.@pahowho High Level report on Universal Health in the 21st Century: 40 Years of Alma-Ata https://t.co/TtCCO85KIe The recommendations are very high level and aspirational, but aspirations are good things #wp
I’ve been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 3 of the Consultation, there are also posts on Day 1 and Day 2.
Workshop 3: Review of Urban HEART guidance
There was a widespread view that the current Urban HEART guidance works quite well but that there are a few areas where it might be enhanced. There was discussion about the selection of interventions and responses being difficult in practice, and that it involves considerable negotiation. There wasn’t agreement about the best ways to reflect this in the guidance but it was a recurrent theme, and one that’s familiar in the context of HIA and negotiating recommendations.
Community participation is another aspect of Urban HEART that has been difficult to provide guidance on. Participatory rapid assessments, health assemblies, surveys, workshops, and the use of mobile and electronic engagement tools were all discussed as ways to involve communities in Urban HEART processes, though these were all recognised as having limitations.
There was quite a lot of discussion about the extent to which HIA might be integrated into Urban HEART, though it was agreed that Urban HEART and HIA are complementary rather than being processes that could be integrated. This is because Urban HEART helps to identify needs and areas for action at the city level, whereas HIA is most useful where there is a proposal or a limited set of options to assess. So whilst there are procedural similarities they serve quite different purposes and integrating them might complicate things rather than helping. The diagram below from the Urban HEART User Guide shows how WHO conceptualises Urban HEART’s role in local planning cycles. Some related procedures like multi-criteria decision analysis and equity lenses were also discussed, and how they might be integrated into Urban HEART.
An important issue that was discussed was that we need to focus on enhancing the equity focus of Urban HEART rather than simply improving the technical aspects of the process. The value of Urban HEART is its equity focus rather than its health focus, and we need to prioritise that in any revisions. This is something I hadn’t really considered before and I think it poses a challenge to the HIA practitioners: beware focusing on improving technical aspects of the assessment process at the expense of an equity focus. Technically perfect assessments won’t necessarily result in inequities being better addressed.
The need to demonstrate economic effectiveness/cost-benefit was also discussed. This is familiar territory for HIA practitioners! I confess that I have mixed feelings about this. Whilst I can see that there are benefits to even limited economic approaches to describing the economic benefits of HIA or Urban HEART (willingness to pay analyses, estimated savings based on case studies, etc), ultimately Urban HEART and HIA are about informing and improving planning and decision-making. They’re not readily comparable to other health interventions because they’re fundamentally different types of interventions.
The need for an online guide, repository and clearinghouse for evidence was discussed. We’re very fortunate in HIA to have the HIA Gateway. The consensus was that something similar is required for Urban HEART.
City case presentations
Madeleine Ntetani-Nkoussou discussed the use of Urban HEART in Brazzaville, Congo. There’s a number of issues in Brazzaville associated with informal settlement/slums and rapid urbanisation. The physical and service infrastructure has struggled to keep pace. Potable water access and access to water sealed toilets remain big issues, as is food security. urban HEART helped the city identify the four arrondissement that required greater activity, in particular around the provision of health services and prevention activities.
Plenary discussion: Next steps
One issue that was raised is whether there a need or mechanism to involve state and national governments in Urban HEART? Though this approach would have relevance to them, a big part of the appeal of Urban HEART is the clarity of the indicators and its applicability at the city level.
The distinction between Urban HEART as an indicator/diagnostic tool and a framework to guide implementation came up a few times. It’s intended to be both, but there’s a tension, which most HIA practitioners would have encountered as well.
There was quite wide-ranging and detailed discussion about approaches to building capacity for Urban HEART, which I won’t describe in detail here because I’m not able to do justice to the range of issues discussed. Some of the broad topics touched on included:
sharing best practice, particularly in the form of brief case studies focused on key learning
building Urban HEART into WHO and country-level work plans
linking to professional groups/associations
ensuring the health sector comes along the journey and that Urban HEART doesn’t become the sole responsibility of cities/other sectors
how often does Urban HEART need to be revisited/redone
how can we make Urban HEART sell itself, i.e. so it doesn’t need much ongoing support
compendiums of best practice and then thinking how some of these best practice cases might be synthesised
how to advance an equity agenda in settings where it’s not on the political agenda
These issues are all eerily familiar to people who’ve worked on HIA! It was an excellent Consultation with lots of food for thought that also highlighted how well-designed Urban HEART is and how much work has gone into its development. I plan to do another post in a few days that brings together some of the critical points and what the implications might be for HIA.
I’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 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 Philippines, Tehran 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?
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.
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
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.
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.
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.