WHO Urban HEART Consultation Day 2

KobeI’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 2 of the Consultation, there are also posts on Day 1 and Day 3.

Workshop 1: Review of Urban HEART concepts

The first workshop focused on factors affecting health equity that might be missing from or not sufficiently emphasised in Urban HEART. These include things like gender, food and nutrition, emergency preparedness, conflict and security, universal health coverage and environmental sustainability.

The issue of within-neighbourhood disaggregation was discussed, particularly in terms of age and gender, but there was a broad recognition that this data simply isn’t available for most indicators and that this may add a layer complexity to an already imposing process. There was also a recognition that many indicators of health equity might not be sensitive enough, or may reflect structural or systemic inequalities, to change at the local or city level. These issues will be very familiar to those who have looked at equity and vulnerability within impact assessments.

There was quite a bit of discussion about the degree to which Urban HEART needs to be regarded as a standardised, readily-comprehensible approach or something that can be adapted to local needs. This is a debate I’ve encountered several times in relation to HIA and the answer seems to lie somewhere between those two extremes.

City case presentations

A presentation from Dr Oyelaran-Oyeyinka from UN-HABITAT emphasised the important role cities play as the engine rooms of economic development, though the challenge is to ensure that’s inclusive development. Internationally the urban-rural divide is diminishing but the rich-poor divide is increasing.

Kelly Murphy from St Michael’s Hospital in Toronto presented on her work adapting Urban HEART for use in developed countries. The City of Toronto has adopted Urban HEART as a mechanism to guide funding of Neighbourhood Improvement Areas and Issue to 2020.

The difficulties encountered in Toronto include:

  • working together (team changes, maintaining relationships, timelines, expectations)
  • Urban HEART being easy to use but not easy to produce (the process is clear but the sources of data is not, potential misinterpretation of results, e.g. stigmatising areas or only focusing in “red” areas when gains could be made in “yellow” ones).

The facilitating factors in Toronto incude:

  • WHO Brand associated with Urban HEART lent it credibility
  • trusted convenor
  • established relationships
  • credible technical expertise (epidemiologist with recognised track record and relationships)
  • senior champions (administrative rather than elected representatives)
  • City’s willingness to innovate
  • lead partner providing secretariat support (so the process “belonged” to someone)
  • community involvement
  • specific funding from CIHR to get the ball rolling, though the City of Toronto has now adopted this as a process within its “Wellbeing Toronto” monitoring and reporting activities

Kelly spoke about the need to talk about equity for all sectors, as opposed to health equity, and responsiveness to policy processes. Urban HEART was regarded as a clear tool that “made sense”. Despite being a developed city, Toronto found that Urban HEART was a useful approach and that the domains of the tool were still relevant.

Jose Velandia Rodriguez from Bogota, Columbia also spoke about his experience using Urban HEART in Bosa, a region within Bogota.

Workshop 2: Review of Urban HEART indicators

Most cities that have used Urban HEART have had to adapt the core indicators to some extent, or only use some of them. Most cities have also used secondary or suggested indicators as well, rather than solely the core indicators. The evaluations of city case studies so far have emphasised the need to integrate environmental and qualitative indicators/information to a greater extent.

There was a wide-ranging discussion of how and whether universal health coverage should be reflected in the Urban HEART indicators. There was a broad agreement that there should be at least one amongst the core indicator set that deals with universal health coverage, given the global focus on it, but it’s hard to identify what the key domains of UHC are. It’s generally regarded as having three dimensions – access to health services, utilisation of health services and financing of health services. There was recognition across the workshops that whilst UHC financing clearly has an impact, it often lies beyond the scope of local government to influence. They have a greater role in access and utilisation, often by providing co-funding or premises and in some cases payments to cover the direct health care costs of the poor.

