November 1, 2022

Satellite Session Report: Actors and alliances to transform health and wellbeing in cities

The Seventh Global Symposium on Health Systems Research is ongoing in Bogota Colombia. The theme of this year’s Conference is Health Systems Performance in the Political Agenda: Sharing lessons for current and future global challenges which directs attention at the significant strife the world has faced during the COVID-19 pandemic. On the first day of the conference, ARISE held a satellite in partnership with CHORUS, African Cities, Pathways to Equitable Healthy Cities and Slum Dwellers International. This report was put together by Kate Hawkins, Lynda Keeru, Zoe Duckworth and Hayley Stewart.

This satellite session was chaired by Sally Theobald of LSTM, and brought together researchers, decision-makers, community representatives and practitioners working on systems strengthening and social determinants of urban health and wellbeing. They mapped out current research, advocacy and action; identify challenges, synergies and gaps and discussed how to connect and expand communities of practice in this area.

The session was opened by Kate Hawkins who provided a report back on the International Conference on Urban Health which had been held the week before:

Key messages from the International Conference on Urban Health, by Kate Hawkins

Dr. Nathalie Roebbel, WHO’s Urban Health Team Lead , made a presentation on ‘Setting Global Research Priorities for Urban Health’ and highlighted the appalling statistics of urban health and the urgent need to act locally for health. Nathalie expounded on the role of Urban Health Research Agenda (UHRA) developed by WHO that spells out the set of global urban health research priorities for 2022–2032. It is the body that is tasked with ensuring that citizens in urban areas have equitable access to safe and sustainable transport systems, green spaces, and healthy, sustainable living and working environments.

Vinod Rao works at SPARC and in his presentation, he pointed to one of the key challenges they identified in the urban health system as part of the ARISE Consortium; the rarity in investment in preventive promotive health. Even where state institutions are making budgetary provisions, it is much less in preventive health in comparison to curative perhaps because it provides a much more tangible outcome from a political perspective. Where these investments are made, they are often low, misplaced or not catering to the real issues at hand. He shed light on the work SPARC is doing in India with women from slums as co-researchers, who work together with researchers to get viewpoints on persistent issues. More participatory action allows more nuanced solutions to emerge which makes these solutions much more impactful.

In her informative presentation, Rumana Huque, educated participants on community-led responsive and effective urban health systems (CHORUS). It is a Research Programme Consortium whose focus is co creation and evaluation of interventions that will improve the health of poor communities’ in urban areas. They work in five countries that struggle to register progress in promoting urban health. Her presentation outlined the challenges that hinder this progression including rises in ill-health among urban poor due to a score of issues, like pluralistic health systems and the management of health by city corporations where health is not always a top priority. CHORUS is aware of the gaps in action and supporting research, information and policy. They propose joining, expanding or linking communities of practice as a sure solution to the aforementioned gaps; to among other reasons ensure wide dissemination and utilization of findings by research users to inform policy and programme decisions.

Ibrahim Dadari from UNICEF outlined some of the challenges they face as an organization in promoting urban health due to rapid urbanization. Rapid urbanization leads to growth in slum population and informal settlements. People in these settings are usually not reached with many social services including immunization. The rapid urbanization has not been factored much in policy formulation, resource allocation and prioritization. UNICEF has focused on urban immunization and urban health generally by identifying four priority areas which he spelt out to advance urban immunization. UNICEF worked with other partners to establish the urban immunization working group to deliberate and advance agendas for advocacy in order to mobilize resources to focus on developing urban immunization strategies. Identifying children that have not been immunized in urban settings is still a challenge particular because some of the urban settings do not conform to some national geographic boundaries. This area needs prioritization. Research needs to be tailored to particularities of programming within these urban settings by leveraging the private sector, civil society, Information Technology , faith based organizations among others.

Cecilia Tacoli from the African Cities Research Consortium working on health, wellbeing and nutrition in African cities, explained the three interconnected dimensions required to understand urban development: the political settlement, the city systems and the urban development domain. This is translated into the health, wellbeing and nutrition by focusing on healthy diets. Healthy diets are crucial to the prevention of ill-health while access to nutritious diets reflects the income and non-income of urban health which is intimately connected to other urban systems. She explored what is limiting and enabling the uptake of healthy diets and for whom by carrying out studies in Freetown, Lilongwe, Kampala and Nairobi.

Cudjoe Bennet gave a USAID reflection on urban health pointed out strengthening quantitative and qualitative data to better understand the context and intra urban health gains and disparities. This is useful for closing urban health policy gaps and promoting the use of learning approaches. USAID has focused its attention on supporting global efforts in urban governance of the public and private sectors. USAID also aims to support its staff and implementing partners to build activities into health sector programming that strengthen urban resilience. USAID has also directed its efforts into building healthy cities and analyzing data and synthesizing it to better understand intra urban disparities.

