paper is published in Winters, Jeffrey A. The political impact of new the Journal of Urban Health in June 2007, with information sources and technologies in similar title and the same authors). Indonesia. Gazette 64, no. 2 (April 2002): 109- 119. Zainal M, Ismail SM, Ropilah AR, Elias H, et al. Prevalence of blindness and low vision in Woods, Robert. Urban-rural mortality Malaysian population: results from the National differentials: An unresolved debate. Population Eye Survey 1996. British Journal of Ophthalmology. and Development Review 29, no. 1 (March Sep 2002. Vol. 86, Iss. 9; p. 951. 2003): 29. World Bank, (2004). “Social Accountability: An Zimmer, Zachary, Julia Kwong. Socioeconomic Introduction to the Concept and Emerging status and health among older adults in rural and Practice.” World Bank, Washington, D.C. urban China. Journal of Aging and Health 16, no. 1 (February 2004): 44-70. World Bank, (2006a). “Global monitoring report 2006. Millennium development goals.” Washington, D.C., World Bank.

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Annexes from Pakistan, a huge influx of refugees caused a grinding famine. It was in this context that Annex 1: CASE STUDIES Grameen Bank and BRAC started their programmes. Whereas BRAC143 was set up as a Case study: Bangladesh support and rehabilitation programme, the Graemeen Bank was established as a purely Microcredit in urban setting: Grameen Bank microcredit institution. BRAC expanded and and BRAC increased its attention to education and skills training; eventually, microcredit was also added Kirsten Havemann as one of the major pillars of the programme. Technical Officer, Health Governance Research Today, BRAC is still refining this holistic WHO Centre for Health Development “credit-plus” approach. The broader ambition of Kobe, Japan BRAC is stated succinctly in the “Seventeen Promises”, something of a credo for BRAC and Summary its members. Grameen Bank144 has added some The Grameen and BRAC microcredit initiatives in Bangladesh have reported success in reducing 143 The seventeen promises are the following: 1) We vulnerability and enhanced social networks and shall not do malpractice and injustice; 2) We will work empowerment among its village members. As a hard and bring prosperity to our family; 3) We will result, villages have been prevented from falling send our children to school; 4) We will adopt family deeper into poverty. However, there is no clear- planning and keep our family size small; 5) We will try cut conclusion as to whether microcredit has to be clean and keep our house tidy; 6) We will always succeeded in addressing social gradients among drink pure water; 7) We will not keep our food the poor or the wider socioeconomic and cultural uncovered and will wash our hands and face before we determinants of health. take our meal; 8) We will construct latrines and will not leave our stool where it doesn’t belong; 9) We will Description cultivate vegetables and trees in and around our house; Trough the scope and outreach of their 10) We will try to help others under all circumstances; microcredit efforts, the Grameen Bank and the 11) We will fight against polygamy and injustices to Bangladesh Rural Advancement Committee our wives and all women; 12) We will be loyal to the (BRAC) have found fame in the international organization and abide by its rules and regulations; 13) setting. Both have generated an international We will not sign anything without having a good wave of interest and been the main source of understanding of what it means (we will look carefully inspiration for the microcredit movement, which before we act); 14) We will attend weekly meetings was launched in 1997 as a “global movement to regularly and on time; 15) We will always abide by the reach 100 million of the world’s poorest families, decisions of the weekly group meeting; 16) We will especially the women of those families, with regularly deposit our weekly savings; 17) If we receive a loan, we will repay it on time. credit for self-employment and other financial 144 and business services, by the year 2005” (MCS, 1) We shall follow and advance the four principles 1997). In fact, Muhammad Yunus, the “Father of of Grameen Bank – Discipline, Unity, Courage and the Grameen Bank”, was recently awarded a Hard Work – in all walks of our lives; 2) Prosperity we shall bring to our family; 3) We shall not live in Nobel Peace Prize for his efforts in providing dilapidated houses. We shall repair our houses and access to funds to the poor. work towards constructing new houses at the earliest; 4) We shall grow vegetables all the year round. We In Bangladesh, 16 million people are clients of a shall eat plenty of them and sell the surplus; 5) During microcredit institution. More than 2.3 million the plantation seasons, we shall plant as many are involved in the programme of Grameen Bank seedlings as possible; 6) We shall plan to keep our and more than 2.7 million in the programme of families small. We shall minimise expenditures. We BRAC (CDF, 1999). The roots of Grameen shall look after our health; 7) We shall educate our Bank and BRAC go back to the early seventies children and ensure that we can earn to pay for their when, after the independence of Bangladesh education; 8) We shall always keep our children and

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training and education to its programme over the provide a space that is acceptable for other years but overall, BRAC represents a more village women to access. Our findings indicate holistic approach to development through clearly that when women are village phone (VP) microcredit. Both credit schemes work through operators, female Grameen Bank members are peer pressure and group solidarity where members more likely to feel comfortable using a phone and of groups of five take solidary responsibility for will likely have more equitable access to a phone. the loans. Social networks are therefore of vital There is evidence of increased social status that importance for the implementation of the Village Phone operators have gained in their microcredit schemes and their sustainability. The villages. For example, the fact that better-off repayment rate rarely falls below 90% – a figure villagers now come to a poorer woman’s house to that commercial banks in Bangladesh have not use the phone is significant (Bayes, von Braum reached (Develtere and Huybrechts, 2002). and Akhter, 1999). The woman’s house is a Although the group mechanism has always been centre of activity, with people waiting to make or considered the key factor of Grameen Bank’s receive calls. Moreover, the woman becomes very success, not everybody is in agreement on this aware of the private and personal matters of front. Jain (1996) sees strong decentralization, many villagers. These factors, plus the added combined with an extensive information and income, contribute to her increased status in the communication system, as the source of success village (Bayes, von Braum and Akhter, 1999). for both Grameen Bank and BRAC. The specific organizational structure makes good management During interviews it was related how the phone is and transparency possible. On decentralization, integrated into a woman’s busy routine, both day Grameen Bank goes even further than BRAC by and night. When the phone is mobile, the employing members in the head office and giving operator has the ability to keep it with her while everybody the opportunity to become she is doing household chores or operating shareholders. another business enterprise. While there is clearly an inconvenience with phone calls and One success story: village phone operators errands, most women operators we interviewed Degree of mobility is one of eight indicators used felt that the benefits overrode the limitations. in a study to assess the degree of women’s The average income earned contributes 30–40% empowerment (Hashemi, Schuler and Riley, of the household income (Bayes, von Braum and 1996). Having a telephone in the house may Akhter, 1999). It is therefore not surprising that therefore not only be a profitable business many family members of Village Phone operators opportunity for a woman operator, but may also are also involved in the business. When a phone call is received, children are sent off as messengers to inform a village member. the environment clean; 9) We shall build and use pit- Husbands, sons and daughters of VP operators latrines. We shall drink water from the tube-wells. If it that we met proudly confirmed that they knew is not available, we shall boil water or use alum; 10) how to operate the phone. Adolescent children We shall not take any dowry at our sons’ wedding, were able to easily tell us the international neither shall we give any dowry at our daughters’ dialling codes for countries such as Saudi Arabia wedding. We shall keep the centre free from the curse and Kuwait. of dowry. We shall not practice child marriage; 11)