The discussion on this was wide-ranging and quiet comprehensive. Rather than recapping it here I’ll just note that WHO is currently developing a UHC indicator set, which will be drawn on in selecting the UHC indicators to be included in Urban HEART. The indicators will need to focus on access and quality and have some sensitivity to vulnerability and equity at the local level. In general, geographic distribution of services is an available indicator in many settings, but beyond that it’s hard to say what will be available. Health care-related impoverishment (where people are pushed into greater poverty by healthcare costs) and catastrophic health expenditure were identified as important measures with clear equity implications, though it is unclear about how these can be turned into indicators reliably or meaningfully.

There was also discussion about how to incorporate ageing-related indicators into Urban Heart, though the consensus was that it may be more important to ensure there is disaggregation of other indicators by age rather than adding new indicators. It may be useful to refer people to WHO’s guidance on age-friendly cities where appropriate.

Emergency management indicators have already been committed to in some form, following WHO discussions with other UN agencies. These might include existence of emergency standard operating procedure plans in local government agencies. Other indicators might include prevalence of disaster-resistant buildings, e.g. earthquake-resistant buildings, people trained in emergency response, presence of local emergency response groups/networks, etc.

Qualitative data may help to fill in gaps and supplement other indicators. There was some discussion about how to integrate and present qualitative data in Urban HEART.

A bigger issue is that there is a need to ensure Urban HEART has as few possible indicators as possible in order to enhance usability, and that the indicators included are all equity-sensitive and available. They also essentially need to be geo-coded, at least at a neighbourhood level, and very few indicators are in *any* setting. Addressing this will be no easy task.


WHO Urban HEART Consultation Day 1

IMG_4183I’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on some of the issues discussed on Day 1, with some of my thoughts and reflections scattered throughout. There are also posts on Day 2 and Day 3.

Urban HEART grew out of the Commission on the Social Determinants of Health‘s work and dates back to 2007. Early activity on piloting and developing a tool were led by a few countries, notably Iran. The final report from the CSDOH gave further impetus and led to more piloting of Urban HEART in more cities. After piloting Urban HEART was extensively reviewed and Version 1 was published in 2010.

Urban HEART is conceptualised by WHO as a tool for assessment and response to health equity issues at the city level. Urban HEART was designed to meet four criteria:

  • ease of use
  • comprehensive and inclusive
  • feasible and sustainable
  • links evidence to action

It’s a stepwise process with a lot of similarities to HIA. In contrast to HIA it doesn’t need a proposal (even a general one or options) to assess. Rather it allows municipalities to identify issues for action and responses at the city level, and in that way it’s more like a needs assessment or planning activity. It’s useful where some willingness to act on health already exists, so Healthy Cities is a useful basis for action. Higher-order support is always required (which may be less true for HIA?).

Data that informs Urban HEART is almost always spread across agencies – no single one holds or reports on even the core indicators. This means multiple permissions and interagency liaison is often required, which reiterates the need for higher-order permission and negotiation at the earliest stages. Whilst this is undoubtedly desirable for HIAs as well it hasn’t always been possible in my experience and HIAs often fly under the radar, at least in the early stages. I’m not sure that would be possible for Urban HEART but I’m not sure that’s a bad thing. The under-the-radar HIAs I’ve been involved in have often encountered resistance when their recommendations are presented. A clear, unambiguous mandate and imprimatur as a basis for proceeding isn’t a bad thing.

A survey of Consultation participants that was conducted in advance found that most participants thought Urban HEART works well overall, is easy to use and successfully links evidence to action, but is less successful at being comprehensive and organisationally sustainable.

Case studies from the City of Paranaque in the PhilippinesTehran in Iran and Indore in India provided a range of useful, practical lessons on the use of Urban HEART (and they were quite inspirational). The Inore case in particular modified the indicators in a way to suit the local context, in their case by ensuring that the indicators were all meaningful and comprehensible to anyone, from residents to national bureaucrats. The case studies also highlighted the need for Urban HEART to not be a one-off activity but as an activity that needs to be revisited/undertaken semi-regularly.

