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. 1 Improving Urban Population Health Systems CENTER FOR SUSTAINABLE URBAN DEVELOPMENT | JULY 15-20, 2007 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, 2 Improving Urban Population Health Systems CENTER FOR SUSTAINABLE URBAN DEVELOPMENT | JULY 15-20, 2007 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