We shall not inflict any injustice on anyone, neither Conclusion shall we allow anyone to do so; 12) We shall collectively undertake bigger investments for higher Several assessments (Develtere and Huybrechts, incomes; 13) We shall always be ready to help each 2002) have shown that access to microcredit in other. If anyone is in difficulty, we shall all help him or the villages of Bangladesh has definitely her; 14) If we come to know of any breach of discipline succeeded in reducing members’ vulnerability in any centre, we shall all go there and help restore and therefore prevented them from falling even discipline; 15) We shall introduce physical exercise in further into poverty. The direct and indirect all our Centres. We shall take part in all social effects on health are clear, such as improving activities collectively. children’s health and welfare as well as food

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consumption and promoting health knowledge Bank and BRAC voice their opinions on (Hadi, 2001). national and international development issues. However, what effect and impact their advocacy Assessment of the social impact of these strategies have is not known. initiatives has been done through an examination of the situation of poor women in References the patriarchal society of Bangladesh. Several Bayes A, von Braum J and Akhter R. 1999. Village pay authors shared the opinion that Grameen Bank phones and poverty reduction: Insight from a Grameen and BRAC have a positive influence on their Bank initiative in Bangladesh. Information and female members. Women’s increased Communication Technologies and Economic involvement in family decisions, expanding Development 8. knowledge, awareness and an improved situation CDF. 1999. Microfinance statistics of NGOs and other for children were the most important ways in MFIs. Dhaka: Credit and Development Forum. which membership helped boost their status. Develtere P, Huybrechts A. 2002. Evidence on the social and economic impact of Grameen Bank and First of all, the social inputs of the programmes in BRAC on the poor in Bangladesh (report). Leuven: terms of individual empowerment and Katholieke Universiteit. capabilities (knowledge, awareness, health) Hadi A. 2001. Promoting health knowledge through would also affect non-members in the microcredit programmes: experience of BRAC in community. Secondly, an increase in the supply Bangladesh. Health Promotion International. 16, 219- 227. of credit would lead to a decline in interest rates.

Wages may also be positively affected by microcredit programmes. However, it is also clear that the poor are not a homogeneous group: social gradients play a big role leading to self- selection and self-exclusion, due often to ill- health on the part of female-headed households. It is indicative that these microcredit schemes alone cannot eliminate vulnerability but that more is needed. Poor people who do not have the needed assets, social relations or self-confidence have to be reached differently.

Finally, it is not clear what impact Grameen Bank and BRAC – or other microcredit programmes – have on the wider social, economic and political environment. While on the one hand religious leaders see Grameen Bank and BRAC as endangering traditional values, on the other hand local and national leaders have tried to work together with them. Grameen Bank and BRAC have continued to mobilize their members around very sensitive issues such as the ones retained in the “sixteen decisions” of Grameen Bank and the “seventeen promises” of BRAC. However, no research has been done on the impact of this sensitization and mobilization on the ideas and practices of members, nor on the way family members and other villagers react to them. The same applies for the advocacy work done by both institutions. Increasingly, Grameen

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Case study: China This also led to applying measures used in controlling SARS to HIV/AIDS prevention. HIV/AIDS prevention in Beijing, China For the city of Beijing, as for the country as a Kirsten Havemann whole, the culmination of the control of Technical Officer, Health Governance Research HIV/AIDS was a legislative framework to control WHO Centre for Health Development the pandemic. Major initiatives are currently Kobe, Japan being implemented: 1) case detection through surveillance, such as Voluntary Counseling and Summary Testing, which is free for the poor and 2) Innovative approaches to fighting HIV/AIDS in educating the public through community China have shown that certain key campaigns and social marketing with the aim of interventions, combined with an enabling raising awareness and reducing stigma. National environment, must be present for success. This is legislation has outlined requirements for local apparently more so in urban settings due to the governments, educational institutions, ministries, concentration of intravenous drug users, businesses, health providers, custom and border commercial sex workers and the urban setting as control and the media. One example is given a departure, arrival and transit point, men having below from the Ministry of Railways. It has sex with men and plasma donors. Four factors addressed the floating population in Beijing in have driven China’s response to the HIV/AIDS view of the sheer size and broad movement of pandemic: 1) building of social capital (bonding, this population, and its work may well prove a bridging and linking) among people within the “tipping point” in AIDS prevention and control government system; 2) creating and in China.145 dissemination of scientific information; 3) external influence – partly provoked by the Beijing SARS epidemic; and 4) political will to act One billion passengers ride China’s vast railway created by the three other factors. system each year. Millions are rural migrants seeking jobs in the cities. A significant number Description may engage in behavior that puts them at risk of In 2002 it was predicted that China could have acquiring HIV, but many know next to nothing 10 million infected HIV-infected individuals by about how the virus spreads or how to prevent 2010. The following year, the emerging SARS infection. epidemic further challenged the effectiveness of existing HIV/AIDS interventions by putting Train travel offers a unique opportunity to stress on the health sector’s capacity. But instead educate this large floating population about HIV. of compromising resources and technical inputs, Since 2002, an innovative campaign has this motivated the government to take aggressive mobilized Chinese railway workers for this task. action on HIV-related issues. SARS not only (See a video on this campaign: showed how infectious diseases could threaten http://www.unfpa.org/video/2006/china_railway_ economic and social stability but also how a 06.htm) health security risk could affect China’s policies. Policy-makers announced a change of focus from “On average passengers will spend two hours in purely economic goals to more focus on health the station and 20 hours on the train,” notes Han and social well-being with an increased resource Shu Rong, Deputy Director General in the envelope. The fact that controlling SARS Ministry of Railways’ Department of Labour and created contact within and between government Health. “There is a lot of time to conduct offices at a different level as well as linking the government with international agencies such as the WHO and other UN agencies and the US 145 Anonymous. AIDS cases soar in China with Center for Disease Control stimulated stronger estimated 500,000 infected. AIDS Weekly. Sep 25 networks, communication and collaboration. 2000:19.

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activities on AIDS prevention. It’s easy for flash messages about HIV and in the waiting people to accept it.” rooms large screens televise instructive videos. Station workers often distribute brochures. On the 44-hour journey from Beijing to During busy travel periods, such as the annual Panzhihua, a city located in the south of Sichuan spring holiday when up to 300,000 passengers a province, two half-hour prevention messages are day use the station, workers staff tables to give broadcast over the train’s video screens, one in out information face-to-face. In the station’s the morning and one in the evening. Staff also clinic, health personnel provide counseling. hand out flyers, and they have been trained to People who want to know their HIV status are answer questions about HIV. “We pay special referred to testing facilities. attention to providing information to the passengers,” says conductor Jiang Xiao Ying. Condom promotion, once a sensitive topic in China, is an explicit part of the railway “The main target group is men between 25 and campaign. Information materials stress the 40,” Han states. “Rural people are shy talking effectiveness of condoms in preventing HIV about sexual issues. We conducted research on infection. Condom vending machines have been the effectiveness of different approaches to shape installed in station toilets, but Han acknowledges messages for migrants and it seemed that that they are often out of order, adding, “We are HIV/STD prevention activities are acceptable trying to procure better machines.” among rural-to-urban migrants146 and that there is an urgent need for HIV/STI prevention To Siri Tellier, former UNFPA Representative in programs that address the cultural, social, and China, the railway campaign is indicative of a economic constraints facing the migrant high level of official commitment to fighting the population in China.147 epidemic: “I think it’s quite clear and widely recognized that the Chinese Government has “In a limited time, we try to get across really taken much stronger steps to prevent HIV information about the three HIV transmission in the last three years.” routes and prevention. Our research indicates (http://www.unfpa.org/news/news.cfm?ID=831& that passengers learn a lot.” Language=1, last accessed 25th of April, 2007).

