Megumi Kano

Prioritizing action on health inequities in cities: An evaluation of Urban Health Equity Assessment and Response Tool (Urban HEART) in 15 cities from Asia and Africa

Following the recommendations of the Commission on Social Determinants of Health (2008), the World Health Organization (WHO) developed the Urban Health Equity Assessment and Response Tool (HEART) to support local stakeholders in identifying and planning action on health inequities. The objective of this report is to analyze the experiences of cities in implementing Urban HEART in order to inform how the future development of the tool could support local stakeholders better in addressing health inequities. The study method is documentary analysis from independent evaluations and city implementation reports submitted to WHO. Independent evaluations were conducted in 2011–12 on Urban HEART piloting in 15 cities from seven countries in Asia and Africa: Indonesia, Iran, Kenya, Mongolia, Philippines, Sri Lanka, and Vietnam. Local or national health departments led Urban HEART piloting in 12 of the 15 cities. Other stakeholders commonly engaged included the city council, budget and planning departments, education sector, urban planning department, and the Mayors office. Ten of the 12 core indicators recommended in Urban HEART were collected by at least 10 of the 15 cities. Improving access to safe water and sanitation was a priority equity-oriented intervention in 12 of the 15 cities, while unemployment was addressed in seven cities. Cities who piloted Urban HEART displayed confidence in its potential by sustaining or scaling up its use within their countries. Engagement of a wider group of stakeholders was more likely to lead to actions for improving health equity. Indicators that were collected were more likely to be acted upon. Quality of data for neighbourhoods within cities was one of the major issues. As local governments and stakeholders around the world gain greater control of decisions regarding their health, Urban HEART could prove to be a valuable tool in helping them pursue the goal of health equity.

Developing a Conceptual Framework of Urban Health Observatories toward Integrating Research and Evidence into Urban Policy for Health and Health Equity

Detailed information on health linked to geographic, sociodemographic, and environmental data are required by city governments to monitor health and the determinants of health. These data are critical for guiding local interventions, resource allocation, and planning decisions, yet they are too often non-existent or scattered. This study aimed to develop a conceptual framework of Urban Health Observatories (UHOs) as an institutional mechanism which can help synthesize evidence and incorporate it into urban policy-making for health and health equity. A survey of a select group of existent UHOs was conducted using an instrument based on an a priori conceptual framework of key structural and functional characteristics of UHOs. A purposive sample of seven UHOs was surveyed, including four governmental, two non-governmental, and one university-based observatory, each from a different country. Descriptive and framework analysis methods were used to analyze the data and to refine the conceptual framework in light of the empirical data. The UHOs were often a product of unique historical circumstances. They were relatively autonomous and capable of developing their own locally sensitive agenda. They often had strong networks for accessing data and were able to synthesize them at the urban level as well as disaggregate them into smaller units. Some UHOs were identified as not only assessing but also responding to local needs. The findings from this study were integrated into a conceptual framework which illustrates how UHOs can play a vital role in monitoring trends in health determinants, outcomes, and equity; optimizing an intersectoral urban information system; incorporating research on health into urban policies and systems; and providing technical guidance on research and evidence-based policy making. In order to be most effective, UHOs should be an integral part of the urban governance system, where multiple sectors of government, the civil society, and businesses can participate in taking the right actions to promote health equity.

Metrics in Urban Health: Current Developments and Future Prospects

The research community has shown increasing interest in developing and using metrics to determine the relationships between urban living and health. In particular, we have seen a recent exponential increase in efforts aiming to investigate and apply metrics for urban health, especially the health impacts of the social and built environments as well as air pollution. A greater recognition of the need to investigate the impacts and trends of health inequities is also evident through more recent literature. Data availability and accuracy have improved through new affordable technologies for mapping, geographic information systems (GIS), and remote sensing. However, less research has been conducted in low- and middle-income countries where quality data are not always available, and capacity for analyzing available data may be limited. For this increased interest in research and development of metrics to be meaningful, the best available evidence must be accessible to decision makers to improve health impacts through urban policies.

