<div class="title-block" style="border-bottom-color: #628bb3"><h1><img class="title-image" src="http://www.heart-resources.org/wp-content/themes/heart/images/health.svg">Health</h1><div class="post-type-description"></div></div> – Health and Education Advice and Resource Team http://www.heart-resources.org Providing DFID staff and other development actors with health, education and nutrition knowledge and expertise from around the world Fri, 02 Mar 2018 13:10:49 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.4 The free healthcare initiative in Sierra Leone: Evaluating a health system reform, 2010‐ 2015 http://www.heart-resources.org/doc_lib/free-healthcare-initiative-sierra-leone-evaluating-health-system-reform-2010%e2%80%90-2015/ http://www.heart-resources.org/doc_lib/free-healthcare-initiative-sierra-leone-evaluating-health-system-reform-2010%e2%80%90-2015/#respond Wed, 14 Feb 2018 13:16:29 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=30308 Read more]]> This article presents the findings of a theory‐based evaluation of the Sierra Leone Free Health Care Initiative (FHCI), using mixed methods. Analytical approaches included time‐series analysis of national survey data to examine mortality and morbidity trends, as well as modelling of impact using the Lives Saved Tool and expenditure trend analysis.

We find that the FHCI responded to a clear need in Sierra Leone, was well designed to bring about needed changes in the health system to deliver services to the target beneficiaries, and did indeed bring funds and momentum to produce important systemic reforms. However, its ambition was also a risk, and weaknesses in implementation have been evident in a number of core areas, such as drugs supply.

We conclude that the FHCI was one important factor contributing to improvements in coverage and equity of coverage of essential services for mothers and children. Modelled cost‐effectiveness is high—in the region of US$ 420 to US$ 444 per life year saved. The findings suggest that even—or perhaps especially—in a weak health system, a reform‐like fee removal, if tackled in a systematic way, can bring about important health system gains that benefit vulnerable groups in particular.

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Social Health Protection in low- and middle-income countries: the practical challenges, a brief discussion paper http://www.heart-resources.org/assignment/social-health-protection-in-low-and-middle-income-countries/ http://www.heart-resources.org/assignment/social-health-protection-in-low-and-middle-income-countries/#respond Tue, 23 Jan 2018 17:30:24 +0000 http://www.heart-resources.org/?post_type=assignment&p=30315 Read more]]> A seminar organised by Oxford Policy Management in June 2017 brought together practitioners and policy makers to exchange insights on practical challenges for the implementation of social
health protection (SHP) programmes, and social health insurance (SHI) in particular. Kicked-off with a presentation of recent experiences from Bangladesh and Pakistan, the discussion touched
on a range of issues, including how to reach and incorporate the poor and non-poor in the informal sector, working with private providers and moving towards strategic purchasing.

There was agreement that SHI means far more than raising contributions, as it is sometimes construed, and reaches into deep health sector reforms. These require careful staging, sustained political commitment and a focus on good governance, but also a continued engagement with core principles of universal health coverage (UHC), primarily equity. Nevertheless, some of the implementation challenges faced today are not new. Investing further in the existing health system learning mechanisms, formal and informal, will be key to avoid repeating implementation failures of the past.

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Transition and Recovery of Nepal’s Health System: Project Completion Review http://www.heart-resources.org/assignment/transition-recovery-nepals-health-system-project-completion-review/ http://www.heart-resources.org/assignment/transition-recovery-nepals-health-system-project-completion-review/#respond Fri, 12 Jan 2018 17:00:09 +0000 http://www.heart-resources.org/?post_type=assignment&p=30289 Read more]]> This project completion review (PRC) provides details on the outputs, lessons and recommendations from the DFID funded programme ‘Transition and Recovery of Nepal’s Health System’ which came to a close in May 2017.

The aim of the programme was to provide technical assistance to support the recovery of Nepal’s damaged health services, across 31 districts affected by a series of catastrophic earthquakes and aftershocks in April-May 2015.