How should we stratify/disaggregate equity analyses?

One issue that was identified at the Consultation is whether looking at geography and sub-municipal spatial areas as the unit of analysis always appropriate? For example might gender, poverty or age at the city level be a more appropriate way of analysing health equity issues? This is a recognised tension because all health equity analyses should use gender and SES for stratification but cities are often focused on neighbourhoods and a spatial approach. In many ways it points to a bigger, perhaps more overtly political discussion about what do we mean by health equity?

Scaling up

It was noted that approaches scaling up Urban HEART might not be the same in all cases because it’s so linked to the scope and role of government, so this will vary markedly. Encouraging progress has been made internationally, as the map below illustrates.

urban heart world map

Questions arising from Day 1

  • How can we promote Urban HEART better?
  • How can we involve NGOs or the private sector? Should we?

My general reflections

  1. An issue I have encountered is the limited availability of *any* health indicators at the city/local government level, let alone sub-city levels, given that cities can be quite small in scale with limited resources in Federalist systems.
  2. The health sector will always need to be involved in the use of Urban HEART in some capacity because they hold the data, or some of the data, but they needn’t be a roadblock. A pragmatic approach to getting the best available data but to focus on response strategies and interventions helps.
  3. In some ways the most useful thing that health systems can do is to regularly report on a broad range of health indicators at city and sub-city (disaggregated) levels, so cities can pick up Urban HEART and other related approaches and run with them.


The application of Equator Principles in high-income OECD countries

Map of the Ichthys LNG Project Area in North West Australia
Map of the Ichthys LNG Project Area in North West Australia

There’s a very interesting post by Mehrdad Nazari about the use of the Equator Principles and related performance standards in an Australian setting:

The Equator Principles website highlights that “Designated Countries [such as Australia and other high income OECD countries] are those countries deemed to have robust environmental and social governance, legislation systems and institutional capacity designed to protect their people and the natural environment”. The EPIII also notes that for “Projects located in Designated Countries, the Assessment process evaluates compliance with relevant host country laws, regulations and permits that pertain to environmental and social issues”. In the preceding paragraph, the EPIII highlights that for “Projects located in Non-Designated Countries, the Assessment process evaluates compliance with the then applicable IFC Performance Standards on Environmental and Social Sustainability (Performance Standards) and the World Bank Group Environmental, Health and Safety Guidelines (EHS Guidelines) (Exhibit III).”

Despite the proponents in the Ichthys LNG Project reportedly used the EPIII performance standards in an Australian context. Read the post in full here.

Speaking in a purely personal capacity I’d like to see more use of the Equator Principles in developed countries. They’re rigorous and well-understood internationally, and can help to allay international investor concerns and facilitate due diligence on a project. An excellent point is made in the comments for Mehrdad’s piece:

Although Australia is a developed country, projects like this are usually situated in remote areas which have many of the same characteristics as developing nations: delicate & untouched environment, indigenous traditional landowners, etc. Local laws regulate these issues but, by hedging its bets, the bank does not have to due diligence local law to the same extent – and the syndicate’s lawyers don’t have to convince 41 credit committees.

Thanks to Martin Birley for alerting me to the piece, cross-posted at the HIA Blog.

Using social media for messaging about healthy eating and active living

I was fortunate to have the opportunity to do a session on “using social media for messaging about healthy eating and active living” with Dr Becky Freeman from the University of Sydney recently. I’ve attached the slides from the session below, which probably won’t adequately capture what was covered but may provide some background if you have any questions. If you do, please email.

Does health impact assessment protect health? Is that the right question?

There’s a thought-provoking piece at ABC Environment on Does environmental impact assessment protect the environment? The piece quotes several well-known Australian EIA academics about how well EIA in Australia is performing in terms of environmental protection.