Disaggregating health inequalities within Rio de Janeiro, Brazil, 2002-2010, by applying an urban health inequality index

An urban health index (UHI) was used to quantify health inequalities within Rio de Janeiro, Brazil, for the years 2002-2010. Eight main health indicators were generated at the ward level using mortality data. The indicators were combined to form the index. The distribution of the rank ordered UHI-values provides information on inequality among wards, using the ratio of the extremes and the gradient of the middle values. Over the decade the ratio of extremes in 2010 declined relative to 2002 (1.57 vs. 1.32) as did the slope of the middle values (0.23 vs. 0.16). A spatial division between the affluent south and the deprived north and east is still visible. The UHI correlated on an ecological ward-level with socioeconomic and urban environment indicators like square meter price of apartments (0.54, p < 0.01), low education of mother (-0.61, p < 0.01), low income (-0.62, p < 0.01) and proportion of black ethnicity (-0.55, p < 0.01). The results suggest that population health and equity have improved in Rio de Janeiro in the last decade though some familiar patterns of spatial inequality remain.Um indice de saude urbana foi utilizado para quantificar desigualdades na saude no Rio de Janeiro, Brasil, 2002-2010. Oito indicadores de saude foram gerados no nivel dos bairros utilizando dados de mortalidade. Os indicadores foram combinados para formar o indice. A distribuicao ordenada dos valores do indice fornece informacoes sobre a desigualdade entre os bairros, por meio da relacao entre os extremos e o gradiente dos valores medios. Ao longo da decada, a proporcao dos extremos caiu em 2010 em relacao a 2002 (1,57 vs. 1,32), assim como a inclinacao dos valores medios (0,23 vs. 0,16). A divisao espacial entre o sul afluente e o norte carente esta ainda visivel. Os valores do indice correlacionam com indicadores socioeconomicos e urbanos como o preco do metro quadrado de apartamentos (0,54, p < 0,01), baixa escolaridade da mae (-0,61, p < 0,01), baixa renda (-0,62, p < 0,01) e proporcao de pretos etnicos (-0,55, p < 0,01). Os resultados sugerem que a equidade na saude no nivel da populacao tem melhorado no Rio de Janeiro na ultima decada, embora padroes familiares da desigualdade espacial permanecam.

Measuring the Impact of Environment on the Health of Large Cities

The relative significance of indicators and determinants of health is important for local public health workers and planners. Of similar importance is a method for combining and evaluating such markers. We used a recently developed index, the Urban Health Index (UHI), to examine the impact of environmental variables on the overall health of cities. We used the UHI to rank 57 of the world’s largest cities (based on population size) in low- and middle-income countries. We examined nine variables in various combinations that were available from the Demographic and Health Surveys conducted in these countries. When arranged in ascending order, the distribution of UHIs follows the previously described pattern of gradual linear increase, with departures at each tail. The rank order of cities did not change materially with the omission of variables about women’s health knowledge or childhood vaccinations. Omission of environmental variables (a central water supply piped into homes, improved sanitation, and indoor solid fuel use) altered the rank order considerably. The data suggest that environmental indicators, measures of key household level risk to health, may play a vital role in the overall health of urban communities.

Disgregando desigualdades en el ámbito de la salud en Río de Janeiro, Brasil, 2002-2010, mediante la aplicación de un índice urbano de desigualdad en salud

An urban health index (UHI) was used to quantify health inequalities within Rio de Janeiro, Brazil, for the years 2002-2010. Eight main health indicators were generated at the ward level using mortality data. The indicators were combined to form the index. The distribution of the rank ordered UHI-values provides information on inequality among wards, using the ratio of the extremes and the gradient of the middle values. Over the decade the ratio of extremes in 2010 declined relative to 2002 (1.57 vs. 1.32) as did the slope of the middle values (0.23 vs. 0.16). A spatial division between the affluent south and the deprived north and east is still visible. The UHI correlated on an ecological ward-level with socioeconomic and urban environment indicators like square meter price of apartments (0.54, p < 0.01), low education of mother (-0.61, p < 0.01), low income (-0.62, p < 0.01) and proportion of black ethnicity (-0.55, p < 0.01). The results suggest that population health and equity have improved in Rio de Janeiro in the last decade though some familiar patterns of spatial inequality remain.Um indice de saude urbana foi utilizado para quantificar desigualdades na saude no Rio de Janeiro, Brasil, 2002-2010. Oito indicadores de saude foram gerados no nivel dos bairros utilizando dados de mortalidade. Os indicadores foram combinados para formar o indice. A distribuicao ordenada dos valores do indice fornece informacoes sobre a desigualdade entre os bairros, por meio da relacao entre os extremos e o gradiente dos valores medios. Ao longo da decada, a proporcao dos extremos caiu em 2010 em relacao a 2002 (1,57 vs. 1,32), assim como a inclinacao dos valores medios (0,23 vs. 0,16). A divisao espacial entre o sul afluente e o norte carente esta ainda visivel. Os valores do indice correlacionam com indicadores socioeconomicos e urbanos como o preco do metro quadrado de apartamentos (0,54, p < 0,01), baixa escolaridade da mae (-0,61, p < 0,01), baixa renda (-0,62, p < 0,01) e proporcao de pretos etnicos (-0,55, p < 0,01). Os resultados sugerem que a equidade na saude no nivel da populacao tem melhorado no Rio de Janeiro na ultima decada, embora padroes familiares da desigualdade espacial permanecam.