Overall, outcome and output indicator results demonstrate that the programme has been successful, though not all targets were achieved by the close of the programme.

The follow-up actions required following project closure are as follows:

  1. For DFID: in order to fast-track the mobilization of support in case of emergencies in disaster-prone countries, to consider the inclusion of an earmarked budget allocation to respond to disaster situations in all health sector operations. Such budget could be re-allocated before programme closure in case no emergencies arise.
  2. For DFID: given the familiarity and success of the combined Financial Aid and Technical Assistance aid modality in Nepal, both in the regular support to the health sector and the earthquake response programme, a similar aid modality should be considered for future disaster recovery and relief operations.
  3. For MoH and DFID: to limit the number and severity of permanent disabilities resulting from spinal cord injuries during future earthquakes, ensure that a public awareness campaign is launched on the safe transport and correct referral process of people possibly having injured their spinal cord. Such campaign should be targeted at the public, rescue workers, para-medical personnel and health workers. This action would also reduce the risks for people injured during other accidents, especially in road traffic accidents and accidents in the construction sector.
  4. For the TA team: to continue monitoring the progress and quality of the unfinished infrastructure work initiated under the programme.
  5. For MoH and DFID: to maximize the durability of the infrastructure financed under the programme, permanent as well as semi-permanent (the pre-fabricated structures), advocate with the National Planning Commission and the Ministry of Health for a reasonable budget in the Annual Work Plan and Budgets for maintenance.
  6. For DFID and TA team: to elaborate a module for the prevention of gender-based violence and physical abuse (e.g. awareness and anger management counselling) to be used in the immediate aftermath of possible future earthquakes or other disasters.
  7. For DFID and the TA team: in order to be able to again respond effectively in case of any future disaster, to engage with the government and other External Development Partners (EDPs) on changing disaster preparedness modalities as the devolution in Nepal evolves and changes in decision making, operational structures and procedures, and communications channels materialize. For instance, the role 
of the District Officer of Health may change under the upcoming provincial structure and support to her/his office may have to be re-directed to provincial and/or municipal structures.
  8. For MoH, DFID and External Development Partners: to build on progress made in mental health in terms of the institutional arrangement, treatment protocols and people trained in both the diagnosis and treatment of mental health problems and provide resources for its sustainability and scale-up.

Download the full report for further details.

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Pollution and Poverty http://www.heart-resources.org/reading_pack/pollution-and-poverty/ http://www.heart-resources.org/reading_pack/pollution-and-poverty/#respond Fri, 20 Oct 2017 09:08:31 +0000 http://www.heart-resources.org/?post_type=reading_pack&p=30148 Read more]]> Girls and pollution
Pure Earth 2017

K4D is facilitating a learning journey on pollution and poverty. This learning journey is designed to raise awareness of the huge impact of pollution across different sectors of international development and to encourage the integration of pollution control solutions into policymaking and programming, in a multidisciplinary approach. The journey starts by raising awareness of the scale of the impact of pollution and the existence of solutions to reduce pollution by promoting the landmark report published on 20 October 2017 by The Lancet Commission on Pollution and Health.

Introduction

Pollution currently poses one of the greatest public health and human rights challenges, disproportionately affecting the poor and the vulnerable. Pollution is not just an environmental issue, but affects the health and well-being of entire societies. Despite the huge impacts on human health and the global economy, and the opportunity to apply simple and affordable solutions, pollution has been undercounted and insufficiently addressed in national policies and international development agendas. Prioritising and increasing investment in pollution cleanup and control presents an extraordinary opportunity to save lives and grow economies.

Pollution and health: six problems and six solutions

Pollution and Poverty: six problems and six solutions

The Lancet Commission Pollution and Health report

The Lancet Commission on Pollution and Health published its landmark report on 20 October 2017. This is the first global analysis of all forms of pollution and its impact on health, economic costs, and the environmental and social injustice of pollution. The aim of the Commission is to reduce air, soil and water pollution by communicating the extraordinary health and economic costs of pollution globally, providing actionable solutions to policymakers and dispelling the myth of pollution’s inevitability.

