WHO Urban HEART Consultation Day 1

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 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 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.

Megumi Kano from the WHO Centre for Health Development gave an overview of the synthesis of evaluations of Urban HEART.  The synthesis was only of Kobe Centre-funded pilots in developing countries and may not reflect all use. The synthesis showed that "core indicators" (see Urban HEART User's Guide) were not used in all cases, in fact some of the "suggested indicators" were used as often. All case studies used the matrix, though data validation was rarely mentioned. Another difficulty was the lack of not only disaggregated sub-city level data but trend data over time. Interventions tended to focus on physical environment and infrastructure and social and human development, rather than economics or governance.

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.

Map of countries who have built capacity to use Urban HEART, 2008-2011

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.

Cross-posted on my HRH blog