Dr Sharon FrielDepartment of Epidemiology and Public Health, University College London

&National Centre for Epidemiology and Pop Health, Australian National University

Wellington Aug 2009

The concrete road to freedom?

Urban health equity through action on the social determinants of health

www.who.int/social_determinants

Reframing Development

Economic Growth

Freedoms / Empowerment: MaterialPsychosocialPolitical

HUMAN

DEVELOPMENTHealth Equity

Environmental Sustainability

Healthy, Equitable and Sustainable

Places

Sustainable urbanisation

– Healthy urban systems

– Viable rural living

– Environmentally sensitive

Worldwatch, 2007

Growth in urban living

New urban health challenges

Communicable & non-communicable diseases

HIV/AIDS

Road traffic injuries

Urban violence and crime

Underweight and overweight

KNUS report 2007

Under five mortality, Kenya

0 50 100 150 200 250 300

Embakasi slum in Nairobi

Kibera slum in Nairobi

Informal settlements in Nairobi (average)

High-income area in Nairobi (estimate)

Nairobi

Kenya (urban excluding Nairobi)

Kenya (rural)

Kenya (rural and urban)

Under 5 mortality rate (per 1000)

CSDH KNUS Report 2007

Urban obesity in select low and middle income countries

Prevalence of Under and Over-weight in Urban Areas

0 10 20 30 40 50 60 70 80

Uganda

South Africa

Egypt

Uzbekistan

China

India

Mexico

Percent

% Overweight % Underweight

Mendez et al 2006

Prevalence of diabetes, China 2002

Wang et al 2005

Global Trends in Road Traffic Deaths

WHO and WB, 2004

East Asia & Pacific

East Europe &

Central Asia

LAC

South Asia

SSA

HIC

MENA

0

5

10

15

20

25

30

35

2000 2020

de

ath

s p

er

10

0,0

00

Life expectancy at birth (men)

77Australian average

59Australian Indigenous

82

76

75

72

66

65

61

54

Greater Glasgow (affluent area)

UK

US

Mexico

Lithuania

Philippines

India

Glasgow (deprived area)

World Health Report 2006, Hanlon et al 2006, AIHW 2008

Balk et al 2008, in UNHABITAT State of the World’s Cities 2009

Levels of Urbanisation, 2000 (by Ecosystem)

China – population and urban growth: total and in low elevation coastal zones

11391262

337423

119 14456 78

0

200

400

600

800

1000

1200

1400

1990 2000

China Urban China LECZ China Urban LECZ China

Po

pu

lati

on

in

mil

lio

ns

McGranahan et al, 2007

Getting Hotter:temperature change 2000-2100

PollutionRevolution

Se v

erit

y

Sanitary Revolution

SustainabilityRevolution?

Optimistic Vision of Urban Environmental

Revolutions (Affluent cities)

Mid 19th

Century

Mid 20th

Century

Early 21st

Century

Slide: Gordon McGranahan

City/regionalburdens

Se v

erit

y

Household burdens

Global burdens

Pessimistic Vision of Urban Environmental Displacement – Affluent Cities

Local Global

Immediate Delayed

Affects health directly

Affects health through life support systems

Mid 19th

CenturyMid 20th

CenturyEarly 21st Century

Slide: Gordon McGranahan

Determinants of urban health equity

Population composition Population composition –– size, density, size, density,

diversitydiversity

Physical living conditionsPhysical living conditions

Social environmentSocial environment

Natural environmentNatural environment

National and local governanceNational and local governance

Vlahov et al, 2008

AJ Houweling, 2008

Climate Change

Urbanisation Health Inequity

Proportion of urban populations living in slums

UNHABITAT 2009

Poor access to health services

Slide: Jean-Christophe Fotso, APHRC, Kenya

Global slum upgrading

Cost estimate: less than US$ 100 billionCost estimate: less than US$ 100 billion

Finance on shared basis, for instance byFinance on shared basis, for instance by

–– international agencies and donors (45%),international agencies and donors (45%),

–– national and local governments (45%), andnational and local governments (45%), and

–– households themselves (10%), helped by households themselves (10%), helped by

micromicro--credit schemes. credit schemes.

Urban planning and design for health equity

Shaping the obesity epidemic: the built environment

Transport, Energy and Urban Dwellers

Worldwatch Institute, 2007

Proportion of homes measured as non-decent by tenure: England

0

10

20

30

40

50

60

70

1996 2001 2003 2004 2005 2006

Private rented Social rented Owner occupied

Source: www.poverty.org.uk from English House Condition Survey

Issues of..• Waste management• Education• Child care• Poverty alleviation• Work

UNHABITAT, State of the World’s Cities 2008/09

FOOD AVAILABILITY

FOOD AFFORDABILITY

FOOD ACCEPTABILITY

The Urban Nutrition Transition

Pay more for health in low income

neighbourhoods, UK

Food Magazine, 2008

0

5

10

15

20

25

1988 1995 2001 2007

Po

un

ds S

terl

ing

Regular basket Healthy Basket

Healthy basket 2007• 58% more

expensive than regular basket in low-income areas

• 39% more expensive in affluent areas

CSIRO Climate Adaptation Flagship:

Sustainable Cities and Coasts Theme

Identifying and Characterising Resilient Urban Food Systems in Australia to

Protect and Promote Population Health in a Changing Climate

Collaborative Research Program betweenCollaborative Research Program between

the ANU National Centre for Epidemiology & the ANU National Centre for Epidemiology &