Besides educating the passengers, the Ministry of Thirdly, a free anti-retroviral therapy programme Railways undertakes HIV awareness efforts aimed was piloted in late 2002 in Shanghai and scaled at protecting the 2.2 million Chinese railway up in 2003. At the same it became a policy that workers and their families. the urban poor was provided with free anti- retroviral therapy under the “Four Free and One Education is also underway in nine major transit Care policy”. However, a high dropout rate hubs as part of a pilot effort started by the mainly due to drug side-effects has led the Ministry with support from the United Nations government to explore options with the Population Fund (UNFPA). Officials hope they pharmaceutical industry for alternative regimes. will eventually be able to expand the programme to many more of the country’s 5,700 train The last intervention the government addressed stations. Some 70,000 people pass through the was mother-to-child transmission. After initial Beijing West Station each day. Electronic boards pilot testing that was done simultaneous with the anti-retroviral treatment trial, the government 146 Yang HLX, Stanton B, Fang X, et al. Willingness to decided that it was necessary to develop national participate in HIV/STD prevention activities among guidelines that stipulate that mothers who test Chinese rural-to-urban migrants. AIDS Educ Prev. positive be offered counseling, the option of December 2004;16(6): 557-570. abortion or anti-retroviral therapy, and where 147 Hong Y, Stanton B, Li XL, et al. Rural-to-Urban feasible, a Caesarian section delivery take place Migrants and the HIV Epidemic in China. AIDS and to reduce the likelihood of transmission. Free Behavior. July, 2006;Volume 10(4):421-430.

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formula milk is also provided to infants for 12 months.

Achievements The prevalence of HIV/AIDS in China is about 0.05% and the number of detected cases 840,000.148 It is evident that the prevalence as well as the total number of HIV/AIDS cases peaked in 2004 with the onset of active testing. So what has caused this turnaround? From the literature it seems that a combination of events such as the SARS epidemic in 2003 combined with a gradual consensus and social capital- building among various levels of the government and administrative structure. Personal relationships were formed that facilitated the consideration and examination of previous unrecognized policy options for detection, prevention and care. This was combined with timely access to information on effective intervention strategies that could change the course of the epidemic. The incremental approach to intervention made the scaling up of “best practice” approaches more effective. Policy recommendations with regard to mass health education campaigns were preceded by small pilot projects that showed their feasibility or efficacy among populations at high risk. Once the evidence was collected, an iterative process of involving the press and garnering political support gathered momentum. Legislation was passed and enforcement ensured through a comprehensive media campaign.

With prevalence rates still low, the success does not come without critical warning, for, as stated by UNAIDS executive director Peter Piot at the opening speech of the National AIDS/STD Conference in Beijing in 2001, “What happens in China will determine the global burden of HIV/AIDS.”

148 Wu Z, Sullivan SG, Wang Y, Rotheram-Borus MJ, Detels R. Evalutaion of China’s repsonse to HIV/AIDS. The Lancet. February 24, 2007; 369: 679- 690.

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Case study: Japan Figure 1: Outline of the Health Promotion Law Healthy Japan 21

Kirsten Havemann 1. Basic policies for health promotion in Technical Officer, Health Governance Research place; WHO Centre for Health Development 2. Systems for health promotion developed in Kobe, Japan prefectures and municipalities; 3. Guides for medical checkups developed; Summary 4. Guides for national surveys on health and Healthy Japan 21 is a health promotion strategy nutrition available; to enable the citizens of Japan to live a happy 5. Guides for health promotion in place; and fulfilling life and contribute to the sustainability of society. 6. Guideline for preventing passive smoking in place; This strategy has nine major areas of 7. Guidelines for labeling of nutritional value intervention and is implemented from national of food in place. to municipal and village level through an iterative planning process involving local The strategy of Healthy Japan 21 is being intersectoral teams of authorities and citizens. implemented through national guidelines that Progress is monitored through regular surveys and will direct the municipality and prefectural the results fed back to the communities through administrative systems in promoting healthy the media. lifestyles, together with intersectoral and multilevel interventions based on scientific Description evidence with predefined indicators and targets. The aim of this initiative is to enable people to lead a happy and fulfilling life, as well as From national to local level: each level of contribute to a sustainable society. government in Japan must play a key role in the implementation of Japan 21, and each level is Healthy Japan 21 has set specific health-related delegated its own roles and responsibilities. For goals that relate to mortality, morbidity and example: lifestyle-related risk factors. Access to information and the establishment of proper 1) National government is directed to environments is also part of the plan. All refer to develop implementation strategies, set national health promotion activities based on up targets and monitor implementation. new concepts to help all individuals living in 2) Prefectures must support cities and st Japan in the 21 century to achieve good health. municipalities in implementing Healthy Japan 21 and ensure intersectoral and The health promotion activities are realized multilevel collaboration. Through a through the activities of individuals based on participatory planning process, local their own vision of health, and supported by a strategies and targets are defined in each variety of health-related organizations (WHO, prefecture, such as the Action Health 2005). Index for Hyogo Prefecture. Local organizational structures are put in place The Health Promotion Law was passed in 2003. to ensure effective and efficient The law established targets to help prevent implementation. The media are lifestyle-related disease. It set nine areas of involved to ensure that the population intervention: nutrition intake and eating habits; is aware of the strategies and targets as physical activity and exercise; rest and mental well as progress achieved. Furthermore, health; tobacco; alcohol; dental health; diabetes mellitus; cardiovascular disease, and cancer.