Nancy Njoki, a community and national leader from Kenya gave an insightful presentation on the challenges in promotion of urban health. Rural urban migration that causes congestion in an area with already limited resources. Overstretched resources, lack of basic needs like water, the broken or lack thereof of health systems and poverty are big hindrances in the goal of promoting urban health. Muungani wa Wanavijiji, is a movement for slum dwellers mobilize and organize groups to strengthen community groups and saving groups. These saving groups become centres for passing information for advocacy. They use informal settlement associations to promote inclusivity and ensure that they leave no one behind. They also practice peer-to-peer exchanges for community members to learn from each other through learning exchanges. This practice gives community members the ownership and zeal to advocate for their challenges. She discouraged researchers from going out to communities with predetermined questions and without involving community members as it interferes with the uptake of the research outcomes. Communities of practice lead to an increase of co-production of knowledge and the community is able to understand and follow up on action points from the research particularly for decision making. It also promotes sustainability of projects and programs.

Haja Wurie who is part of ARISE, gave a brilliant presentation where she highlighted the fact that urban policies for health and wellbeing are not holistic and do not cover the unique challenges of informal settlements. There is also continued proliferation of informal settlements that has negative consequences in regard to health and wellbeing in urban spaces. Even without continuing urbanization, existing informal settlements are already faced with increased vulnerabilities, challenges and inequalities.

All this causes a shift in health seeking behavior from formal to informal sectors which affects things like vaccination against COVID-19 which falls under the formal sector. Evidence shows that for informal settlements, targeted messaging should be employed to improve vaccine awareness. Policies need to be designed taking all these into account. It is therefore important to engage in research to provide the much needed evidence for policy and practice and ensure that accountability and community ownership is provided. This in turn empowers communities to advocate for their health and wellbeing.

Zahidul Quayyum of Pathways to Equitable Healthy Cities expounded on their organization. It is a global partnership that aims to improve population health, enhance health equity and ensure environmental sustainability in cities through the co-production of knowledge. They partner with civil society and other partners to generate evidence. They provide timely, rigorous and scientific evidence on how urban change and development can be managed to to make a positive impact on people’s and communities’ health and enhance health equity. They also influence synergetic advocacy among stakeholders to inflict policy changes. They work in five cities: London, Beijing, Vancouver, Bangladesh and Accra. Some of their research activities include: co production of knowledge, handling housing and neighborhood issues, dealing with poverty and inequality in urban areas, dealing with (waste, sanitation and waste management) and transport and mobility in urban areas. He gave a detailed list of key challenges to promoting urban health. They already have in place a community of practice and network made up the different key stakeholders. The views of all these stakeholders are absorbed and used in generating policy scenarios. Data banks and future projections are intended to enable stakeholders gain access to information on impacts of policy changes. Insufficient research funding, limited dissemination of research findings, lack of research findings being utilized by policy makers and lack of implementation are some of the gaps in action Zahidul called attention to. He also mentioned the advantages of being part of communities of practices.

Shahreen Chowdury gave a moving and enlightening presentation capturing the experiences of people living with disabilities in Bangladesh and Liberia during COVID-19. This was done using the photovoice tool. People living with disabilities are among those groups that bore the brunt of COVID-19. Notably, the research established the lack of disability research in the Global South. The challenges that people living with disabilities encountered during the pandemic include: the lack of disability inclusion in pandemic preparedness and mobility issues during harsh weather conditions like heavy rain. All these affected their capacity to meet their basic needs. Some interventions that were put in place interfered with the communication of some of the groups like the deaf who could not lip read because of the presence of masks. The photovoice approach captured some of the interventions that were implemented like community healing spaces for people with mental health issues The presentation elaborated that the best way to have meaningful inclusive participation is ensuring that people living with disabilities are represented and their voices heard. The presentation was concluded on a powerful note: Nothing about us without us is for us!!

Sushil Baral in his presentation reiterated that the complexity of urban health systems is a reality that needs a solution. Some of the key challenges to progress in urban health are known while others remain unknown. These challenges fall under four categories: policy, systems, organizational and people oriented. These challenges include: poverty, inequality, migration, unplanned urbanization, weak coordination among stakeholders, lack of basic services and unemployment. He expounded on their community of practice and their focus area. In order to achieve their intended objectives, they employ co-creation through participatory practices and embedded approaches. His presentation also highlighted the lessons they had gained in action and supporting research, information and policy. They discovered that the evidence is limited and there are many unknowns. The complexities of urban areas challenge co-creation, and processes must build on existing foundations if solutions to the complex problems are to be found. Action requires time and effort in building trust in relationships to achieve ownership and long term goals. The process of change is often politically driven and technical approaches must be backed by political ownership.