The Commission on Pollution and Health is an initiative of The Lancet, the Global Alliance on Health and Pollution (GAHP), and the Icahn School of Medicine at Mount Sinai. The Commission comprises many of the world’s most influential leaders, researchers and practitioners in the fields of pollution management, environmental health and sustainable development.

Global Commission on Pollution and Health Infographic
Infographic on the Commission by the Mount Sinai Health System

The findings of The Lancet Commission on Pollution and Health will be live streamed from the first two launch events to be held at the Icahn School of Medicine at Mount Sinai, in New York City and at Maastrict University, Brussels. Please refer to the bottom of this webpage for further details.

Pollution and poverty

Pollution is strongly linked to poverty. Nearly 92% of pollution-related deaths occur in low- and middle-income countries. Children face the highest risks and are the most vulnerable victims of pollution because small exposures to chemicals in utero and early childhood can result in lifelong disease, disability, premature death, as well as reduced learning and earning potential. The health impact of pollution is likely to be much larger than can accurately be quantified today because of insufficient data collection and scientific research from many pollutants.

Pollution is costly. Pollution-related illnesses result in direct medical costs, costs to healthcare systems and opportunity costs resulting from lost productivity and economic growth. Welfare losses due to pollution are estimated at $4.6 trillion per year, 6.2% of global economic output. The claim that pollution control stifles economic growth and that poor countries must pollute in order to grow is false.

Pollution control solutions and strategies

This global problem can be solved. Solutions to controlling pollution are feasible, cost-effective and replicable. Many of the pollution control strategies that have been widely used and have proven cost-effective in middle- and high-income countries are now ready to be exported and adapted for use by cities and countries at every level of income. The most effective strategies control pollution at its source. Their application in carefully planned and well-resourced campaigns can enable developing countries to avoid many of the harmful consequences of pollution and leapfrog over the worst of human and ecological disasters. Planning processes that prioritise interventions against pollution, that link pollution control to protection of public health, and that integrate pollution control into development strategies are critical first steps in fighting pollution. The Lancet Commission on pollution and health make six recommendations to raise global awareness of pollution, end neglect of pollution-related disease, and mobilise the resources and political influence that will be needed to effectively confront pollution.

Pollution and Health: Six Solutions

A further 12 key strategies to reduce air, soil, water and occupational pollution are highlighted in the report.

Infographic: 12 Key Funding Strategies to Reduce Pollution and Save Lives
12 Key Funding Strategies to Reduce Pollution and Save Lives

Pure Earth is an organisation whose mission is to identify and clean up the poorest communities throughout the developing world where high concentrations of toxins have devastating health effects. Pure Earth devises clean-up strategies, empowers local champions and secures support from national and international partnerships.  This clip shows some of the solutions to the pollution crisis in action.

Controlling pollution to achieve the Sustainable Development Goals

Partnership and coordinated efforts to control pollution are key to achieving the Sustainable Development Goals (SDGs) due to the numerous ways that pollution affects communities around the globe. For example, severe pollution causes frequent illness, disability and inability to work (SDG 1: No poverty); the impacts of pollution are sources of instability (SDG 16: Peace, justice and strong institutions); highly toxic wastewater poisons soil and food supplies (SDG 2: Zero hunger) and toxic chemicals contaminate soil, migrate into crops and into our bodies (SDG 15: Life on land). More information on achieving the SDG’s through addressing pollution can be found here.

