Copyright 2009 The Johns Hopkins University and Marilyn Rice. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License . Your use of this material constitutes acceptance of that license and the conditions of use of materials on this site.
Transcript
Copyright 2009 The Johns Hopkins University and Marilyn Rice. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this site.
Municipalization and Urban Health: Tendencies in the Americas, Lessons Learned, and Challenges
Marilyn Rice, MA, MPH, CHES PAHO/WHO
Section A
Urban Trends
4
Urban Trends
More urban than ever
More unequal than ever
Democracy, inequality, and exclusion
Sociopolitical framework
Local power and municipalization
Urban health—a new paradigm
5 Source: Stephens, C. (2000, August). Threats to urban health. International Food Policy Research Institute. Retrieved from http://www.ifpri.org/2020/focus/focus03/focus03_09.pdf
The Future Looks More Urban Than Ever
By 2006, roughly half the world’s population is residing in an urban area
By 2030, three-fifths will live in an urban area
Cities are much more than a conglomerate of people with individual risk factors and health needs, they … - Offer opportunities for educational, professional, cultural, and
economic growth - Are the center of innovations
6
The Future Looks More Unequal Than Ever
Globalization in cities has generated a new geography of poverty, unemployment, and social exclusion
Deterioration in values related to common well-being, equity, and active participation of citizens
Loss of legitimacy of institutions, fragmentation, complexity of civil society organizations, and growth of poverty and inequities have created an increasing demand for new institutional democracy, one that introduces right to participate as a benefit of citizenship
7
Democracy, Inequality, and Exclusion
Democracy, poverty, and inequality: Latin American triangle (UNDP, 2004) - Proliferation of electoral democracy in the region - Extension of poverty and inequality
Democracy - Representative and/or participative - Civil, political, and social rights - Citizenship as autonomy or solidarity?
8
Democracy, Inequality, and Exclusion
Reduction of exclusion will only occur through a new form of democracy, one that is capable of recognizing excluded populations as citizens, generating public spaces for participation, social control and consolidation of efforts, as well as implementing healthy public policies and effective redistribution of resources (Fleury, 2005)
9
City of Citizens: A Sociopolitical Framework
Cities as territories politically and socially constructed with their citizens
Democratic management and strengthening of citizen participation
Strengthening of social cohesion
Reduction of inequities and exclusion
Deliberated democracy and social inclusion
Strengthening of social and political networks
10
Local Power, Innovation, and Networks
Contribute to development of new paradigm for strengthening local level, based upon need for real democracy and development processes with social inclusion
This presupposes the existence of innovative environments, articulation among economic and social policies, networks, leadership, teaching and research institutions, healthy public policies, social participation, and intersectorality
11
Local Power, Innovation, and Networks
The principal characteristic of innovative cities is collectivity, with different sectors of society and their participation through different governmental spheres
12
Region Territory (thousands of km2)
Population (millions of
inhabitants)
Number of municipalities
Latin America 21,000 450 16,600
Canada 6,100 30 4,657
U.S.A. 10,000 250 19,200
Europe 24,500 575 122,682
Source: Carvajal, Palma E. (1998). El nuevo municipio latinoamericano: descentralización y democracia. ILPES, LC/IP/R 135.