Bachera Aktar from BRAC James P Grant School of Public Health, BRAC university in Bangladesh, shared the ARISE Hub experience in Bangladesh in her presentation. 1.5% of the total population of Bangladesh live in slums (one third of the Dhaka population). 75% of slum households live in one room. Rapid urban growth is bringing about many challenges and there are many sectoral programs working apart or in parallel and often times have inadequate communication and coordination. Urban informal settlements are very dynamic in Bangladesh and even within the settlements themselves, there is diversity among the populations. Vulnerabilities and marginalization are multidimensional and inequities exist in every aspect. Health and wellbeing of slum dwellers is a burning issue. The urban health system in Bangladesh is very pluralistic, pragmatic and complex. The health care delivery system is also very poor in terms of functionality. Residents mostly depend on informal health care providers with NGOs as the primary health care providers. Private sector services are often unaffordable and inaccessible to slum dwellers. There are scores of challenges facing urban health: no comprehensive urban health policy, inequitable distribution of services, lack of government stewardship and lack of coordination among others that she enumerated. ARISE Hub in Bangladesh worked to connect communities with city actors. Their focus is on ensuring that informal settlement dwellers are included in city development planning and that their needs and priorities are met.

We were joined by Jeff Knezovich and Kabir Sheikh from The Alliance for Health Policy and Systems Research, who both endorsed the importance of health systems work in complex, pluralistic urban settings. Jeff said there needs to be further engagement and stressed the particular importance of strategic engagement with local stakeholders and decision-makers. Kabir acknowledged the need for new conceptual frameworks that address the complexity at the intersection of power, politics and health system in urban environments.

We appreciate the attendees’ enthusiastic response to the breakout sessions and below we share a summary of comments.

What are your reflections on the satellite presentations?

There is a need to have knowledge of the political landscape and form a connection between researchers and decision makers. Better quality of data needs to be provided and better sharing channels developed. A couple of presentations uncovered the fact that in many settings, public health is not a priority and a shift to informal engagement is required. We also heard that the capacities of young people need to be built and a greater focus given to multisectoral engagement. Many of the speakers highlighted pertinent issues such the plurality of HSS, voices from municipalities and the fact that migration has big impacts. Many reminded the participants that it is at the core of the work of health systems to include vulnerable groups and leverage on co-production. More focus is needed on conflict-affected settings and how to integrate system thinking approach in these fragile settings. A lot of work is currently being done on urban health which features both short-term and long term research studies to find solutions to complex problems.

What is needed to expand the impact of work on health and wellbeing in urban areas?

Implementation would require using the evidence collected and ensuring that the actions taken are based on data. Participants agreed that co-researchers are an important aspect of any research study as they provide an opportunity to build on local knowledge and in turn develop the capacity of the community. Policy expectations and the capacity of people need to be a match. Multisectoral engagement is key. Noteworthy, is the fact that different groups have different needs and require different solutions to their unique challenges. There is a lack of integrated databanks for core issues like health, mobility and housing in urban areas. There was a general agreement that there are methodological issues that often hinder the definition of who the urban poor really are. If health and wellbeing in urban areas were to improve, a reduction in the gap between government and communities is urgently needed. Accountability must be put in place in all processes and systems and the evidence driven data implemented. Equitable partnership between different types of providers like government, private and informal sectors must be improved and data sharing encouraged; and the different dynamics like language and data considered.

If we were to expand and connect existing communities of practice what would we aim to achieve? With what scope and which principles?

Participants noted down the following as some of the stakeholders the Communities of Practice (COPs) would target:

Urban planners
Resilient cities network
Mass media
Political leaders and non-health stakeholders
Civil servants in cities at different levels (national/local)

In order to achieve the targets, set out for the COPs, the different COPs need to be mapped out and aims and objectives. The COPs need to be brought together and synergies pulled together as one COP may not be practical. Diversity across COPs is required and different sub-groups of focus identified and created. It is also pertinent to leverage research on COPs and identify what works.

Participants brainstormed on how to bring people together and the suggestions included:

Make specific resources available for COP and include decision makers in COP (not just health, but other sectors e.g. planning)

The session was closed by Tolib who made a few brilliant observations:

The theme of cities stood out and is important, as clearly articulated by consortia in the room.
There is a clear demand for responsive, participatory urban systems, built on equity and justice.
It is clear that there is a growing body of knowledge and a noticeable increase of like-minded individuals who are interested in the work of improving the health and wellbeing of residents in urban areas.
This presents a great opportunity to identify existing COPs and spell out the gaps that exist.
The reflections on COPs and their roles in combining efforts is very helpful. Participants seemed to agree that rather than reinventing the wheel, the focus should be on building on what already exists and mapping and filling existing gaps.
The idea of building a mega community of practice that could help bring others together to share was welcomed.
Tolib also suggested the group should consider setting up an informal working group for Health Systems Global or putting in an application for a Thematic working group.

In her final remarks Sally Theobald reflected on the enthusiasm and dynamism in the session, and commended participants willingness to share and reflect together. She highlighted the key themes coming out of the presentations and discussions, including co-production, community engagement and ownership. She noted that urban contexts are not going away and a strategic approach is critical to meeting goals of health, equity and justice. Sally wrapped up the session by committing to writing up this report. She also said that an analysis of current COPs would be undertaken with gaps mapped out and synergies identified. This will be followed by a discussion on how all stakeholders can come together and learn from each other about what works best.