WHO Urban HEART Consultation Day 2

I'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.