Municipalities in the Americas and Europe
13 Source: Retrieved from http://www.citypopulation.de/World.html
Cities with More Than One Million Inhabitants
Argentina 3 Bolivia 2 Brazil 21 Canada 5 Chile 1 Colombia 6 Costa Rica 1 Cuba 1 Dominican Republic 1 Ecuador 2 El Salvador 1
Guatemala 1 Haiti 1 Mexico 11 Nicaragua 1 Panama 1 Paraguay 1 Peru 1 Puerto Rico 1 United States 53 Uruguay 1 Venezuela 5
14
Municipalization
Decentralization of the state, basic objectives - Transfer of competencies and recognition of political autonomy
to municipalities, supporting citizen participation and local economic development
- Between 1990 and 2000, increase in number of municipalities
15
Characteristics of Municipalities in Latin America
Rural, semi-urban, marginal urban
Fifty percent have less than 25,000 inhabitants
Two percent have more than 500,000 inhabitants (about 142 municipalities)
Little access to resources, decision centers, and public services
Weak inter-institutional collaboration
16
Urban Public Health
Concentration of populations in urban areas - 1990—67% - 2005—72% - 2007—78%
Public health - WHO’s broad concept of
health allows an understanding of urban health as dependent upon work and life conditions of the people that inhabit a city
17
Strategic Action
Health promotion as the new public health (Ottawa Charter) - Healthy public policy - Intersectoral collaboration - Social participation - Local capacity development - Focus on settings
PAHO/WHO Healthy Municipalities, Cities and Communities
18
New Topics in Urban Health
Health and quality of life in cities Environment Migration and health of city immigrants City systems and services Equity Local governance Healthy public policies and city planning
19
New Topics
Social innovations
Reduction of poverty and hunger
Violence
Obesity
Sedentary lifestyles
Mental health
20
Urban Health Transcends Traditional Functions
Healthy cities transcend the limits of functions of organizational principles, they go beyond health policies to healthy public policies that address health-determining factors
The healthy cities initiative defined planning as a public exercise, with broad community participation and multiple sectors
Likewise, new forms of social communication are introduced
Healthy cities develop a new approach to public management, and they address the strengthening of municipal administration and local teams with this new approach (Kickbush, 1998)
Section B
Urban Examples
22
Examples of Urban Context
Selected cities of Latin America - Asuncion, Paraguay - Buenos Aires, Argentina - Lima, Peru - Montevideo, Uruguay
23
Asuncion, Paraguay
Asuncion has six districts, or principal neighborhoods 1. La Catedral 2. La Encarnación 3. San Roque 4. Lambaré 5. Recoleta 6. Santísima Trinidad
Important to recognize differing priorities among the six districts.
24
Asuncion, Paraguay
Asuncion has six districts, or principal neighborhoods 1. La Catedral 2. La Encarnación 3. San Roque 4. Lambaré 5. Recoleta 6. Santísima Trinidad
Important to recognize differing priorities and differing populations among the six districts
Important to combine data collected by different sectors (transportation, education, health, etc.)
25
Community-Identified Needs
Need for more urban planning
Flooding
Garbage
Housing
Social participation
Education
Health
Buenos Aires Strategic Plan
Created a 10-year strategic plan to deal with the effects of urbanization
Addressing both present-day and future problems created by population influx
26
Buenos Aires: City-Based Assessment
Who is our population?
Where do people live?
Where do people work?
What are the different needs in the different districts and different sectors?
27
28
Economic Distribution of Population
Adapted by CTLT from EPH Indec, 2004
Ciudad de Buenos Aires: Distribución de la Población Ocupada por Actividad Económica
29
Allocation of Resources
Adapted by CTLT from EPH Indec, 2004
30
Indigent Population and Poverty
Adapted by CTLT from EPH Indec, 2004
31
Indigent Population and Poverty
Adapted by CTLT from EPH Indec, 2004
32
Metropolitan Lima
43 districts
Extension: 2817.30 km2
Population: 7,496,831 inhabitants
33
Poverty in Lima
Sixty percent of the population lives in the northern section: north, east, and south
Eighty percent of the poor live in these sections
The marginal neighborhoods are populated by migrants in these sections of Lima
Lima maintains a standard of segregation in the central periphery
Poverty and Age of Community
Poorest population of Lima lives on the outskirts of the city
Wealthiest population lives in the center of the city, which is adjacent to the coast and port
34
35
Violence
One in three people over 18 years of age was a victim of some assault
One of every three car owners has been subject to theft
Three of every 10 people have been the subject of attempted or actual robbery
Two out of every five violent deaths are from traffic accidents
36
Slums
In the newly developing slums, about 1,000 tons of garbage is left uncollected daily
Sixty-three percent of new construction is built without functioning licenses
5.7% of the population between 6 and 17 years of age do not go to school
37
Montevideo City
Photo by Gustavo. Creative Commons BY-NC-SA.
38 Source: Unidad de Información Geográfica Intendencia Municipal de Montevideo.
Rural and Urban Limits in Montevideo
Within city boundaries, there are still rural structures and contexts
Majority of urban development is located in the center city
39
2001-2003
Fuente: Elaboración en base a la ECH. Montevideo Observatory of Social Inclusion.
Unemployment Rates
Montevideo average: 16.4 %
40
Fuente: Elaboración en base a la ECH. Montevideo Observatory of Social Inclusion.
2001–2003
Poverty Distribution by Neighborhoods
Montevideo average: 33.6%
41
Fuente: Consulta a actores locales 2004. Montevideo Observatory of Social Inclusion.