There’s no consensus in the piece about whether EIA is successfully protecting the environment or not, though some different ways of thinking about it are discussed. I think that’s because the article dances around the core issue: what is the purpose of EIA? This may seem axiomatic and uncontested but I wonder if it’s an under-examined difference between the goals and purpose of impact assessments.

In a sense we’re lucky in the HIA field. The yoke of regulatory requirement and government mandate hasn’t weighed us down too much… yet. Practice is still evolving and hasn’t been circumscribed by regulations and legal challenge to the same extent as EIA. Because of this, my impression is that there’s more acceptance that an HIA will probably have a limited impacts on health outcomes in itself. The stated goals of HIA are to protect health, promote health and to reduce health inequalities (and possibly to improve governance and public decision-making, as well as learning). HIA seeks to influence decision-making and implementation in order to influence a range of determinants of health, which in turn will impact on health outcomes, as shown below:

Diagram - HIAs Influence

This is an idealised representation of an HIA’s influence. Other assessment processes, organisational considerations and even broader social conditions will play much larger roles. In fact the process depicted is never linear either. Health outcomes and determinants are constantly changing, and decisions are constantly revisited. The delay between an activity and eventual health outcomes can sometimes stretch to decades. At each step there are a multitude of other factors that exert influence, apart from the HIA.

Though HIA’s goal is to protect health, like EIA’s is to protect the environment, the practical purpose of an HIA is to change decisions and implementation – the first step in the process depicted above. We should think about the purpose of EIA the same way. It’s not an environmental intervention, it’s a decision-making intervention/ Burdening it with expectations of environmental protection isn’t realistic.

If we do acknowledge that it will be difficult if not impossible for an HIA to demonstrate its role in changing health outcomes, we should redouble our efforts to prove its effectiveness in influencing decisions and implementation. I made a related argument in a recent article:

In some ways the issue of effectiveness may have less currency in relation to other forms of IA [than HIA]. Impact assessment, in particular environmental impact assessment, is used in some form in almost every country. Its use is common, accepted, well understood and not usually actively compared to other interventions or activities. This is not necessarily true for health impact assessment though because of the resource constraints and associated health disciplinary and epistemological concerns… if HIA’s use is to continue to be supported in increasingly resource-constrained health systems that demand evidence of the comparative effectiveness of interventions.

The right question is not whether HIA changes health outcomes. Instead it’s does HIA change decisions, implementation and ways of working?

Health Impact Assessment: A triumph over common sense?

I’m giving a plenary talk at the 4th Asia Pacific Health Impact Assessment Conference in Seoul this week. I’ve attached the slides, a detailed paper and abstract below.

Download the detailed paper of the talk (21 pages PDF)


Evaluations of health impact assessments (HIAs) have highlighted its potential impacts on decision-making, implementation and broader factors such as intersectoral collaboration (Harris-Roxas et al. 2011, Harris-Roxas et al. 2012b, Wismar et al. 2007). Tensions often arise between stakeholders about the outcomes of HIAs however. Studies that have looked at this have found that there are:

  • Often disagreements between stakeholders about the perceived purpose of the HIA and what form it should take (Harris-Roxas et al. 2012a, Harris-Roxas & Harris 2011); and
  • The perception that an HIA’s recommendations could have been identified through normal planning and implementation processes and that the HIA didn’t necessarily have to be conducted (Harris-Roxas et al. 2011). In other words, that an HIA’s recommendations are “common sense”.

These two issues, about the perceived purpose of HIA and the “common sense” nature of HIAs’ recommendations, lie at the heart of any discussion of the HIA effectiveness. These issues have also been under-explored in the literature to date.
This plenary will present initial findings from a study that looked at two decision-support equity-focused HIAs of similar health sector proposals (local health service obesity prevention and treatment service plans) longitudinally. This involved conducting 23 semi-structured interviews with key stakeholders before, during and after the HIAs, and document reviews. One of the HIAs was completed while the other one was screened and determined to be unnecessary. This study is unique in relation to HIA to the authors’ knowledge, because it looks at expectations and perceptions of effectiveness before and after the HIAs were completed. It also compares two similar planning situations, one in which an HIA was conducted and one in which the HIA was screened out.