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progress is reported via the internet to increasing, especially young women in their ensure accountability. teenage years. Smoking is a known risk for 3) Cities, municipalities and villages noncommunicable diseases such as cancers, develop local plans in specific areas, ischemic heart diseases and for low birth weight such as the ones related to mother and and premature delivery. childcare and services for the elderly. These plans are aligned with the For alcohol control: alcohol is a traditional prefectural and national plans through stimulant during social events in Japan, and a an iterative process and widely survey from 2002 showed that 50% of men and disseminated through the Internet 10% of women regularly consume alcohol. (http://www.city.kobe.jp/cityoffice/18/m Japan’s significant consumption is facilitated by enu03/h/hoken/) and press. easy access such as alcohol sold from vending machines. Healthy Japan 21 has put legal and For nutrition: the traditional Japanese diet, high regulatory frameworks in place for reducing in carbohydrates and salt and low in animal alcohol consumption. protein, has gradually improved, but these improvements have been counteracted by an For dental health: dental care is part of the increase in lifestyle-related diseases related to agenda of Healthy Japan 21, with particular focus “environmental impact”. The outcome is seen in on the elderly, as the effect of odontopathy on behaviors such as skipping breakfast and eating the elderly is worse than on the younger fast food of unbalanced nutritional value. generation. Not only do elderly people have Healthy Japan 21 addresses this problem not only problems chewing their food without teeth, they through individual health education but also are also at higher risk of pneumonia. Healthy through promotion of environments that are Japan 21 has put a movement known as “8020 conducive to healthy eating habits. (Hachimal Niimaru)” in place, aiming at keeping 20 teeth throughout the lifespan and maintaining For physical activity and exercise: prevention of the ability to chew, thus preventing tooth decay lifestyle-related diseases is related to the level of and peridontitis from early life on. physical activities that a person engages in. Lifestyle changes such as decreased walkability in For diabetes mellitus: diabetes is on the increase the elderly, adults and children have contributed in Japan and is associated with obesity, ageing, to the increased morbidity of noncommunicable reduced physical activity and impaired glucose diseases. Health education about the importance tolerance, as well as family history of diabetes. of keeping fit and healthy is currently ongoing for Healthy Japan 21 is campaigning for preventive preschoolers, schoolchildren and adults. measures that address obesity through physical activity and nutrition. For metal health and rest: according to the 1996 Attitude Survey on Good Health, 54.6% of the For cardiovascular diseases: these will be population experienced stress during the month addressed indirectly through nutrition, physical prior to the survey; men cited work-related stress exercise, tobacco control and alcohol reduction, and women cited family-related and work-related as well as reduction in stress-inducing stress. Stress is a predisposing factor for environments. hypertension, diabetes and sleep disorders – up to 23% of the population was found to suffer from For cancer prevention: Healthy Japan 21 has sleep disorders, often addressed through alcohol emphasized early detection of cancer through consumption, leading to a high prevalence of screening as well as healthy lifestyles (see above). accidents. However Fukuda et al. 2007 have shown that there are notable socioeconomic differences in For tobacco control: the trend of smoking in cancer-screening participation in Japan Japan shows that the prevalence among males is depending on marital status, rural-urban setting, decreasing while the prevalence among women is income and employment.

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The evaluation takes place at local and national Case study: Pakistan levels. In Kobe, the city has set up a system for registering citizens who wish to participate in Orangi Pilot Project in Pakistan Healthy Japan 21. This participation not only involves following the set health guidelines but Mojgan Sami also ensuring that the participants have a voice Technical Officer in the development of strategies and can be part WHO Centre for Health Development of the monitoring process. This system has been Kobe, Japan expanded to shops, restaurants and hotels. Healthy Kobe 21 aims to register 1,000 How and when poor people demand convenience stores and supermarkets as well as sanitation services, and how to meet these: the hotels and restaurants by 2010. Each registered case of the Orangi Pilot Project in Karachi enterprise receives the Healthy Kobe 21 sticker In the early 1980s, Dr Akhtar Hameed Khan, a that can then featured on its website or displayed world-renowned community organizer, began on the premises working in the Orangi slum of Karachi. Instead (http://www.city.kobe.jp/cityoffice/18/menu03/h/ of telling the people what to do, or what they hoken/hp21do/sapoitiran.htm). needed to do, he went asking what issues they had that he could help resolve. While Conclusion community members had a relatively satisfactory The social issues that postwar Japan has faced supply of water, they faced “streets that were resulting from globalization, industrialization, filled with excreta and wastewater, making rapid economic growth, technological movement difficult and creating enormous innovation and not least rapid urbanization have health hazards.” What did the people want, and been vast. Policy and research have been how did they intend to get it? he asked. What combined to develop effective strategies to they wanted was clear: “people aspired to a improve health and decrease inequity. The lesson traditional sewerage system...it would be difficult learned is that urban communities have become to get them to finance anything else.” And how interdependent and share issues in ways that they would get it, too, was clear – they would transcend local, national and international have Dr Khan to persuade the Karachi borders. Japan and its cities have an important Development Authority (KDA) to provide it for role in sharing their scientific approach and free as it had done (in their eyes, at least) in the knowledge as exemplified by the Healthy Japan richer areas of the city. 21 approach. This can be further enhanced through policy solutions based on scientific Dr Khan then spent months going with evidence and participatory action research. The representatives from the community to petition first type of research will be through specialized KDA to provide the service. Once it was clear studies that support environmental factors for that this would never happen, Dr Khan was ready improving health, and the second type of studies to work with the community on finding will be through reflective participatory action alternatives. (He would later describe this first research that addresses multiple determinants of step as the most important thing he did in health and promotes skills in human relations Orangi – liberating, as he put it, the people from (Takano, 2007). the demobilizing myths of government promises.)

With a small amount of core external funding, the Orangi Pilot Project (OPP) was started. The services that people wanted were clear; the task was to reduce the costs so that these were affordable and to develop organizations that could provide and operate the systems. On the technical side, the achievements of the OPP architects and engineers were remarkable and

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innovative. Coupled with an elimination of http://siteresources.worldbank.org/INTGENDER/ corruption, and the provision of labour by Resources/toolkit.pdf). community members, the costs (in-house sanitary latrine and house sewer on the plot, and A report on the Orangi Pilot Project in Pakistan underground sewers in the lanes and streets) are mentions how it was discovered that wives were less than US$ 100 per household. often more concerned than husbands about disease and sanitation, as the burden of caring for The related organizational achievements are the sick often fell to them. Project staff saw many equally impressive. The OPP staff has played a examples of women forcing their reluctant catalytic role, explaining the benefits of husbands to pay their contribution to the sanitation and the technical possibilities to project’s low-cost sanitation component. (Khan, residents, conducting research and providing Akthar Hameed. Orangi Pilot Projects Programs. technical assistance. The OPP staff never Orangi Pilot Project – Research Training handled the community's money. The total costs Institute. 1992, p. 22.) It was also noted that of OPP’s operations amounted, even in the mothers saw most clearly the connection project’s early years, to less than 15% of the between filth and disease, although they did not amount invested by the community. The always know the specific causes or methods of households’ responsibilities include financing prevention. However, they were the ones with their share of the costs, participating in the job of caring for sick family members and for construction, and election of a “lane manager”, ensuring household cleanliness, thus managing who typically represents about fifteen hygiene at the household level. The project households. The lane committees, in turn, elect therefore was intended to reach them with members of neighbourhood committees (typically messages on proper hygiene and sanitation. Since around 600 houses) who manage the secondary it is customary for women to stay inside their sewers. homes, sessions could not be held at clinics. Instead, the project introduced mobile training The early successes achieved by the Project in teams composed of a lady health visitor and a the 1980s created a “snowball” effect, in part social organizer. An activist family or “contact because of increases in the value of property lady” was chosen for each 10–20 lanes in the where lanes had installed a sewerage system. As area. Meetings were held at these homes. The the power of the OPP-related organizations contact lady activists became trusted advisors and increased, so they were able to bring pressure on conveners for their neighbours, providing a the municipality to provide funds for the means for the health extension teams to hold construction of secondary and primary sewers. discussions with neighbourhood women to spread The Orangi Pilot Project has led to the provision learning about good sanitation practices. of sewerage to over 600,000 poor people in Karachi and to attempts by at least one progressive municipal development authority in Pakistan to follow the OPP method and, in the words of Arif Hasan, “to have government behave like an NGO.” Even in Karachi, the mayor has now formally accepted the principle of “internal” development by the residents and “external” development (including the trunk sewers and treatment) by the municipality. The experience of Orangi demonstrates graphically how peoples’ demands move naturally from the provision of water to removal of waste from their houses, then their blocks and finally their neighbourhoods and towns (See page 121 –