Zones of High Exclusion
Housing problems are more universal throughout the city
42
Montevideo: A New Form of Local Governance
City campaign to encourage participation across zones and sectors
Yellow circle: Political arm of government (policy making)
Orange circle: Institutional arm (implementation of policy)
Green circle: Community arms (participation and community organization)
Section C
Trends and Networks
44
Trends and Networks
Trends in urban health
The Healthy Municipalities, Cities and Communities (HMC) Movement in the Americas
The network of HMC of the Americas
45
Reflections on Tendencies
Participatory processes are fundamental, but sometimes they lack full representation, there are gaps in information, and they grow in uncoordinated ways
Citizens demand security, and reports to police increase
Among the main determinants of urban health are poverty and inequity
Mutual support and joint action is more frequent
Health promotion, as a strategy for improving urban health, is a process of social production with responsibility
46
Construction and Development of Capacities
Incorporation of urban health into development plans with local governments using all possible networks
Institutional strengthening
Intersectoral committees with social participation
Create and articulate entities that work to promote health and quality of life
47
The HMC Movement in the Americas
PAHO introduced the strategy in the region in the 1990s
Main objectives are to … - Promote health, together with people and communities, in
settings where they study, work, play, love, and live - Establish and strengthen a social pact among local authorities,
community organizations, and public and private sector institutions
- Use local planning and social participation in management, evaluation, and decision making
48
“A municipality begins the process of becoming healthy when its political leaders, local organizations, and citizens commit themselves to improving the health and quality of life of all of its inhabitants.”
— Pan American Health Organization. (2002). Mayor’s guide for promoting quality of life.
HMC Movement
49
The HMC Movement in the Americas
In 2007, 18 of the 38 countries in the region actively involved with the HMC strategy
South America Argentina Brazil Ecuador Guyana Paraguay Peru Uruguay
Central America Costa Rica El Salvador Honduras Nicaragua Panama
North America Canada Mexico U.S.A.
Caribbean Cuba Dominican Republic Trinidad and Tobago
Countries in “orange” have national networks. Those in “yellow” are not implementing the HMC strategy.
50
HMC Network of the Americas: Vision
The HMC Network leads the development and strengthening of the HMC strategy and positions health promotion on the political agenda of the member countries in order to contribute to sustainable local development, improve the social determinants of health, and strengthen the conditions of equity and peace in the region of the Americas
51
HMC Network of the Americas: Mission
That the HMC Network of the Americas constitutes the main and model advocacy forum of the region of the Americas for healthy public policies, strengthening partnerships at continental level, articulating HMC networks’ activities, and promoting the sharing of experiences and solidarity among its members, thus ensuring the sustainability of achievements, improving conditions of equity and quality of life, and facing new challenges
52
HMC Network of the Americas: General Objectives
Promote the creation and the strengthening of national HMC networks in the Americas with a health promotion perspective
Promote healthy public policies, decentralization, and democratization of local governments
Improve local capacity for the implementation, management, and evaluation of HMC initiatives
Integrate the work of subregional networks with other initiatives linked to integration, political, economic, and social processes, seeking joint efforts and consolidation
53
Countries with National HMC Networks
Argentina Costa Rica Cuba El Salvador (recently established) Mexico Paraguay Peru Other countries, such as Brazil, Canada, and the U.S., have various
regional networks
Section D
Lessons Learned and PAHO Resources
55
Lessons Learned and PAHO Resources
Participatory evaluation empowers
Lessons learned from application of participatory evaluation methodology
PAHO HMC resources
56
Empowerment and Local Transformation
Lessons learned through participatory evaluation of healthy municipalities, cities, and communities
57
Priority area Pillars Policies Participation Sustainability Intersectoral Structures
Political context and timing was by far the most important factor affecting the implementation of participatory evaluation in the participating countries
Election periods and political transitions often caused major delays (if not termination) of initiatives, shortage/change of personnel and funds, and great uncertainty about the future of the initiatives, and their evaluation
This has consequences for the evaluation of programs under implementation, but especially for programs conducted by the previous administration and not continuing under the new one
60
Political Context
Transitory nature of local and national political contexts can weaken programs and public policies, particularly when there is a change in political parties
It is important to form a strong coalition among all sectors of society to strengthen and sustain the HMC initiatives and their evaluation, and to provide continuity during these transitional periods - Rice, M., and Franceschini, M. C. (2007). Lessons learned from
the application of a participatory evaluation methodology to Healthy Municipalities, Cities and Communities Initiatives in selected countries of the Americas. Promotion & Education (Vol. XIV, No. 2.).
