CREATING HEALTHY CITIES IN TANZANIA USING THE SOCIAL DETERMINANTS OF HEALTH FRAMEWORK TO UNDERSTAND HOW URBANISATION IMPACTS ON HUMAN DEVELOPMENT IN TANZANIAN CITIES TECHNICAL REPORT – November 2016 1 THE UK DEPARTMENT FOR INTERNATIONAL DEVELOPMENT The Department for International Development (DFID) leads the UK’s work to end extreme poverty. DFID aims to build a safer, healthier, more prosperous world. To end the need for aid it focuses on creating jobs, unlocking the potential of girls and women and helping to save lives during humanitarian emergencies. https://www.gov.uk/government/world/organisations/dfid-tanzania THE UCL INSTITUTE OF HEALTH EQUITY The UCL Institute of Health Equity (IHE) is led by Professor Sir Michael Marmot and seeks to increase health equity through action on the social determinants of health, specifically in four areas: influencing global, national and local policies; advising on and learning from practice; building the evidence base; and capacity-building. The Institute builds on previous work to tackle inequalities in health led by Professor Sir Michael Marmot. His team at IHE has led a number of international reviews of health inequality, including the Global Commission on the Social Determinants of Health, [1] and the Review of Social Determinants and the Health Divide in the WHO European Region. [2] www.instituteofhealthequity.org IFAKARA HEALTH INSTITUTE The Ifakara Health Institute (IHI) is an independent, non-profit Tanzanian health research organisation that has been running for more than 50 years. The public health impact of its research is at the core of its mission and operations, and it has a strong track record of influencing policy and practice through knowledge and research translation. IHI is a valued partner of the Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), the President’s Office – Regional Administration and Local Government (PO-RALG), Local Government Authorities, and various donor and non-governmental organisations, which are also among the main users of its research output. www.ihi.or.tz ABOUT THIS REPORT This report was written by Sara Thomas, Angela Donkin and Ruth Bell from the UCL Institute of Health Equity. Research and analysis were conducted by Gemma Todd, Eveline Geubbels, Masuma Mamdani and Francis Levira from Ifakara Health Institute. This research has been funded by UK aid from the UK Government. The views expressed do not necessarily reflect the UK government’s official policies. 2 ACKNOWLEDGEMENTS This research was informed and shaped by the contributions of experts from the Tanzanian government, NGOs and youth groups in both health and wider issues of human development in Tanzania. When evidence was not found it could suggest gaps in the literature, as highlighted in the report. We are grateful for the advice and challenge of these experts. Appendix 1 provides a list of the organisations and individuals who contributed. 3 CONTENTS Section 1: Introduction ........................................................................................................................... 6 Urbanisation and the social determinants of health .......................................................................... 6 The social determinants of health ...................................................................................................... 8 Section 2: Methodological issues in mapping health inequality .......................................................... 11 Data in tanzania ............................................................................................................................ 12 Is there an urban advantage?....................................................................................................... 13 The characteristics of Dar es Salaam ................................................................................................ 19 The Importance of addressing methodological issues ..................................................................... 24 Section 3: the impacts of urbanisation on health ................................................................................. 25 Comparison of rural versus urban health outcomes ........................................................................ 25 Urban health concerns ...................................................................................................................... 44 Non-communicable diseases ............................................................................................................ 47 Section 4. Applying the social determinants of health to urban areas ................................................. 52 4. 1 Life course stages ........................................................................................................................... 52 Early Years and childhood development .......................................................................................... 53 Child protection ................................................................................................................................ 56 Education and training ...................................................................................................................... 61 Employment ...................................................................................................................................... 68 Older ages ......................................................................................................................................... 77 3.2. Wider society: changes to the built environment and social norms ............................................. 79 Social Environment ........................................................................................................................... 79 Built Environment ............................................................................................................................. 85 Natural Environment ........................................................................................................................ 91 4.3. Systems .......................................................................................................................................... 92 Overview of Governance in Tanzania ............................................................................................... 92 Civic engagement .............................................................................................................................. 93 4 Social protection ............................................................................................................................... 94 Urbanisation and systems ................................................................................................................. 96 Pressure on Sanitation Facilities ....................................................................................................... 97 System responses to improve equity .............................................................................................. 100 4.4 the Macro-level context ................................................................................................................ 105 CONCLUSION .................................................................................................................................... 107 An SDH framework for tanzanian cities ................................................................................ 107 Appendix 1: Acknowledgements ........................................................................................................ 112 Appendix 2: Information on key survey methodologies ................................................................. 114 appendix 3: Overview of policies to target vulnerable populations ............................................... 115 References .......................................................................................................................................... 121 5 SECTION 1: INTRODUCTION Population health, and the distribution of good health outcomes, are key measures of how well a society is doing. Tanzania has made significant strides in improving the health of the population, which has resulted in an increase in average life expectancy from 51 years in 2002 to 62 years in 2012. [3] Similarly to other countries in Africa, Tanzania’s statistics on a number of health measures leave much room for improvement. DFID Tanzania has commissioned UCL Institute of Health Equity (IHE) to help it understand the key drivers of poor health in this rapidly urbanising country, within the context of the wider social, economic, environmental and cultural issues that are relevant to sustainable human development in Tanzanian cities. DFID would also like to identify further work, opportunities and partnerships across sectors in order to improve urban health, wellbeing and living conditions. IHE has led a number of international reviews of health inequality, including the global Commission on the Social Determinants of Health, chaired by Professor Sir Michael Marmot, [1] and the World Health Organisation (WHO) European Review of Social Determinants. [2] The social determinants of health (SDH) approach has been used by a number of international organisations including WHO, [4] the United Nations Development Programme (UNDP) [5] and the United Nations Children’s Fund (UNICEF), [6] by transnational organisations including the European