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Case study: Philippines In healthcare, for example, GIS maps give city planners the ability to, in one glance, monitor Cebu City’s Geographic Information the spread and distribution of Cebu’s programs Systems for maternal and child healthcare. Through colour-coded representations of the city’s various Ira Pedrasa barangays (villages), for example, they can Manila, Philippines immediately see where there are too few health workers, or where there are higher or lower Geographic Information System (GIS) incidences of infant mortality. technology has long been used to improve governance efforts in such concerns as land use, Such ability to quickly analyse and understand in traffic management, and even tax collection. The turn allows the local government to formulate ubiquity of computers (and the explosion of policies and/or direct its limited resources. Cebu computing power) has allowed planners and officials credit GIS technology with helping policy-makers to translate demographics and them to narrow the gap between the health statistics into graphical representations of specific realities of “disparity areas” and that of the larger communities’ realities, concerns, resources, and region and country to which the city belongs. needs. GIS technology has thus made planning and resource allocation easier and more efficient. GIS, for example, shortened the working time it Planners could literally see trends pictured on took for officials to check areas where computer monitors, and that has allowed them to immunization was not being delivered and/or is more concretely discuss problems and point out still urgently needed. So impressed and rewarded possible solutions. has Cebu been in its experience with GIS that the city’s own GIS Center now assists local In the Philippines’ Visayas region, a number of government departments on problems such as local governments are leading the way in how to improve tax collection and how to exploiting the technology to improve urban prevent fires in the community. They also help centers. In the province of Capiz, for example, a the city’s Urban Poor Division in seeking options “Backyard GIS” system – built on the backs of for affording shelter and tenure for the urban low-end computers in the city, and using existing poor. GIS, in other words, has now become a data from previous government surveys – was standard support service provided by the city used to help policy-makers and community government to all its departments. members to take part in what was billed a “Participatory Planning Budgeting Workshop”. With leaders and their constituents looking at the same picture and standing over the same page, GIS helped Capiz folk to identify the community’s infrastructure and investment plans and projects, and develop their list of priorities for funding.

In the larger Visayan metropolis of Cebu, GIS technology is used by the city government to, among other things, quickly identify “disparity areas”, towns and villages that need help the most. Engineer Nicesoro Iroy of Cebu’s Planning and Development Office says GIS technology gave them “a poverty mapping system” that could more compellingly call officials’ attention to problem areas.

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Case study: Philippines and have a “willingness to serve the community for free.” Human resource development through the volunteers programme of Marikina To both the volunteers and the city, of course, City and implications for local there were more compelling motivations. Mayor governments in the Philippines Marides Carlos-Fernando, who started the volunteer program, says it was also an Ira Pedrasa intervention for “emergency employment” – Manila, Philippines something to provide “transformation and preparation for people for the real work.” With nearly half a million people living in their territory, the officials of Marikina City know Each batch of volunteers in Marikina is asked to that, much like any other municipality in the augment public work for three to six months Philippines, the formal health care systems are far before another wave of volunteers takes its place. from fully equipped to deliver everything their During this period, the volunteers (mostly from residents need. The ideal situation for example, the population’s urban poor) each work four says city health chief Dr Alberto Herrera, is to hours a day for a wage of 100 pesos (roughly $2). have at least one health worker for every 20 They do as much as there is to be done, from families in the city. Yet Marikina only has clerical jobs to health-related work. around 200 barangay health workers for its more than 450,000 people. The impact on the city’s health systems was immediate. But even beyond this, Mayor Spread out over 15 barangays that each have Fernando says the program was also about 20,000 to 30,000 residents, the number of health “creating opportunities for the people.” The workers could hardly be expected to rise, given volunteerism is just a start. After the volunteers’ Marikina’s limited resources. As it stands, the stints are over, their names and qualifications are city can only afford to give an official barangay added to an employment pool where both private health workers a monthly allowance of 500 pesos and public entities can try to match (around $10). organizational needs with individual skills. Mayor Fernando says the volunteer program gives her And yet Marikina has augmented its health force constituents added capacity and capability to over the past three years, thanks to a bold compete in the job market. “We have a success volunteer programme that targets health and rate of 75%” in terms of placement of their unemployment issues at the same time. The former volunteers, she says. “The remaining 25% Marikina City Volunteer Corps started mostly come from the older sets whose operations in 2004, with the aim of promoting employability is unfortunately lower. But even the spirit of volunteerism and creating a network they can still find opportunities in odd jobs such of free helpers in city programs. Among other as cleaning the surroundings.” things, it has added 4,000 people to the local healthcare system and the actual workforce. The Marikina government allots some 15 million pesos ($300 000) a year to maintain the program. “We teach them primary health care and The dividends, clearly, are much higher than preventive medicine,” Dr Herrera says. The that. volunteer health workers are skilled enough to take people’s blood pressure, for example, as well as to teach families the ways and virtues of basic hygiene. The requirements for joining Marikina’s volunteer corps are simple. The city government’s official website says one needs only be a resident of Marikina, be at least 17 years old,

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Case study: India young children, and men can – and should – also serve as role models in sustaining changes in Self-Employed Women’s Association habits.” (United Nations Department of (SEWA) Economic and Social Affairs, Commission on Sustainable Development. A gender perspective Mojgan Sami on water resources and sanitation. Background WHO Centre for Health Development Paper No. 2. February 2005.) Kobe, Japan According to case studies outlined by the One SEWA – India World Action campaign (online 2007), one of In 1971, Mrs Ela Bhatt organized a small group of the union leaders of SEWA Bharat, Sanjay women workers in the cloth markets of Kumar, noted: Ahmedabad in Gujarat, India, to demand fair treatment of women by the merchants. Their There is much to be done in terms of victory triggered more groups to start organizing strengthening women’s leadership, their themselves in different sectors. In response to an bargaining power within and outside their appeal from the women and at the initiative of homes and their involvement in policy- Mrs Ela Bhatt, the Self-Employed Women’s making and decision-making. It is their Association (SEWA) was born on 3 December issues, their priorities and needs which 1971. SEWA’s success in Gujarat inspired other should guide and mould the development regions, and SEWA organizations were started process in our country. for unorganized women workers in other states. Together, ten member organizations form SEWA Quoted from SEWA website: Bharat, with the mandate to highlight the issues of women working in the informal sector and to Over the last fifty years there has been strengthen the capacity of these women and the considerable urbanization in India as rural organizations that serve them. SEWA considers migrants both rich and poor came to the itself the largest membership-based organization cities and towns in search of employment. in India and advocates on issues concerning One of the outcomes of the laws, regulations women workers by carrying their voices to and approaches to urban management that policy-makers at the national level. SEWA also have prevailed over this period is that slum supports its member organizations to build and communities have come to constitute a large strengthen their own capacities. SEWA considers and growing percentage of the population in itself “both an organization and a movement, cities and towns. Almost 28% of the Indian with each strengthening and carrying forward the population live in the urban areas (2001 other.” census), of these, approximately 67% do not have access to toilet facilities, 52% are In 2004, SEWA reported that more than 93% of uncovered by sanitation and sewerage all workers in India were considered self- infrastructure and 20% do not get safe employed, and more than half of were women. drinking water. SEWA has concentrated much of its work on gaining access to water for productive enterprises. The slum population in urban areas consists of In addition, as women are often responsible for families working primarily in the informal sector providing water for their household, the lack of where there is no well-defined employer- adequate sanitation undermines needs to be employee relationship and the workers and taken into consideration, as the relative benefits producers tend not to be covered by social of having safe water supply in a community can security provisions of any kind. In India, as in be jeopardized if there are no safe sources of most developing countries, the informal sector is sanitation. In addition, according to a report very large and growing. Although informal sector from the United Nations, “Women play a crucial workers are a major part of the urban workforce, role in influencing the hygiene behaviours of due to lack of infrastructure facilities, the