61
Aim for a Truly Intersectoral Process
Incorporating a variety of local partners (MOH, NGOs, universities, community members, community-based organizations, etc.) was important for the sustainability of the HMC initiative and its participatory evaluation in the countries
It is crucial to get buy-in from the main stakeholders in order to begin and sustain the implementation of the participatory evaluation methodology
Lack of support from critical stakeholders, such as municipal program managers or key personnel at public institutions, can seriously deter or isolate the advancement of the initiative
62
Conducting a Participatory Evaluation Takes Time
But it is worth it
Participatory evaluation process was lengthy and time consuming due to various factors - Need to bring together and guarantee the buy-in from people
from various backgrounds, sectors, and interests - Stakeholders come with different perspectives and paradigms,
and often from institutions and organizations with rigid and bureaucratic structures and work cultures
- Different levels of education among the community leaders
63
Time Is Needed
Recognize the time needed for institutions, organizations, and individuals to adapt and accept a new methodology and paradigm that can greatly change how they function and work. Given the appropriate time and stimulation, people become motivated and apply dedicated efforts to implementing these new programs and methodologies.
This initial process is an opportunity to strengthen alliances and trust among participants and their institutions (for example, municipal managers, representatives from the community, and NGOs)
64
Set Aside Resources for the Evaluation
Lack of sufficient resources can limit or interrupt the participatory evaluation process
Allocation of scarce community resources to conduct a participatory evaluation was a common problem that resulted from a general lack of understanding about the effectiveness and the usefulness of the results generated on the part of program managers and others responsible for funding and budget
It is important to educate stakeholders on the benefits and the appropriateness of participatory evaluation in producing key information for decision making at all levels
It is important to advocate for the establishment of a fund for health promotion evaluation from the initial planning stages of any initiative (PAHO, 2005)
65
Reach Consensus on Definition of Key Concepts
There is a general lack of understanding about - The concept of health promotion (often considered an approach
to disease prevention) - The participatory evaluation methodology which has a large
qualitative component
There are doubts about the benefits of conducting a participatory evaluation, mostly related to the time it takes to conduct the process and the usefulness of the data it will produce
Resistance by those in key institutions is common
66
Address Concerns about Participatory Processes
Concerns can arise related to … - Fears of receiving negative comments - Prejudice against actions taken with “too much” input from
community members - Fears that the process would generate “unrealistic demands” on
the part of community
This can be particularly true of communities that are not well represented, in which, traditionally, programs and approaches are implemented from the top-down and truly representative and participatory mechanisms for community participation were scarce or non-existent
67
Institutional Context and Individual Factors
Working with institutions with rigid and bureaucratic structures can be a major challenge for those engaged in conducting a participatory evaluation due to lack of institutional support, excessive bureaucracy, lack of coordination among public sector institutions, strict guidelines regarding the use of funds, conflicts between the different actors involved (federal, state, municipal)
High turnover of personnel at all levels and institutions can be very disruptive and difficult to deal with since it can seriously impair the continuity, feedback, and appropriate application of the participatory methodology
68
Institutional Context
On the positive side, working with institutions can open channels of communication with other levels and sectors, improve organizational climate, and open spaces for exploring new modes of multi-sectoral collaboration
Working with institutions also offers the opportunity to regularize processes and methodologies within their work plans, programs, etc.
69
Strong Leadership Is Central
Strong leadership is central to the sustainability of the evaluation initiative
A common determinant of successful experiences with the participatory evaluation in the countries was the existence of strong, sustained, and dynamic leadership to take the process forward
Active commitment and engagement from institutions both at the local and national levels is key to the success of the initiative, as is collaborative work among these institutions
The role of national and regional HMC networks can be central in these efforts, providing the potential for far-reaching connections to municipalities throughout a country or region, as well as a connection with key stakeholders that can support the evaluation process
70
Participatory Evaluation Can Be Empowering
Conducting a participatory evaluation can be an empowering process by itself
There was an empowering effect of applying a participatory methodology—communities and stakeholders were more willing and interested in participating and maintaining this participation
The process provided a very rich opportunity to discuss, exchange, and reflect on countries’ experiences with the HMC strategy
71
HMC Resources
HMC listserves (English and Spanish) with over 300 members from various countries in the Americas - http://listserv.paho.org/archives/red-mcs.html
HMC newsletter published every trimester in English and Spanish with articles submitted by countries - http://www.bvsde.ops-oms.org/bvsdemu/bolmunici/
bolmunici.html
HMC Web site at Virtual Library - http://www.bvsde.ops-oms.org/sde/ops-sde/bv-
