Module 9: Concepts in Effective Program Models

Beyond customized interventions that address specific urban issues, there are several concepts that apply to each type of city program and, when utilized correctly, can lead to effective solutions to reduce urban inequalities.

Utilize Social Collective Efficacy

Numerous studies have shown that social capital interventions can improve health status. Enacting these interventions is a unique challenge in cities, where residents tend to lack the widespread social networks that are more common in rural areas. Interventions that aim to maximize social capital involve tackling social exclusion through various means including employment, education, and housing. Having a solid social network helps people to better trust available services (as they can discuss experiences with friends) and facilitates a sense of belonging. Additionally, social networks help individuals gain access to more facilities and health resources. Furthermore, results of social networks including “self-esteem, autonomy, and connections” with community members help build health “resilience” in both the physical and mental sense.(1) Thus, health programs should be designed to strengthen and take full advantage of urban social networks in order to maximize efficacy. In Ethiopia, “TB clubs” have proven to be an example of a successful intervention organized throughout urban communities; these clubs help to “reduce the stigma associated with the disease and to encourage patients to adhere to the demands of the short-course regimen of treatment.”(2)

When dealing with urban governance, community participation should play a critical role. Communities can prioritize issues and evaluate and monitor the outcomes of interventions. Participation also helps to ensure that policies are sustainable, consider human rights, and encourage local ownership. Moreover, when city dwellers form a solid foundation of collective participation, they become empowered, and will likely remain involved in future planning and policy initiatives.(3)

Case Study: Community Participation in Urban Catalonia, Spain

In urban areas of Catalonia, community participation has proven to be invaluable in the success of the Neighbourhood Health Plan implemented in 2004. In Barcelona, nine related programs were also enacted, led primarily by the city’s Public Health Agency, but also supported by health unions, government sects, community groups, and other local associations. Each region involved in the program has created a “community group […] to oversee action.” Such action includes identifying health inequities, brainstorming possible solutions, supervising projects, and evaluating outcomes. Community involvement in these projects has helped to tailor each program to the needs of the participating neighborhoods.(4)

Promote “Joined-Up Governance”

The strategy of “joined-up governance” refers to partnerships between public health agencies and “concerned actors in other sectors of municipal, regional, and national government.”(5) The most effective partnerships involve the private sector, which covers a significant portion of healthcare in cities.(6) Decentralization of administrative bodies facilitates partnerships, and enables “vertical partnerships among national, regional and local governments” to “complement [the] horizontal partnerships of stakeholders within cities.”(7) When smaller units of city organization (such as community groups) partner with municipal powers and the central government, they are better able to facilitate large-scale urban health policies.(8)   

Roles of City Stakeholders

Adapted from Hidden Cities, a 2010 joint report by WHO and UN-HABITAT, the following list, though not exhaustive, demonstrates multiple functions of city groups that can impact urban health equity. Each group provides unique contributions that, when combined with those of other groups, facilitate large-scale programming.(9)

• Ministries of Health – Collect information on health determinants and urban policy's impact on urban health; collaborate with other sectors such as “housing, transport, industry, water and sanitation, education, environment, and finance agencies”; conduct evaluations of programs and look into additional improvements.

• Local Governments – Encourage communication between government officials and community planning groups; link with NGOs and allow healthcare professionals to contribute to planning; facilitate the exchange of information “across government and with civil society and the community.”

• Civil Society – Ensure community participation; involve “residents of informal settlements” through community groups; collaborate with governments on “participatory planning and budgeting” to distribute funding to community-specific needs.

• Researchers – Gather and analyze data on population growth, urbanization, health inequalities, and the success of interventions.

• Urban Planners – Prevent exposure to pollution through zoning and land regulations; create and use building practices that protect residents' health; develop “compact cities” that facilitate access to “green areas, public transport and bicycle paths”; consider health outcomes in city planning processes.

• International Agencies – Encourage and publicize health-conscious environmental policies; “support women's rights, poverty reduction and equity-promoting strategies”; pressure government officials and policy-makers to employ “sociodemographic information” in urban planning.

NGOs as Intermediaries

While the importance of community demands illustrates the effectiveness of “bottom-up” approaches over “top-down’’ strategies, NGOs facilitate both types of policies by acting as a link between municipal governments and local groups.(10) Albert Wright from the UNDP-World Bank Water and Sanitation Program outlines criteria that an NGO must meet in order to successfully implement participatory approaches. These criteria include:

• Decentralized authority and flat management

• Community-level organization that facilitates decision-making

• Constant planning and consulting with local communities

• Ensuring that local communities contribute funds, labor, materials, or facilities, so that they become clients of the NGO rather than beneficiaries

• Requirements and compensation for new staff, including training and incentives

• Strong field presence with a high percentage of local staff

• Positive perceptions by the community

• Turnover of community client groups as they succeed in their objectives (11)

Case Study: NGOs as Facilitators of the Orangi Pilot Project in Karachi, Pakistan