Research into pollution and pollution control

Research is needed to understand and control pollution and to support change to pollution-related policy. The Lancet Commission on Pollution and Health recommends the following research:

  • Explore emerging causal links between pollution, disease, and sub-clinical impairment, for example between ambient air pollution and dysfunction of the central nervous system in children and the elderly
  • Quantify the global burden of disease associated with chemical pollutants of known toxicity such as lead, mercury, chromium, arsenic, asbestos, and benzene
  • Identify and characterise the adverse health outcomes caused by new and emerging chemical pollutants, such as developmental neurotoxicants, endocrine disruptors, novel insecticides, chemical herbicides, and pharmaceutical wastes
  • Identify and map pollution exposures particularly in low- and middle-income countries
  • Improve estimates of the economic costs of pollution and pollution-related disease
  • Quantify the health and economic benefits of interventions against pollution and the costs of interventions.

Evidence of pollutants causing disease ranges from the well-established, to emerging effects and the unknown, where the effects of pollutants on human health are only beginning to be recognised and are not yet quantified. The Commission proposes a framework for organising scientific knowledge about pollution and its effects on human health, and to help focus pollution-related research through the concept of a pollutome.

Word-cloud of key words relating to pollution and health
Word-cloud on The Lancet Commission Pollution and Health report and social media campaigns

Upcoming Launch events of The Lancet Commission Pollution and Health report

Further details of upcoming events can be found here.

Delhi

14 November 09:30-11:30

More details.

Philippines

30 November 08:00-17:00

More details.

Previous Launch Events

New York City

Icahn School of Medicine at Mount Sinai

23 October 10:00-12:00 EST

Live stream available: https://global.gotomeeting.com/join/785131213

Brussels

Maastrict University

26 October 10:00-12:00

Live stream available: https://www.youtube.com/user/maastrichtuniversity

Ottawa

CSIH Canadian Conference on Global Health

31 October 13:00-14:30

Qatar

7 November 09:00-10:00

More details.

Media coverage of The Lancet Commission Pollution and Health report

Global pollution kills 9m a year and threatens ‘survival of human societies’, The Guardian, Oct 19 2017

Pollution linked to one in six deaths, BBC News, Oct 19 2017

Pollution-related deaths exceed 9m per year, Financial Times, Oct 19 2017

Pollution is killing millions of people a year and the world is reaching ‘crisis point’, experts warn, The Independent, Oct 19 2017

 

K4D logo

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Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity. Workshop Report http://www.heart-resources.org/doc_lib/unpicking-power-politics-transformative-change-towards-accountability-health-equity-workshop-report/ http://www.heart-resources.org/doc_lib/unpicking-power-politics-transformative-change-towards-accountability-health-equity-workshop-report/#respond Tue, 10 Oct 2017 14:20:26 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=30128 Read more]]> While ‘accountability’ has become an increasingly popular buzzword in health systems debates and health service delivery, it has multiple – and contested – meanings.

From 19-21 July 2017, Institute of Development Studies (IDS) brought together 80-plus activists, researchers, public health practitioners and policy makers to examine critically the forces that shape accountability in health systems, from local to global levels. Their partners in convening this workshop, as part of a new IDS programme on ‘Accountability for Health Equity’ were the Unequal Voices project, Future Health Systems, the Open Society Foundations, the Impact Initiative and Health Systems Global.

This is the workshop report for the event which is a record of the presentations and discussions that occurred over the course of these three days.

Read the related blog article by Erica Nelson for further insight into the Accountability for Health Equity workshop.

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Independent Evaluation of the Reduction of Maternal and Neonatal Mortality in Kenya – Formative Evaluation Findings http://www.heart-resources.org/assignment/independent-evaluation-reduction-maternal-neonatal-mortality-kenya-formative-evaluation-findings/ http://www.heart-resources.org/assignment/independent-evaluation-reduction-maternal-neonatal-mortality-kenya-formative-evaluation-findings/#respond Wed, 12 Jul 2017 11:41:55 +0000 http://www.heart-resources.org/?post_type=assignment&p=29800 Read more]]> The Reduction of Maternal and Neonatal Mortality Programme (MNH Programme) in Kenya aims to reduce delays in mothers and newborns receiving good maternity care. The three main problems the programme seeks to address are: 1) delay in decision to seek care; 2) delay in reaching care; and 3) delay in receiving care.

