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 Mayor's 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.

Intersectoral action: local governments promoting health.

Many local governments around the world promote health through intersectoral action, but to date there has been little systematic evidence of these experiences. To bridge this gap, the World Health Organization Centre for Health Development conducted a study in 2011-2013 on intersectoral action for health (ISA) at local government level. A total of 25 cases were included in the final review. Various approaches were used to carry out ISA by local governments in low-, middle- and high-income countries. Several common facilitating factors and challenges were identified: national and international influences, the local political context, public participation and use of support mechanisms such as coordination structures, funding mechanisms and mandates, engaging sectors through vertical and horizontal collaboration, information sharing, monitoring and evaluation, and equity considerations. The literature on certain aspects of ISA, such as monitoring and evaluation and health equity, was found to be relatively thin. Also, the articles used for the study varied as regards their depth of information and often focused on the point of view of one sector. More in-depth studies of these issues covering multiple angles and different ISA mechanisms could be useful. Local governments can offer a unique arena for implementing intersectoral activities, especially because of their proximity to the people, but more practical guidance to better facilitate local government ISA processes is still needed.

Local governments and civil society lead breakthrough for tobacco control: lessons from Chandigarh and Chennai.

Smoke-free legislation is gaining popularity; however, it must accompany effective implementation to protect people from secondhand smoke (SHS) which causes 600,000 deaths annually. Increasing numbers of smoke-free cities in the world indicate that municipalities have an important role in promoting smoke-free environments. The objectives were to describe the local initiative to promote smoke-free environments and identify the key factors that contributed to the process. Observations were based on a case study on the municipal smoke-free initiatives in Chandigarh and Chennai, India. India adopted the Cigarette and Other Tobacco Products Act in 2003, the first national tobacco control law including smoke-free provisions. In an effort to enforce the Act at the local level, a civil society organization in Chandigarh initiated activities urging the city to support the implementation of the provisions of the Act which led to the initiation of city-wide law enforcement. After the smoke-free declaration of Chandigarh in 2007, Chennai also initiated a smoke-free intervention led by civil society in 2008, following the strategies used in Chandigarh. These experiences resonate with other cases in Asian cities, such as Jakarta, Davao, and Kanagawa as well as cities in other areas of the world including Mexico City, New York City, Mecca and Medina. The cases of Chandigarh and Chennai demonstrate that civil society can make a great contribution to the enforcement of smoke-free laws in cities, and that cities can learn from their peers to protect people from SHS.

Street smoking bans in Japan: a hope for smoke-free cities?

OBJECTIVES: This study analysed 112 municipalities enforcing municipal smoking restrictions on streets in Japan to examine anti-smoking measures implemented in urban settings from a health perspective and derive lessons for future tobacco control. METHODS: Municipal governments implementing ordinances which restrict smoking on streets were identified through grey literature review. Implementation period, characteristics, scope, and department responsible were examined. RESULTS: Since the first municipal regulation was introduced in 1997, many other municipalities have followed. Enforcement of fines started in 2002, which is now a common practice nationwide. Nevertheless, the health impact of exposure to secondhand smoke is not clearly articulated in the ordinances. Street smoking bans have been developed in connection with "beautification" and littering prevention for environmental purposes, and local health departments do not have responsibility for these ordinances. CONCLUSIONS: There is potential to further prevent secondhand smoke exposure if such measures are expanded to indoor environments and integrated into broader policies. For policy-makers and advocates, the Japanese experience provides information on an additional tobacco control intervention as well as clues in the process of design, implementation and enforcement of such municipal measures. A more comprehensive and health-driven approach is required to effectively address the harm of secondhand smoke in Japan.

Barrio Adentro and the reduction of health inequalities in Venezuela: an appraisal of the first years.

This article presents an update on the characteristics and performance of Venezuela's Bolivarian health care system, Barrio Adentro (Inside the Neighborhood). During its first five years of existence, Barrio Adentro has improved access and utilization of health services by reaching approximately 17 million impoverished and middle-class citizens all over Venezuela. This was achieved in approximately two years and provides an example of an immense "South-South" cooperation and participatory democracy in health care. Popular participation was achieved with the Comités de Salud (health committees) and more recently with the Consejos Comunales (community councils), while mostly Cuban physicians provided medical care. Examination of a few epidemiological indicators for the years 2004 and 2005 of Barrio Adentro reveals the positive impact of this health care program, in particular its primary care component, Barrio Adentro I. Continued political commitment and realistic evaluations are needed to sustain and improve Barrio Adentro, especially its primary care services.

Challenging the neoliberal trend: the Venezuelan health care reform alternative.

Throughout the 1990s, all Latin American countries but Cuba implemented to varying degrees health care sector reforms underpinned by a neoliberal paradigm that redefined health care as less of a social right and more of a market commodity. These health care sector reforms were couched in the broader structural adjustment of Latin American welfare states prescribed consistently by international financial institutions since the mid-1980s. However, since 2003, Venezuela has been developing an alternative to this neoliberal trend through its health care reform program called Misión Barrio Adentro (Inside the Neighbourhood). In this article, we introduce Misión Barrio Adentro in its historical, political, and economic contexts. We begin by analyzing Latin American neoliberal health sector reforms in their political economic context, with a focus on Venezuela. The analysis reveals that the major beneficiaries of both broader structural adjustment of Latin American welfare states and neoliberal health reforms have been transnational capital interests and domestic Latin American elites. We then provide a detailed description of Misión Barrio Adentro as a challenge to neoliberalism in health care in its political economic context, noting the role played in its development by popular resistance to neoliberalism and the unique international cooperation model upon which it is based. Finally, we suggest that the Venezuelan experience may offer valuable lessons not only to other low- to middle-income countries, but also to countries such as Canada.