The Orangi Pilot Project (OPP) perfectly illustrates community empowerment and collaboration between local groups, NGOs, community organizers, and municipal authorities. With the leadership of community organizer Akhtar Hameed Khan, the OPP has helped bring low-cost sanitation solutions to households the Orangi squatter settlement of about 900,000 residents in Karachi, Pakistan. By building up local NGOs that can plan and finance community latrines and house drains, the OPP has been able to pressure the municipal authorities of Karachi to contribute funding for more sewers. Architects and engineers play a pivotal role in the OPP; with the help of the communities, they have installed in-house latrines, house drains, and shallow sewers at the cost of about USD $25 per household. New community organizations have also formed in order to share costs, participate in construction, and elect representatives. However, with more success comes additional community demands, and the project has grown to a large-scale collaboration. The OPP has now supplied quality sewerage to over 90% of the households in Orangi. This example in Orangi demonstrates the power of NGOs and community participation to enact far-reaching projects. The OPP is proof that we must not underestimate the effectiveness of collaboration between local community groups and governmental authorities.(12)

Address Affordability Over Physical Accessibility

In urban areas, it is not physical distance that prevents most people from accessing care but rather financial barriers. While cities may have more facilities than do rural areas, urban life is typically more cash-dependent than rural life. Indrajit Hazarika of the Indian Institute of Public Health suggests that while individual empowerment is an important goal, an “intermediate step would be to bring poor people under a social security net, to provide financial assistance and facilitate their access to health services.”(13) In fact, there are numerous arguments supporting the claim that countries should allocate more of their national budget towards public healthcare, especially since many developing nations cannot allocate enough to cover a significant portion of the population.(14) However, government officials are not the sole players in facilitating public healthcare; local markets have the ability to increase access to medicines and health services. As price controls on medications have been problematic when there is a lack of enforcement, one effective solution may be to “manag[e] both demand and supply conditions” and more carefully consider the role of local markets in addition to manufacturers’ prices.(15)

Create Evidence-Based Programs

In order for interventions to be as appropriate and efficient as possible, proper research is an absolute necessity. In particular, there must be extensive longitudinal research that can determine causes of risk factors, and ways to build resilience in a community. Furthermore, there must also be disaggregated research that can distinguish between various strata of city dwellers.(16) Since many of the most impoverished urban dwellers live in uncharted areas it is crucial to recognize these overlooked communities and include them in official maps and intervention policies in order to effectively improve the health of their residents.(17) In many studies and policy plans, the most difficult aspect of the intervention is gathering accurate information about inequities, and applying this information through efficient methods.

One example of a successful resource for program design is the World Health Organization’s Urban HEART (Urban Health Equity Assessment and Response Tool). This tool, completed in 2009, is based on experiences in cities from ten countries, and is used to inform proposed interventions. This tool helps local governments, central governments, community groups, and civil society organizations to identify the most pressing problems through disaggregated data and choose the most appropriate responses to address inequities. Urban HEART is designed to use data (that is already available) to determine specific inequities in a particular region. Parañaque City in the Philippines recently used Urban HEART to improve healthcare for pregnant women through an in-depth analysis conducted by a multi-sectoral team. Results were then employed in efficient and appropriate interventions, such as the construction of local birthing facilities. The research facilitated by Urban HEART, as well as the program’s resulting success, have stimulated further improvements in both Parañaque City and the surrounding communities.(18) 

Conclusion

As demonstrated by the analyses and case studies presented here, rapid urbanization is changing global perceptions of poverty and health. As more people crowd into cities, more health issues arise, calling for additional research, innovation, and networking between city activists and policymakers. Cities contain gaping inequities that can be eliminated with appropriate responses and innovations. In fact, far from being purely burdensome, urbanization offers countless positive prospects for communities, presenting new opportunities for accessible health services. Urbanization should be viewed as an impetus for improving living conditions and public health. The challenge now is to keep up with the changes associated with urbanization and enable equal and widespread access to the new resources that are bound to spring up among these growing communities.

Footnotes

(1) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.

(2) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(3) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(4) Ibid.

(5) Montgomery, M.R. “Urban Poverty and Health in Developing Countries.”Population Bulletin 64 (June 2009): 2-15.

(6) Ibid.

(7) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010. Accessed on 13 June 2011.

(8) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.

(9) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.

(10) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.

(11) Wright, A.M. Toward a Strategic Sanitation Approach: Improving the Sustainability of Urban Sanitation in Developing Countries. UNDP – World Bank Water and Sanitation Program, 2007.

(12) Ibid.

(13) Shetty, P. "Health Care for Urban Poor Falls Through the Gap.”The Lancet 377 (February 2011): 627-628. 

(14) Harpham, T. “Urban health in developing countries: What do we know and where do we go?”Health & Place 15 (2009): 107–116.

(15) Russo, G., & McPake, B. (2010). Medicine prices in urban Mozambique: a public health and economic study of pharmaceutical markets and price determinants in low-income settings. Health Policy and Planning, 25(1), 70-84.

(16) Harpham, T. “Urban health in developing countries: What do we know and where do we go?” Health & Place 15 (2009): 107–116.

(17) Ardakani, Mohammed Assai. The Global Forum on Urbanization and Health. World Health Organization. Kobe, Japan. November 2010. http://www.gfuh.org/interviews34.html. Accessed on 1 July 2011.

(18) World Health Organization (WHO), and United Nations Human Settlements Programme (UN-HABITAT). Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. 2010.