The midterm evaluation documented many positive changes in community attitudes, the use of health services, and in obstetric outcomes in the programme counties. Because of the late start of the MNH Programme, however, these changes could not be directly attributed to programme activities.

The overall MNH Programme approach to improving the quality of maternity care by focusing on the health facilities that provide most of the deliveries is appropriate and efficient. However, it leaves out many smaller health centres that provide a major amount of antenatal care. A further limitation of the MNH Programme has been its predominant focus on public sector health facilities. Support to private and faith-based facilities should be considered.

The close contact of the Maternal and Newborn Initiative (MANI) with county authorities in Bungoma County has resulted in a cohesive operational programme with the ability to introduce interventions efficiently. The mode of delivery differs significantly from that in counties under the UNICEF programme mandate. UNICEF-supported counties are more complex dealing with many different sub-contracted partners which is less successful but more sustainable.

The main needs for health systems strengthening identified by the midterm evaluation in all counties are the development, planning and mobilisation of human resources, the assurance of stable and adequate financing of maternity services, and the provision of appropriate infrastructure.

The midterm evaluation found that the evaluation methodology of documenting changes at county and sub-county level was not appropriate for the programme in Nairobi. Hospitals and health centres are in close proximity, and clients do not seek care within the geographic and political boundaries of their communities. For further evaluation activities, a different approach for Nairobi will be proposed and negotiated.

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Independent Evaluation of the Reduction of Maternal and Neonatal Mortality in Kenya Programme – Project Overview http://www.heart-resources.org/assignment/independent-evaluation-reduction-maternal-neonatal-mortality-kenya-programme/ http://www.heart-resources.org/assignment/independent-evaluation-reduction-maternal-neonatal-mortality-kenya-programme/#respond Wed, 12 Jul 2017 09:59:26 +0000 http://www.heart-resources.org/?post_type=assignment&p=29792 Read more]]> The Reduction of Maternal and Neonatal Mortality in Kenya programme supports a range of interventions to improve maternal and neonatal health (MNH) including training of health workers, health systems strengthening, community mobilisation, and demand generation. It is implemented in six counties with different sociodemographic contexts.

A formal evaluation has been contracted with four components: 1) annual mapping of key data and trends; 2) in-depth comparative studies in matched sub-counties; 3) additional studies to assess specific Programme components and to answer evaluation questions; and 4) comprehensive analysis of the Programme at the start and end of the evaluation phase (2016-18).

Data collected through these four evaluation components will be triangulated. An independent expert group will enforce credibility. Evaluation results will be communicated to Programme partners and stakeholders in 2016 with a view to recommend adjustments of programme activities in order to reach intended outcomes, as and if needed. This synthesis will be repeated towards the end of 2018 in a summative evaluation that will document final programme outcomes and lessons learned.

The first set of findings are reported here.

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Public health surveillance http://www.heart-resources.org/mmedia/public-health-surveillance/ http://www.heart-resources.org/mmedia/public-health-surveillance/#respond Tue, 14 Feb 2017 12:16:42 +0000 http://www.heart-resources.org/?post_type=mmedia&p=29723 Read more]]> Dr Brian McCloskey CBE is the Director of Global Health Security at Public Health England and a Senior Consulting Fellow at the Chatham House Centre for Global Health Security. In this HEART Talks he introduces the HEART Reading Pack he co-authored on public health surveillance.

He explains that public health surveillance is a means to quantify the burden of disease in a community or country. It can be used to measure how the amount of disease is changing over time to understand what is relatively normal, and what is abnormal when something different has happened. It allows us to look at changes over time which helps in evaluating interventions and identify whether targeting is needed. It is also needed to identify unexpected public health events such as Ebola, Zika, and yellow fever to alert people and take actions early.

There are two main systems available. Firstly, health facility-based surveillance uses data already collected by health workers to monitor the normal. Taking this data out is an easy way of doing public health surveillance. Secondly, event-based surveillance which collects information on events as they happen to find the abnormal. There are some global systems for examples Global Public Health Information Network (GPHIN) and ProMED. These are computer-based systems which scan social media and online news looking for anything that might be relevant to public health.