The study’s findings highlight that while many of the recommendations and distal impacts of an HIA (Harris-Roxas & Harris 2012) could notionally be anticipated through common sense analysis, in practice they are rarely foreseen. A similar phenomenon has been demonstrated in other fields such as organisational psychology and management (Orrell 2007, Watts 2011). This study also highlights the critical role that learning plays in impact assessment practice (Morgan 2012, Bond & Pope 2012). This learning takes three forms: technical, conceptual and participatory (Harris & Harris-Roxas 2010, Glasbergen 1999). Learning may also take place at individual, organisational and social levels.

This suggests that “common sense” is anything but common in the real world of planning and decision-making, and for good reasons. What seems obvious in hindsight is rarely apparent in advance. HIA, as a structured process for looking at under-considered impacts, has an important role to play in moving beyond common sense towards broader learning and more nuanced analyses of alternatives.

Bond A, Pope J (2012)
The State of the Art of Impact Assessment in 2012, Impact Assessment and Project Appraisal, 30(1):1-4. doi:10.1080/14615517.2012.669140

Glasbergen P (1999)
Learning to Manage the Environment in Democracy and the Environment: Problems and Prospects (Eds Lafferty W and Meadowcroft J), Edward Elgar: Cheltenham, p 175-193.

Harris-Roxas B, Harris E (2011)
Differing Forms, Differing Purposes: A Typology of Health Impact Assessment, Environmental Impact Assessment Review, 31(4):396-403. doi:10.1016/j.eiar.2010.03.003

Harris-Roxas B, Harris E (2012)
The Impact and Effectiveness of Health Impact Assessment: A conceptual framework, Environmental Impact Assessment Review:accepted, in press. doi:10.1016/j.eiar.2012.09.003

Harris-Roxas B, Harris P, Harris E, Kemp L (2011)
A Rapid Equity Focused Health Impact Assessment of a Policy Implementation Plan: An Australian case study and impact evaluation, International Journal for Equity in Health, 10(6), doi:10.1186/1475-9276-10-6.

Harris-Roxas B, Harris P, Wise M, Haigh F, Ng Chok H, Harris E (2012a)
Health Impact Assessment in Australia: Where we’ve been and where we’re going in Past Achievement, Current Understanding and Future Progress in Health Impact Assessment (Ed Kemm J), Oxford University Press: Oxford, accepted – in press.

Harris-Roxas B, Viliani F, Bond A, Cave B, Divall M, Furu P, et al. (2012b)
Health Impact Assessment: The state of the art, Impact Assessment and Project Appraisal, 30(1):43-52. doi:10.1080/14615517.2012.666035

Harris E, Harris-Roxas B (2010)
Health in All Policies: A pathway for thinking about our broader societal goals, Public Health Bulletin South Australia, 7(2):43-46.

Morgan RK (2012)
Environmental impact assessment: the state of the art, Impact Assessment and Project Appraisal, 30(1):5-14. doi:10.1080/14615517.2012.661557

Orrell D (2007)
The Future of Everything: The science of prediction. Basic Books: New York.

Watts D (2011)
Everything Is Obvious (Once you know the answer). Crown Publishing: New York.

Wismar M, Blau J, Ernst K, Figueras J (Eds.) (2007)
The Effectiveness of Health Impact Assessment: Scope and limitations of supporting decision-making in Europe, European Observatory on Health Systems and Policies, World Health Organization: Copenhagen. International Standard Book Number 978 92 890 7295 3.


Improving public health messaging

I wrote this post for Croakey and Reporting on Health a little while ago. The ideas are relevant to a lot of health-related communication.

If you follow health reporting on TV or in newspapers you could be forgiven for thinking that the only things that happen are scandals in clinical services or trials of new drugs.