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productivity of this sector is much lower than it The Gujarat Mahila SEWA Housing Trust: could be. This is especially true of women, who women see housing as a basic need next only to bear the bulk of the cost associated with the lack work and food. Because a house offers safety to of basic infrastructure. The major cost of poor them and their families, it is perhaps their only infrastructure is in terms of the health of the asset and often it is also their workplace. SEWA slum population, which leads to continuous and SEWA bank have been providing various physical degradation and low productivity. housing services to their members, including housing finance worth Rs 8,262,000 to 1,162 The lack of sanitation, clean drinking water and women, along with technical assistance. In unhygienic surroundings has led to poor Ahmedabad, 158 women received their own morbidity and mortality indicators among the plots under the Urban Land Ceiling Act, and a slum populations. Morbidity patterns among the scheme was set in place to build houses in one slum populations are high and reveal a consolidated plot. preponderance of disease relating to water pollution. In a study of women who have However, in order to strengthen theses efforts, accessed SEWA’s health insurance scheme, it SEWA has joined with other like-minded was found that 62.6% of women suffered from organizations to form a trust specifically water-related complaints. Gastric problems dedicated to promote housing for self-employed including dysentery and typhoid affected 20%, women. The founders of the Gujarat Mahila followed by malaria (12%) and skin diseases SEWA Housing Trust are SEWA, SEWA Bank, (10%). Such high levels of morbidity not only Gujarat Mahila Co-operative Federation, Friends decrease the productivity and the quality of life of Women's World Banking, Foundation for of the slum populations but also lead to heavy Public Interest and the Banaskantha DWCRA expenditures on health care which often result in Association. the family trapped in a vicious cycle of poverty. The Trust aims to provide technical, research SEWA Bharat’s sister organization, Mahila and advocacy support to its members to enable Housing SEWA Trust, runs the Ahmedabad “better provision of all types of housing services Parivartan project, which transforms the physical to self-employed women”. environment in which informal sector workers (http://www.gdrc.org/icm/makiko/sewaE6.html) live by providing a package of seven infrastructure services, including paved roads, individual toilets, water and drainage connections and street lighting. The package is provided on an equitable cost-sharing basis, with community residents contributing one third of the cost. The project is implemented by registered bodies known as “Community Based Associations”, which represent the interests of the residents as well as maintain the newly acquired infrastructure. More information about the project is available at www.sewahousing.org. SEWA Bharat works towards promoting such projects in its member organizations and providing the most basic services such as water sanitation and health to the women of the urban slums of India. These aims are achieved in a demand-driven and financially sustainable way.

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Case study: Singapore The Brisk Walking Clubs represent just one outreach activity. The HPB and CDCs also Health programs for urban elderly provide basic health screenings in the community for people over 50 years old, charging Divine Salvador them a token S$ 2. But it’s the walking clubs, the Singapore organized exercises and the community activities that bring home the point on any given day: in Any given day in Singapore finds its elderly Singapore, the elderly don’t walk alone. citizens walking in groups, as if keeping pace with the city-state’s professionals. But unlike those harried workers, these senior citizens are not in any hurry to get anywhere. They hustle along neighbourhood sidewalks or through city parks, but the destination is the journey itself: the exercise and good health provided and organized for them by the government.

Whether through mass qigong exercises or organized walks, Singapore’s Health Promotion Board (HPB) sees itself as “the main driver for national health promotion and disease prevention programmes.” Among other things, therefore, the HPB helps to promote and support brisk walking clubs throughout the city. There are monthly brisk walks organized to pass through various parks and reserves. Many parks also have fitness stations where people can get together and enjoy mass exercises like qigong.

Established in 2001 and currently headed by Executive Officer Designate Lam Pin Woon, the HPB implements its projects via the Lion City’s five Community Development Councils (CDCs).

The CDCs, established in 1997, consist of 12 to 80 appointed members headed by a mayor. These councils, along with other grassroots organizations, are the main conduit for across- the-board government policies. To date, the five CDCs offer 37 programmes to assist special segments of the population, including the elderly, the young, and the handicapped. Senior Minister Goh Chok Tong says CDCs have “touched the lives of 180,000 needy Singaporeans.”

The elderly represent a special beneficiary sector. “Aside from physical health concerns, there’s the stress and loneliness. You know, empty nest syndrome,” Lam says. “So we are spending a lot of time with them so that they’re not too lonely.”

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Case study: Singapore In Singapore, one cannot just park a food cart by the side of the road or set up a food stand along Food safety among street vendors/hawker the sidewalk. Stalls and stores that sell street food stalls are subject to the same strict food safety regulations as other food establishments. Divine Salvador Singapore The National Environment Agency (NEA), which is tasked to ensure sanitation of hawkers’ Hawkers’ centres in Singapore, like the one in markets, employs strict rules and regulations in popular Bugis Square, are always teeming with giving out – and revoking – food licenses. But the people. The smells wafting in and out of the agency also regularly offers seminars on food centers are testament to Singapore’s cultural safety and hygiene to both vendors and diversity. consumers. It also comes out with advisories on food safety and hygiene, and announces which It is also, of course, testament to two other things establishments have had their licenses suspended the city-state is best known for: food and or revoked. cleanliness. Even with the SARS outbreak, the safety of The foods sold at Singapore’s hawkers’ centres street foods remained unquestioned. Singapore’s are much like street foods sold in other countries response to the SARS threat has been hailed as – cheap, accessible, and a great introduction to successful and exemplary by different agencies the local culture. Almost everywhere else, and organizations, both local and international. however, the term “street food” is also equated with hygienic risk. The lack of running water, If anything, food safety regulations have become exposure to the elements, improperly cleaned stricter and more effective. Beyond SARS, utensils, and often the very absence of business reports of food poisoning remain very rare, permits and regulations place both street vendors according to Mr Lam Pin Woon of the Health and their patrons at risk for disease. Promotion Board (HPB), allowing Singapore to retain its title as the best place to enjoy street Singapore, however, has long rejected the food in the region. formula that street food necessarily equals a lack of quality and safety standards, and therefore actively intervenes to not only apply standards but help the vendors meet such standards.

Running water and electricity for heating and refrigeration are two necessities for food hygiene. Because vendors of street foods usually have little or no access to either, what with food carts parked along sidewalks, hygiene suffers in the preparing and preserving of food, and connoisseurs of street food often run the risk of contracting gastrointestinal diseases.

