Rights, knowledge, and governance for improved health equity in urban settings.

All three of the interacting aspects of daily urban life (physical environment, social conditions, and the added pressure of climate change) that affect health inequities are nested within the concept of urban governance, which has the task of understanding and managing the interactions among these different factors so that all three can be improved together and coherently. Governance is defined as: "the process of collective decision making and processes by which decisions are implemented or not implemented": it is concerned with the distribution, exercise, and consequences of power. Although there appears to be general agreement that the quality of governance is important for development, much less agreement appears to exist on what the concept really implies and how it should be used. Our review of the literature confirmed significant variation in meaning as well as in the practice of urban governance arrangements. The review found that the linkage between governance practices and health equity is under-researched and/or has been neglected. Reconnecting the fields of urban planning, social sciences, and public health are essential "not only for improving local governance, but also for understanding and addressing global political change" for enhanced urban health equity. Social mobilization, empowering governance, and improved knowledge for sustainable and equitable development in urban settings is urgently needed. A set of strategic research questions are suggested.

Improving the health and lives of people living in slums.

Urban poverty, ill health, and living in slums are intrinsically interwoven. Poverty is multidimensional and there is no agreement on a universal definition. UN-HABITAT has introduced an operational definition of slums that is restricted to legal aspects and excludes the more difficult social dimensions. The World Health Organization definition is more comprehensive and uses a health and social determinants approach that is strongly based on the social conditions in which people live and work. Health and improving the lives of people living in slums is at the top of international development agenda. Proactive strategies to contain new urban populations and slum upgrading are the two key approaches. Regarding the latter, participatory upgrading that most often involves the provision of basic infrastructure is currently the most acceptable intervention in developing countries. In urbanization of poverty, participatory slum upgrading is a necessary but not sufficient condition to reduce poverty and improve the lives of slum dwellers. Empowering interventions that target capacity development and skill transfer of both individuals and community groups--as well as meaningful negotiations with institutions, such as municipal governments, which can affect slum dwellers' lives--appear to be the most promising strategies to improve the slum dwellers' asset bases and health. Non-governmental organizations, training institutions, and international development partners are best placed to facilitate horizontal relationships between individuals, community groups, and vertical relationships with more powerful institutions that affect the slum dwellers' lives. The main challenge appears to be lack of commitment from the key stakeholders to upgrade interventions citywide.

The design of housing and shelter programs: the social and environmental determinants of inequalities.

Both developed and less developed countries are becoming increasingly urbanized. The earlier industrialized countries have developed more infrastructure to support the building of healthy housing, in neighborhoods that are strongly linked to municipal and global health initiatives, but to some degree housing and neighborhood issues vary only in degree between the developing and developed worlds. Overall, a billion people, a third of people living in urban areas, live in slums, where environmental determinants lead to disease. Although communicable diseases predominate in the developing world and have reemerged in the developed world, noncommunicable diseases are also growing disproportionately in the developing world. At a global level, the Millennium Development Goals explicitly focus on an integrated approach to slum upgrading. The per capita cost of slum upgrading is almost twice the cost of providing new affordable housing at the outset. It is argued that to improve health and well-being in the slums we need to have interventions that reduce urban poverty in the broadest sense and improve the deficiencies associated with slums. There is an urgent need to scale up the best-practice interventions. Examples are given of successful local community initiatives that have been set up under national strategies in Tanzania and by Indian women's collectives that are globally linked and have helped develop housing and sanitation improvements. The unit costs for such interventions are within the reach of all the key stakeholders. Global commitment is the only missing link.