But journalists and PR people aren’t necessarily all to blame. As health professionals we often do a pretty bad job at explaining what we’re doing.

I’ve been thinking about how we can do a better job of explaining the slightly more complex interventions that are required for a lot of the population health problems we face. New drugs and clinical stuff-ups fit into well understood tropes. We don’t have to explain everything, the audience can take shortcuts because they understand what type of story it is.

When it comes to population health issues it’s often not as easy because the issues are interdependent, and many of the interventions are unfamiliar to a mainstream audience.

A lot of my work is on health impact assessment, which involves developing evidence-informed recommendations to inform decision-making and implementation.

When it’s explained like that, it’s no wonder journalists aren’t interested. It sounds like a technocratic snooze-fest.

Instead, let’s think about the demand for new housing in most Australian cities and the pressures to release new land on the fringe. Also think about how disastrous the design of some new suburbs has been for population health in the past by promoting car dependence, limiting walkability and increasing social isolation. The design of our suburbs matters.

Health impact assessment has been a practical way to get people to think about the health consequences of the way suburbs are designed and here’s a few examples…

Contrast that story with the bland description of health impact assessment in the earlier paragraph. It sounds a lot more engaging.

We often fail to describe this broader story in population health, not just when pitching stories but also when we communicate with other sectors (or even within the health sector).

Here are four ways I think we could get better at messaging.

1. Don’t explain the solution, explain the problem

Or better yet, explain the causes of the problem. This piece from the Atlantic Cities is a good example. It describes the phenomenon of “ghost estates” in Ireland, which came about when 2,800 housing developments were abandoned as a result of the GFC. A community group has started planting trees on these sites to reintroduce some aspects of nature into these abandoned building sites. The piece works because rather than leaping into a description of the NAMA to Nature group, it first describes the problem as well as its causes. Too often we forget the broader context when describing what we’re doing in population health.

 2. Don’t rely on the usual suspects

There’s evidence that people are more willing to listen to arguments when they come from unexpected sources, at argued in this Ramp Up post. A good example recently is the conservative economist Judith Sloane’s calls for an increase in the NewStart allowance. She could hardly be described as a usual suspect when discussing the rights of the unemployed. Different people paid attention to her comments as a result.

3. Avoid jargon and language that alienates people

The importance of this is emphasised in the Robert Wood Johnson Foundation report A New Way to Talk About the Social Determinants of Health. People switch off when things are described in stereotypical or politicised terms. As health professionals we often tend to fixate on the solutions and the jargon that surround them, partly because it’s what occupies most of our time but also because we are already convinced about the importance of the problem.

4. Describe the human impact

This is often the hardest part for population health stories. Individual stories can illustrate broader population issues but they can also be misleading and seem glib. We often understandably resist this because we have an obligation to respect the dignity and privacy of the people we work with and we can’t control how their experiences will be reported. Without the human dimension though it’s difficult for not only journalists but also the audience to connect with the story. Human-scale narratives still matter, even with the most abstract ideas.

A good example of a media piece that embraces history, messiness, complexity and a population approach is Melissa Sweet’s description of Miller for Inside Story. It’s a story about the problems faced by a suburb in South West Sydney.

It’s an almost impossible story to convey in usual journalistic form because it has a lot of history and people involved and doesn’t have a neat narrative arc or resolution. Despite this, the piece manages to convey a lot of the complexity to the reader and provides a number of insights. The point is that it is still possible to tell even the most complicated stories in engaging ways.

We’re confronting big social and population health challenges but we have some ideas about the solutions. We just need to make sure we don’t bury the lede.

Talking Twitter on Radio National Drive, 1 June 2012

I was on Radio National Drive with Julian Morrow, discussing interesting stuff from Twitter. Here some of the Twitter accounts and links I mentioned:

Digital sabbaticals

Political ads from 60 years ago

The new computer game baddies: Drones

Alain de Botton’s “Better Porn”