The Singapore government solved this problem when it decided to organize street food vendors into designated locations and provided them with water and electricity. Today, both vendors and customers enjoy heat, refrigeration, potable water, and, of course, a roof to shelter them as they enjoy their laksa.

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Case study: Thailand Brought together from two Thai offices dealing with urban and rural development, CODI is at Innovation in community-upgrading once a lending institution and an instigator – a among the urban poor through CODI catalyst – for uniting once-frayed communities into more formal, organized and empowered With reporting from Jeerawat Na Thalang and sectors. SEAPA Bangkok, Thailand CODI itself provides soft state loans to organized communities, augmenting international The canals that once earned Bangkok its billing development assistance and, crucially, rewarding as “The Venice of the East” have also inevitably local counterpart funds that the community represented the precariousness and vulnerability members themselves raise from their own of living in this urban jungle. Water represents networks. life anywhere in the world, but pollution in Thailand’s famed waterways and cramped As CODI Director Somsook Boonyabancha settlements along their banks have in the past notes, “CODI is an organization that [believes in decades also made the canals – or klongs – and encourages] people’s management through symbols of illness and potential demise. local organizations that collect savings, offer loans and collectively make decisions and However, the city’s tributaries now also represent implement projects.” the fight to survive, and the promise of winning. Current attempts to revive not just the klongs, CODI invests in networks. Networks after all but also the neighbourhoods clinging to them, give communities courage as well as shared skills provide compelling models for rehabilitating and capacities for managing projects and funds, entire communities. the institute believes. Such skills and capacities spiral upwards towards greater aspirational In recent years, for example, the once initiatives, Somsook notes, further empowering problematic squatters along Bangkok’s Klong the communities. Hualampung have seen their communities cleaned, decongested, and repainted – and One of CODI’s first interventions on water legitimized. The squatters have become organized pollution and urban settlements ran from 1996 to and their properties are now properly leased. To 2002 and saw communities “organized to identify get to this point, no less than five distinct needs and encouraged to take greater control neighbourhoods along the klong were somehow over their environment and development,” noted motivated to band and work together, and then Donovan Storey in a presentation on CODI in learned to coordinate with NGOs, local 2005. “Through small loans of a few thousand governments, financial institutions and other US dollars CODI supported hundreds of poor concerned sectors, such as volunteer communities to become involved in identifying professionals. environmental threats, developing low-cost community-driven responses to these needs, and Around Bangkok’s network of canals, in other organizing themselves into viable collectives to words, a network of neighbourhoods, a network manage funds and projects and to network with of sectors, and then a “network of networks” were other communities facing similar challenges. all instigated and nurtured to bring together this This often acted as a catalyst for canal-cleaning inspiring picture of community empowerment. projects and in some cases involved communities scaling up their actions to focus on tenure, The one government intervention crucial to livelihoods and wider recognition over their spurring this model of urban development was rights and existence.” the formation of the Community Organisation Development Institute (CODI) by the Thai government.

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This effect has been refined into a template that Case study: Thailand CODI has applied in other stories around Thailand. Community-based care and interventions for HIV/AIDS in Thailand In Klong Mekhaa, Chiang Mai, northern Thailand, a project involving approximately With reporting from Jeerawat Na Thalang and 1,000 households of an “informal settlement” SEAPA threatened with eviction saw CODI loans Bangkok, Thailand helping to push residents to clean up the canal, network with other Chiang Mai sectors (they got Buddhist teachings regularly remind followers of architects to volunteer their services, for the Four Noble Truths: Dukkha (Suffering); example) and be rewarded with 30-year leases Samudaya (the origin of suffering); Nirodha (the where their houses stood. Encouraged, the cessation of suffering); and Magga (the path network again turned to CODI for more leading to the cessation of suffering). In community loans, this time for community predominantly Buddhist Thailand, the enterprises, income generating activities, and a application of the Four Noble Truths in credit-saving scheme. HIV/AIDS education and intervention has had profound effects on communities’ ability to “Poverty reduction cannot be achieved simply mitigate the suffering caused by the disease, as through financial mechanisms,” Somsook said in well as raised people’s awareness about their a paper co-cauthored with Diana Mitlin of the power in face of the scourge. Institute for Development Policy and Management. “The change that is required Since 2002, Thai Buddhist monks under the means that people need to learn about possible Sangha Metta Project have been conducting strategies, to have more confidence, to negotiate community HIV/AIDS workshops that begin and to work together as a group. Then they can with one basic exercise: a reflection on the Four change their relations with the city managers and Noble Truths that replaces “Dukkha” – suffering with other stakeholders that influence access to – with “HIV/AIDS.” Ultimately, because resources.” Buddhist teachings say that understanding the Noble Truths leads to Parinna (comprehension of suffering), Pahana (eradication of the cause of suffering), Sacchikiriya (the cessation of suffering), and Bhavana (the development of the path to enlightenment), the Sangha Metta Project uses a shared value – that of religion – to make Thais more aware and involved in HIV/AIDS care and intervention, particularly at the level where the alternatives – ignorance and apathy – are the most dangerous: the community level.

Initiated by monks themselves, the project was a direct response to inadequacies in the formal health response and resources of the national government. Though one of the first Asian countries to acknowledge HIV/AIDS in the local population, Thailand’s response was long hampered by management and resource issues in the public health sector. Documentation of cases was itself problematic, and, beyond medical help, any thought given to counselling and home care

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for persons living with HIV/AIDS (PLWHAs) Southern China, Vietnam, and even Mongolia was limited by a lack of resources and and Bhutan. standardized training for health workers or even volunteers. Efforts on the community level were also severely hampered by stigmatization and misconceptions about HIV/AIDS transmission. Thai leaders were quick to acknowledge that they couldn’t do it on their own. They needed community leaders from various sectors to step forward.

Thailand has now made significant strides in addressing the concerns of PLWHAs since HIV/AIDS first took hold in the country in the 1990s. But the tasks remain daunting. The United Nations Program on HIV/AIDS (UNAIDS) estimates that 570,000 Thais or 1.5% of the country’s adult population are still infected. Condom use is declining and a high number of intravenous drug users in urban areas are HIV-positive. Only 1% of these drug users benefit from HIV prevention services.

It was in this context that community-based interventions such as the Sangha Metta Project provided a breakthrough. The first workshops were directed by abbots at temples in northern Thailand. Those abbots then brought along monks from their respective temples, who in turn extended invitations to lay community leaders, including village headmen, members of village development committees and representatives of the Tambon Administrative Council.

The impact was immediate and has been sustained. Using Buddhist ethics as their starting point and guideline, the community leaders teach about high-risk behavior, set up support groups, provide training for livelihood and help to take care of AIDS orphans. Meanwhile, notes the Buddha Dharma Education Association, “because local people are accustomed to telling monks their troubles, the latter have become a conduit for identifying many undocumented HIV-positive people who can be referred to support groups and public assistance programs.” HIV-friendly temples encourage these people to participate in community activities. The example set by the Sangha Metta Project is now the subject of replication efforts by Thailand's neighbours in Laos, Myanmar, Cambodia,

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Case study: Thailand What truly sets the Thai model apart, however, is its provisions for sustainability, by drawing Health projects from tobacco and alcohol revenue and budgets from the targeted industries taxes themselves. Two percent of annual state revenue from tobacco and liquor tariffs are deducted as Jeerawat Na Thalang contributions to a national health promotion Bangkok, Thailand fund.