International Health Regulations (IHRs) form the framework for disease surveillance around the world, they establish a framework for response, and put in legal requirements for the capacities that people need in their public health system. One of the challenges that came out with Ebola is that money spent on health systems strengthening hasn’t been focussed on public health systems, disease surveillance systems and human resource capacity. The 2005 IHR is a legally binding agreement for 194 member states of the World Health Organization (WHO). It builds on previous IHR’s and was updated because of changing threats. There was a move away from a focus on specific diseases to an ‘all hazards’ approach. It was agreed in coordination with travel and trade organisations. It sets out ‘core capacities’ for member states to deliver IHRs.

All member states must have a National Focal Point for IHRs. There are agreed protocols for risk assessment and reporting to the WHO. There are a number of criteria used to assess whether the WHO declare a Public Health Emergency of International Concern (PHEIC) when binding travel and trade restrictions can be made. All member states were meant to be compliant by 2012 but very few are. There have been four PHEIC since 2005: 1) pandemic flu in 2009; 2) polio became of international concern in 2009 when the decline started to reverse; 3) Ebola in 2014; and 4) Zika in 2015.  There have been in the region of 50,000 events reported to the WHO since 2005. The concern is something important maybe missed between the large number of items reported and the small number declared as PHIEC.

After Ebola IHRs are being revised. What IHRs were set out to do was right, the problem was they weren’t being implemented properly in enough countries. They also weren’t being properly assessed and evaluated. This has prompted a move away from voluntary self-assessment to independent evaluation. A number of countries have challenged the idea of external assessment. Another issue is that assessment is linked to the global security agenda which is seen to be US-led. Formal agreement has yet to be reached on regular assessment on how well countries are reaching IHRs. This assessment is required for targeting countries who need support. This would be in everyone’s best interest.

Improving public health surveillance has many benefits, is an urgent priority, and should be part of health systems strengthening. It is important for the country to get this capacity right. South Korea, for example, lost 0.9% of their GDP in the six months following the outbreak of the Middle East Respiratory Virus (MERS). The health systems strengthening can also benefit, non-communicable disease burdens using the same infrastructure. And also be beneficial maternal and child health. Monitoring trends and identifying what is changing and why can help to target interventions.

Future priorities are:

  • Invest in IHR core capacities
  • Encourage and support independent external evaluation
  • Develop the workforce and the systems
  • Look at IT improvements
  • Look for partners, ie in: agriculture and farming, industry/private sector, and communities.
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Evidence on how to scale up demand-side maternal and newborn health interventions in Zambia http://www.heart-resources.org/blog/evidence-scale-demand-side-maternal-newborn-health-interventions-zambia/ http://www.heart-resources.org/blog/evidence-scale-demand-side-maternal-newborn-health-interventions-zambia/#respond Fri, 09 Dec 2016 10:13:27 +0000 http://www.heart-resources.org/?post_type=blog&p=29709 Read more]]> In order to translate global commitments of ensuring access to sexual and reproductive healthcare services for every woman and every girl into practical, affordable and sustainable interventions, policy makers and implementers need to be able to draw on solid evidence of what does and does not work.

The More Mobilising Access to Maternal Health Services in Zambia programme (MORE MAMaZ), funded by the UK charity Comic Relief (2014-2016), achieved transformational change for women and girls, particularly those who are under-supported at household and community level by successfully scaling up an evidence-based demand-side intervention in support of the Ministry of Health’s safe motherhood policy response.

MORE MAMaZ punched above its weight in so many ways. The health-related results achieved can be seen in this infographic, including institutional delivery rates up at 89% in intervention districts, compared to the national average for rural areas of 56%. There has also been a significant improvement in the proportion of women opting for early antenatal care, which is a key priority of the MOH.