Population Health and CSIRO Sustainable Population Health and CSIRO Sustainable

EcosystemsEcosystems

FrielFriel, Dixon, Capon, Hall, Mason, Barnett, Beatty, Dixon, Capon, Hall, Mason, Barnett, Beatty

Specific objectives:

Characterise diverse urban food sub-systems and assess their merits in providing nutritious and safe food in a sustainable way

Identify the accessibility and affordability of a healthy and sustainable diet across the range of urban food sub-systems

Identify the acceptability to consumers of foods provided through diverse urban food sub-systems, and in doing so assess the potential for and barriers to consumer power and governance in diverse food systems

Macroeconomic and industrial policies affect health in cities

Drivers of Urban Growth in Africa, Asia,

Latin America & Caribbean

17.85.40Administrative / Legislative change

7.98.921.6Improvement in basic living conditions

7.239.316.2Information and services

44.12551.4Investment in transportinfrastructure

2321.410.8Designation of economic zone

74.385.778.4Economic reasons

AsiaLACAfrica

UNHABITAT, State of the World’s Cities 2008/09

Redressing the Urban bias

• Balanced resource allocation

• Sustained investment in rural development:• issues of rural land tenure and rights • year-round rural job opportunities • agricultural development • fairness in international trade arrangements • rural infrastructure including health, education,

roads, and services • policies that protect the health of rural-to-urban

migrants

• Integrate into the broader context of economic and social policies aimed at development and poverty reduction

The Social Determinants of Health

The poor health of the poor, the social gradient in health within countries and the marked inequities

between countries are caused by:

Commission on Social Determinants of Health, 2008

Structural determinantsthe unequal distribution in power, money, goods and service

globally, nationally and locally

Conditions of daily lifeThe consequent unfairness in the immediate

circumstances in people’s lives - access to schools, education, health care, conditions of work and leisure,

their homes, communities, towns or cities

Local government does social

determinants of health equity

ENABLING ACTION:

What’s needed to make health

equity core business for all

sectors

Urban governance for health equity

1. recognises the value of collective and community through a stewardship model of governance

2. systematic consideration of the health effects of all local government policy, systems and processes on all population groups

Levers:

leadership, legislation, partnership,

opportunism, target setting, health

sector leading by example

Health Equity in all

Policies, Systems and

Programmes

Political support, champion, long term vision

Intersectoral mechanisms and support tools

Brazilian and South American network

of just and Sustainable Cities

São Paulo, Rio, Recife, São Paulo, Rio, Recife, BelBeléémm, Belo , Belo

Horizonte, Salvador, Horizonte, Salvador, FlorianFlorianóópolispolis and 15 and 15

smaller citiessmaller cities

Incorporated a network of 200 smaller Incorporated a network of 200 smaller

cities against corruptioncities against corruption

Latin America: Colombia, Argentina, Chile, Latin America: Colombia, Argentina, Chile,

Ecuador, PeruEcuador, Peru

Slide: Daniel Becker, Synergos Brazil

Slide: Daniel Becker, Synergos Brazil

Slide: Daniel Becker, Synergos Brazil

WHO Europe Healthy Cities Network Phase V:

Health Equity in All Local Policies

1. Caring and supportive environments- socially inclusive- vulnerable groups

2. Healthy living- systems and services that support

healthy lifestyles

3. Healthy urban environment and design- physical and social environments

Challenges for Action on the Social

Determinants of Health Equity

Heavy external pressures and vertical processes

Local partnerships under pressure from competing priorities between the partner organisations:

– different accountabilities

– funding and budget concerns

– a lack of understanding of each other’s roles –for example the health service adhering to a medical model of health that excludes the local authorities

Differences between national and local priorities

� Systems thinking and complex adaptive systems versus linear, reductionist model that dominates current policy and implementation

�� DDifficulties demonstrating positive short-term effects of interventions on the SDHs

� Limited influence?

Obesity: The interest and influences of different stakeholders

INFLUENCEINFLUENCE

-10

-5

0

5

10IN

TE

RE

ST

INT

ER

ES

T

Children

Health professionals

Advocacy orgs.

Scientists

ParentsMinistry of Health

Parliament

Farmers

Media

Church

Ministries of Transport

& Agriculture

Retailers

Treasury

President

Advertising industry

Food/drink industry

Food inspectors

Ministry of Education

Teachers

0 5 10

Ministry of Trade

Lobstein T : Analyses based on The Food Commission's experience and new EU policy work.

Health Equity in All Local Policies:

moving forward

Identify approaches that drive a cultural shift within organisations and professions in attitudes towards equity

Demonstrate how to keep a focus on social determinants in face of pressures in the system to focus elsewhere (e.g. service issues, financial pressures, individual lifestyle and behaviour)

Routine monitoring and health equity evaluation

Health equity through action on the social determinants in urban

environments in low and middle income countries

Global Research Network on Urban

Health Equity (GRNUHE)

Supported by the Rockefeller Foundation

i. How to put health equity at the heart of urban governance

ii. How to put health equity at the heart of urban planning/design

iii. How to connect health equity and urban environmental sustainability

iv. How to ensure urban social conditionspromote health equity

HEALTHY URBAN HEALTHY URBAN

SYSTEMSSYSTEMS

Complex Systems Collaborative Research Program:Complex Systems Collaborative Research Program:

ANU National Centre for Epidemiology & Population ANU National Centre for Epidemiology & Population HealthHealth

and CSIRO Sustainable Ecosystemsand CSIRO Sustainable Ecosystems

FrielFriel, Dixon, Capon, McMichael, Kearns, Barnett, Beatty, Dixon, Capon, McMichael, Kearns, Barnett, Beatty

Healthy Urban Systems