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