Behind these results lie other gains which are just as important: considerable empowerment-related gains, which will help to position women and girls so that they benefit from other development-related opportunities in the future; a very significant reduction in gender-based violence; and evidence that the most difficult to reach women and girls are being targeted and supported by their communities.

It is also worth noting that the training approach used by the programme helped produce volunteer retention rates of 82% among volunteers trained 4-5 years ago and 95% among volunteers trained two years ago. These rates are much higher than those achieved by many other similar programmes globally.

MORE MAMaZ showcases to a large extent what Health Partners International does best: developing and supporting implementation of practical and sustainable systems-oriented solutions to global health challenges; achieving value for money – MORE MAMaZ achieved more than MAMaZ while working on a considerably larger scale; and forming honest and lasting partnerships with government and consortium partners, while building sustainable local capacity.

We invite you to read the programme’s seven evidence briefs, which showcase the results achieved, and different components of the approach, and other programme materials, including the 8 key messages for policy makers in the health sector, and to share them within your networks. Many of the strategies and approaches developed by the programme and its local partners lend themselves to adaptation for implementation in different contexts.

By Cathy Green, Technical Lead- Community Health Systems, Health Partners International

For more information on how Health Partners International is transforming health systems and the lives of women and girls please visit www.healthpartners-int.co.uk or contact info@healthpartners-int.co.uk.

 

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Urban Health http://www.heart-resources.org/mmedia/urban-health/ http://www.heart-resources.org/mmedia/urban-health/#respond Tue, 29 Nov 2016 14:54:39 +0000 http://www.heart-resources.org/?post_type=mmedia&p=29705 Read more]]> Dr Helen Elsey is from the Nuffield Centre for International Health and Development, University of Leeds. In this HEART Talks she talks through the urban health HEART reading packs that she has put together with Dr Siddharth Agarwal from the Urban Health Resource Centre in India. The three reading packs are: A) Data and evidence, B) Improving population health – strategies for inter-sectoral action, and C) Interventions and pro-poor service provision.

Urbanisation
The world is urbanising. Globally, more people live in urban areas than in rural areas. By 2050, it is expected that 66% of the world’s population will be urbanites. Africa and Asia are urbanising the fastest. By 2050 56% will be urban in Africa and 64% in Asia. There are currently 28 mega-cities (i.e. with a population of 10 million or more). By 2030, the world is projected to have 41 mega-cities. However, the fastest growing urban areas are medium-sized cities and those with less than 1 million inhabitants located in Asia and Africa. UN-Habitat estimates the number of people living in slum conditions is now 863 million; growing from 760 million in 2000 and 650 million in 1990. Cities are at the forefront of ‘disease transition’ with malnutrition and obesity occurring simultaneously. Water and sanitation provision is grossly inadequate in urban slums. Tobacco consumption is a major concern among urban poor men, and increasingly women; a risk factor for both NCDs and TB. There are multi-sector influences on urban health.

Coordination
Local governments are key to coordinating inter-sectoral action. Donors are increasingly working with local government to strengthen capacity to plan, manage services, link with sector ministries, enforce public health legislation and establish local level governance structures.

There is a need to coordinate health services between local government and health ministries. The urban public health service is woefully inadequate. There has been underinvestment due to years of the perceived ‘urban advantage’. Responsibilities for staff, their training, equipment/drugs, and facilities often fall between the Ministry of Health (MOH) and the Municipality. The poor are left with little option but to use meagre resources on private facilities resulting in high levels of catastrophic health expenditure. There are poor referral mechanisms due to the plethora of NGO and private providers. There is a need for monitoring and enforcement of quality standards among providers and pharmacies. Secondary care is insufficient with maternity hospitals not open all hours and weak services. Tertiary hospitals are overloaded and not easy to access for the poor.