Desagregando desigualdades na saúde no Rio de Janeiro, Brasil, 2002-2010, através da aplicação de um índice urbano de desigualdade de saúde

An urban health index (UHI) was used to quantify health inequalities within Rio de Janeiro, Brazil, for the years 2002-2010. Eight main health indicators were generated at the ward level using mortality data. The indicators were combined to form the index. The distribution of the rank ordered UHI-values provides information on inequality among wards, using the ratio of the extremes and the gradient of the middle values. Over the decade the ratio of extremes in 2010 declined relative to 2002 (1.57 vs. 1.32) as did the slope of the middle values (0.23 vs. 0.16). A spatial division between the affluent south and the deprived north and east is still visible. The UHI correlated on an ecological ward-level with socioeconomic and urban environment indicators like square meter price of apartments (0.54, p < 0.01), low education of mother (-0.61, p < 0.01), low income (-0.62, p < 0.01) and proportion of black ethnicity (-0.55, p < 0.01). The results suggest that population health and equity have improved in Rio de Janeiro in the last decade though some familiar patterns of spatial inequality remain.Um indice de saude urbana foi utilizado para quantificar desigualdades na saude no Rio de Janeiro, Brasil, 2002-2010. Oito indicadores de saude foram gerados no nivel dos bairros utilizando dados de mortalidade. Os indicadores foram combinados para formar o indice. A distribuicao ordenada dos valores do indice fornece informacoes sobre a desigualdade entre os bairros, por meio da relacao entre os extremos e o gradiente dos valores medios. Ao longo da decada, a proporcao dos extremos caiu em 2010 em relacao a 2002 (1,57 vs. 1,32), assim como a inclinacao dos valores medios (0,23 vs. 0,16). A divisao espacial entre o sul afluente e o norte carente esta ainda visivel. Os valores do indice correlacionam com indicadores socioeconomicos e urbanos como o preco do metro quadrado de apartamentos (0,54, p < 0,01), baixa escolaridade da mae (-0,61, p < 0,01), baixa renda (-0,62, p < 0,01) e proporcao de pretos etnicos (-0,55, p < 0,01). Os resultados sugerem que a equidade na saude no nivel da populacao tem melhorado no Rio de Janeiro na ultima decada, embora padroes familiares da desigualdade espacial permanecam.

Inequalities in Noncommunicable Disease Mortality in the Ten Largest Japanese Cities

The burden of noncommunicable diseases and social inequalities in health among urban populations is becoming a common problem around the world. This phenomenon is further compounded by population aging. Japan faces the task of maintaining its high level of population health while dealing with these challenges. This study focused on the ten largest cities in Japan and, using publicly available administrative data, analyzed standardized mortality ratios to examine inequalities in relative mortality levels due to major noncommunicable disease at both city and subcity levels. On average, the ten major cities had excess mortality due to cancer and lower mortality due to heart disease and cerebrovascular disease compared to the country as a whole. Substantial inequalities in relative mortality were observed both between and within cities, especially for heart disease and cerebrovascular disease among men. Inequalities in relative mortality levels within cities appear to be increasing over time even while relative mortality levels are decreasing overall. The widely observed health inequalities signal the need for actions to ensure health equity while addressing the burden of noncommunicable diseases. Increasingly, more countries will have to deal with these challenges of inequity, urbanization, aging, and noncommunicable diseases. Local health governance informed by locally specific data on health determinants and outcomes is essential for developing contextualized interventions to improve health and health equity in major urban areas.