In 2006, the Thai government approved a Bt5 Tobacco products in Thailand now have the billion (US$ 125 million) budget to support highest taxes in the region: there is an excise tax sports and cultural events, but that was only one equivalent to 75% of retail price, an import duty half of the story. On the other side of this equal to 5% of value and a VAT (sales tax) of programmed spending for health, much of the 7%. Then there are municipal taxes. Of the earmarked fund was sourced from a 2% annual revenue generated from all this, 2% is earmarked “sin” tax share from levies on tobacco and for health promotion. alcohol. Thailand already has one of the strictest tax and anti-tobacco regimes in Asia and it is Today, ThaiHealth spends 6% of its budget on considering enforcing new measures to address promoting health issues and for conducting an health issues related to alcohol consumption. annual seminar on “Cigarettes vs. National High taxes, strict marketing restrictions, and Health” to facilitate regular exchanges among aggressive health communication strategies researchers, campaigners, and the general public. helped to bring down smoking from 35% of the It also encourages the formation of networks on 15-and-over population in 1981 to 22% in 2001. smoking control, and an academic centre on smoking control will be established to undertake Graphic and morbid pictures of people dying and further training and research on cigarettes and debilitated cover more than half cigarette packs – health, and to support legal and economic much more powerful than the typical text-based measures that will help expose unethical health warnings seen almost everywhere else in practices of the tobacco industry. the world. When Thailand first considered raising cigarette taxes from 55 to 60% in 1993, For all its progress, though, Thailand’s war on opponents of the tax feared that the government smoking remains a formidable challenge. There would lose revenue while failing to make a dent are still more than 10 million smokers in the in the problem of smoking. In 1994, however, country, and enforcement of the 1992 Tobacco Thailand’s Excise Department showed that Products Control Act and the 1992 Non- revenue from cigarette excise taxes in fact smokers’ Health Protection Act – both of which jumped from 15 billion baht (US$ 0.576 billion) target the illegal marketing and sale of tobacco to 20 billion baht (US$ 0.769 billion). Since products to minors, limit marketing strategies for then, the tax has been increased six times and tobacco companies and compel the full disclosure currently stands at 75% of the retail price. of tobacco product components – are still pocked with loopholes. Meanwhile, the resulting higher prices for cigarettes have corresponded to immediate But by tapping big tobacco’s own revenue stream, declines in smoking. the Thai government has at least given itself a fighting and sustainable chance – even when it Beyond what is required of tobacco companies, comes to taking over sponsorship of large events. the Thai Health Promotion Foundation (ThaiHealth) has in the past five years also actively produced and conducted awareness programs promoting healthy living.

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Case study: Viet Nam for a profit. Since the opening of the new stalls, no poultry can be sold without a stamp of Healthy marketplace in Thai Binh province approval by food safety officials.

Tran Le Thuy Local veterinarians have also been closely Hanoi, Viet Nam monitoring poultry suppliers in their move to stop any smuggling or other illegal means of Poultry sellers in the open market of De Tham selling poultry from the bird-flu-infected areas. were apprehensive about the new stalls built for them. They were not used to the sparkling “The sellers said their business has been better. stones and private water pipes and sewage – too Clients are more confident in buying their clean and luxurious compared to the old and products, even during the epidemic outbreaks, dirty wooden stalls they had been using for years. because of the strict procedures and lower risk of contact,” says Dr Cuong, who helped lead the But when they were told how low the rental fees implementation of WHO’s urgent project. for the stalls were, they went for it. Huge and colourful posters were put up at the “Most Vietnamese markets don’t have separate gates of the markets urging people to wash their areas for each kind of food. Fresh meat and hands constantly and warning them against poultry stalls are often mixed with cooked food. eating sick poultry. The project also organized Also, the sellers’ hands are not clean since there classes to teach sellers about H5N1 and methods is no basic infrastructure for hygiene,” says Dr Do to stop or prevent its spread. Manh Cuong of Vietnam’s Administration of Preventive Medicine under the Ministry of “We are looking for new sources of support to Health. continue and expand the model to other provinces,” says Dr Cuong. “Therefore, markets are at the highest risk of transmitting diseases to a large population, and it “The officials from Quang Ninh and Thai Binh would be very dangerous if it happens to be provinces said publicly that they appreciate what H5N1 – bird flu.” has been done and will consider duplicating such healthy marketplaces when they build new De Tham market in Thai Binh province, which markets.” is located along the Red River delta, suffered heavily from the outbreak of the deadly virus that took the lives of several people two years ago.

It was for this reason that WHO chose to pioneer its Healthy Marketplace initiative in 2005 in this province, in parallel with similar market in the famous tourist district of Ha Long.

The poultry sellers were given gloves, boots, and comforters, to protect them from the virus, instead of handling live chicken with their bare hands as they did before. They also underwent monthly health checkups as a preventive measure against the transmittable disease.

More important, they were told to keep sick poultry out of the stalls; it is commonly known that sick or dead poultry were often secretly sold

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Case study: Viet Nam For the SEA Games, WHO provided technical assistance and financial support in developing Tobacco control the regulations and training workshops for volunteers, on-site officials and key staff Tran Le Thuy members. It also supported the Vietnam Hanoi, Viet Nam Committee on Smoking and Health (VINACOSH) in producing and providing Vietnam’s laws already try to make it tough on crucial information about the harmful effects of smokers in public places. But getting people to tobacco for a nationwide health campaign that respect the law remains a problem. Culture and included television spots, billboard publicities, ignorance about tobacco-related laws and health and press features. issues prevent non-smokers from speaking up next to or in the face of smokers in public places. The overall aim was not only to implement laws, “Enforcement of such policy is difficult,” said Do but to change behaviours – of smokers and non- Thi Phi, former IDE staff who contributed to smokers alike. smoke-free SEA Games project. Together the consortium for a smoke-free SEA Nor is there widespread practice of tolerating Games called for “no tobacco sales, sponsorship, requests to stop smoking in this nation, where advertising, or any form of promotion permitted 52% of men and 1.8% of women are still at any games site.” Smoking was permitted only smokers.” At the Hanoi railway station, says anti- in designated areas, and substantial efforts were tobacco advocate Do Thi Phi, “some guards made to provide useful and accurate information reported having been threatened with beatings about tobacco use to athletes, spectators, and staff by smokers.” – while actively asking smokers to stamp out their cigarettes. To introduce and promote the notion that smokers can and should be reminded to refrain from lighting up in public places, Vietnam declared the 2003 Southeast Asian Games in Hanoi and Ho Chi Minh City tobacco-free – then let volunteers set the example by stubbing out all cigarettes at the games.

Uniformed volunteers approached smokers in the stadiums and politely asked them to put out their cigarettes. It was a simple act, repeated thousands of times throughout the days and venues of the games, and Vietnamese officials believe it’s had a long-term impact.

“Anti-smoking is not a priority for Vietnamese because we are still facing a lot of other (economic) hardships,” said Do Thi Phi, who used to work for the International Development Enterprise, an NGO and partner of the government and the WHO in the anti-smoking push in Vietnam. “The SEA Games was the biggest event so far to attract people’s attention to the issue, and it became an important venue to raise their awareness.”