Public Private Partnerships (PPPs)
There are challenges with different forms of PPPs, private for-profit and not-for profit forms. For-profit PPPs have no incentive to reach out to the urban poor. They are not keen to partner for outreach care which is the key to preventative healthcare and the most crucial for urban deprived communities. Non-profit agencies tend to have few resources. Bangladesh’s Urban Primary Healthcare Programme uses partnerships with NGOs, private clinics and government health centres to expand services to slum and vulnerable communities. There are still challenges with monitoring, quality, and referrals between providers which covered in some detail by in the reading packs.

Health promotion
Helping people remain healthy and not in need of health services is a fundamental goal of any urban health strategy. There is a lack of evidence on which health promotion approaches are likely to be effective in changing ‘lifestyle behaviours’ such as tobacco use, diet, and exercise among the urban poor. Encouraging waist measurement, desired diet, physical activity and mental wellbeing at community level; peer education approaches to nutrition, physical activity, and promoting optimal behaviours in schools have shown some success. Community healthworkers (CHWs) have been effective at changing behaviours in Bangladesh, India, and Ethiopia. CHW and slum women’s groups promoting peer-to-peer health promotion shows promise. Mass media through mobile phones, print, radio and television have wide audience reach in urban centres, but it is hard to compete in the cluttered media environment. Instant messaging for skilled birth attendants is more effective in urban areas. There has been increases in zinc treatment awareness following TV, radio, and newspaper media campaign in urban areas.

Water, sanitation and hygiene (WASH)
WASH needs to be promoted in households and schools to improve, health, nutrition and education. The three interventions of the WASH sector (hand-washing, food storage, garbage disposal) – depend on one another for full realisation of their benefits. For example most sanitation systems cannot function without water. School WASH impacts education outcomes, especially for girls. Menstrual hygiene and girl friendly toilets in schools affect school attendance of girls and reproductive tract infections. Hand-washing with soap and water and other personal hygiene practices have the potential to substantially reduce within household transmission of diarrhoea and improve nutrition. Promoting practices such as hand-washing with soap and water, and safe disposal of child faeces benefit health and nutrition and can be incorporated in a wide range of public health strategies at low cost.

Participatory neighbourhood mapping
Participatory mapping has been used in India to expand the reach of urban services. Slum women’s groups use hand drawn maps to ensure that no family is left out from municipal/NGO lists used for housing, sewage systems, toilets, and entitlements. They are also used to track access to health services eg. immunisation, antenatal care,  and delivery. The maps help identify recent migrants for linkage to services and entitlements. Gentle negotiation is occurring through collective petitions. Inclusive urbanisation requires disadvantaged communities to actively participate in governance.

Healthy places
Pressure from real estate developers, poor governance and corruption undermines local government’s role in controlling urban development to keep healthy places within the city. Access to green spaces reduces mental illness and has been shown to reduce inequities in cardio vascular disease and all-cause mortality in high income countries. Green spaces are rarely considered in controlled and uncontrolled expansion of urban areas. Urban agriculture can make an important contribution to household food security, especially in times of food crisis or food shortages. This needs support and regulation so food is grown in healthy environments.

Health and safe places for children
Urban poor women are more likely to work outside the home than other women in urban or rural settings. Working outside the home provides opportunities to improve income and increase self-esteem and gender equity. However, there is a lack of childcare and supervision for children. This could be solved with early childhood development opportunities. An NGO mobile crèche run day care centres in partnership with government’s National Creche scheme and with support funding agencies in India. Day care centres operate in coordination with builders and contractors near construction sites.

Transport and communications
10 billion trips are made every day in urban centres around the world. An increasing proportion of urban trips are using high carbon and energy-intensive private motorised vehicles. The urban poorest are disproportionately affected by key negative externalities generated by transport, including road accidents, air pollution and displacement when transport developments are occuring. Regulation to improve road safety can make a substantial difference to accidents. For example regulation of ‘matatus’ (mini-buses) in Kenya was introduced where drivers had to increase their driving and safety skills. This legislation resulted in a 73% reduction in accidents. Keeping cities compact, with opportunities for walking, cycling and public transport reduces emissions and support public health.

All of these issues and more are covered in the reading packs which point out key resources.

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