Municipalization and Urban Health: Tendencies in the Americas, Lessons Learned, and Challenges. Marilyn Rice, MA, MPH, CHES PAHO/WHO

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2 Municipalization and Urban Health: Tendencies in the Americas, Lessons Learned, and Challenges Marilyn Rice, MA, MPH, CHES PAHO/WHO

3 Section A Urban Trends

4 Urban Trends More urban than ever More unequal than ever Democracy, inequality, and exclusion Sociopolitical framework Local power and municipalization Urban health a new paradigm 4

5 The Future Looks More Urban Than Ever By 2006, roughly half the world s population is residing in an urban area By 2030, three-fifths will live in an urban area Cities are much more than a conglomerate of people with individual risk factors and health needs, they Offer opportunities for educational, professional, cultural, and economic growth Are the center of innovations Source: Stephens, C. (2000, August). Threats to urban health. International Food Policy Research Institute. Retrieved from 5

6 The Future Looks More Unequal Than Ever Globalization in cities has generated a new geography of poverty, unemployment, and social exclusion Deterioration in values related to common well-being, equity, and active participation of citizens Loss of legitimacy of institutions, fragmentation, complexity of civil society organizations, and growth of poverty and inequities have created an increasing demand for new institutional democracy, one that introduces right to participate as a benefit of citizenship 6

7 Democracy, Inequality, and Exclusion Democracy, poverty, and inequality: Latin American triangle (UNDP, 2004) Proliferation of electoral democracy in the region Extension of poverty and inequality Democracy Representative and/or participative Civil, political, and social rights Citizenship as autonomy or solidarity? 7

8 Democracy, Inequality, and Exclusion Reduction of exclusion will only occur through a new form of democracy, one that is capable of recognizing excluded populations as citizens, generating public spaces for participation, social control and consolidation of efforts, as well as implementing healthy public policies and effective redistribution of resources (Fleury, 2005) 8

9 City of Citizens: A Sociopolitical Framework Cities as territories politically and socially constructed with their citizens Democratic management and strengthening of citizen participation Strengthening of social cohesion Reduction of inequities and exclusion Deliberated democracy and social inclusion Strengthening of social and political networks 9

10 Local Power, Innovation, and Networks Contribute to development of new paradigm for strengthening local level, based upon need for real democracy and development processes with social inclusion This presupposes the existence of innovative environments, articulation among economic and social policies, networks, leadership, teaching and research institutions, healthy public policies, social participation, and intersectorality 10

11 Local Power, Innovation, and Networks The principal characteristic of innovative cities is collectivity, with different sectors of society and their participation through different governmental spheres 11

12 Municipalities in the Americas and Europe Region Territory (thousands of km 2 ) Population (millions of inhabitants) Number of municipalities Latin America 21, ,600 Canada 6, ,657 U.S.A. 10, ,200 Europe 24, ,682 Source: Carvajal, Palma E. (1998). El nuevo municipio latinoamericano: descentralización y democracia. ILPES, LC/IP/R

13 Cities with More Than One Million Inhabitants Argentina 3 Bolivia 2 Brazil 21 Canada 5 Chile 1 Colombia 6 Costa Rica 1 Cuba 1 Dominican Republic 1 Ecuador 2 El Salvador 1 Guatemala 1 Haiti 1 Mexico 11 Nicaragua 1 Panama 1 Paraguay 1 Peru 1 Puerto Rico 1 United States 53 Uruguay 1 Venezuela 5 Source: Retrieved from 13

14 Municipalization Decentralization of the state, basic objectives Transfer of competencies and recognition of political autonomy to municipalities, supporting citizen participation and local economic development Between 1990 and 2000, increase in number of municipalities 14

15 Characteristics of Municipalities in Latin America Rural, semi-urban, marginal urban Fifty percent have less than 25,000 inhabitants Two percent have more than 500,000 inhabitants (about 142 municipalities) Little access to resources, decision centers, and public services Weak inter-institutional collaboration 15

16 Urban Public Health Concentration of populations in urban areas % % % Public health WHO s broad concept of health allows an understanding of urban health as dependent upon work and life conditions of the people that inhabit a city 16

17 Strategic Action Health promotion as the new public health (Ottawa Charter) Healthy public policy Intersectoral collaboration Social participation Local capacity development Focus on settings PAHO/WHO Healthy Municipalities, Cities and Communities 17

18 New Topics in Urban Health Health and quality of life in cities Environment Migration and health of city immigrants City systems and services Equity Local governance Healthy public policies and city planning 18

19 New Topics Social innovations Reduction of poverty and hunger Violence Obesity Sedentary lifestyles Mental health 19

20 Urban Health Transcends Traditional Functions Healthy cities transcend the limits of functions of organizational principles, they go beyond health policies to healthy public policies that address health-determining factors The healthy cities initiative defined planning as a public exercise, with broad community participation and multiple sectors Likewise, new forms of social communication are introduced Healthy cities develop a new approach to public management, and they address the strengthening of municipal administration and local teams with this new approach (Kickbush, 1998) 20

21 Section B Urban Examples

22 Examples of Urban Context Selected cities of Latin America Asuncion, Paraguay Buenos Aires, Argentina Lima, Peru Montevideo, Uruguay 22

23 Asuncion, Paraguay Asuncion has six districts, or principal neighborhoods 1. La Catedral 2. La Encarnación 3. San Roque 4. Lambaré 5. Recoleta 6. Santísima Trinidad Important to recognize differing priorities among the six districts. 23

24 Asuncion, Paraguay Asuncion has six districts, or principal neighborhoods 1. La Catedral 2. La Encarnación 3. San Roque 4. Lambaré 5. Recoleta 6. Santísima Trinidad Important to recognize differing priorities and differing populations among the six districts Important to combine data collected by different sectors (transportation, education, health, etc.) 24

25 Community-Identified Needs Need for more urban planning Flooding Garbage Housing Social participation Education Health 25

26 Buenos Aires Strategic Plan Created a 10-year strategic plan to deal with the effects of urbanization Addressing both present-day and future problems created by population influx 26

27 Buenos Aires: City-Based Assessment Who is our population? Where do people live? Where do people work? What are the different needs in the different districts and different sectors? 27

28 Economic Distribution of Population Ciudad de Buenos Aires: Distribución de la Población Ocupada por Actividad Económica Adapted by CTLT from EPH Indec,

29 Allocation of Resources Adapted by CTLT from EPH Indec,

30 Indigent Population and Poverty Adapted by CTLT from EPH Indec,

31 Indigent Population and Poverty Adapted by CTLT from EPH Indec,

32 Metropolitan Lima 43 districts Extension: km 2 Population: 7,496,831 inhabitants 32

33 Poverty in Lima Sixty percent of the population lives in the northern section: north, east, and south Eighty percent of the poor live in these sections The marginal neighborhoods are populated by migrants in these sections of Lima Lima maintains a standard of segregation in the central periphery 33

34 Poverty and Age of Community Poorest population of Lima lives on the outskirts of the city Wealthiest population lives in the center of the city, which is adjacent to the coast and port 34

35 Violence One in three people over 18 years of age was a victim of some assault One of every three car owners has been subject to theft Three of every 10 people have been the subject of attempted or actual robbery Two out of every five violent deaths are from traffic accidents 35

36 Slums In the newly developing slums, about 1,000 tons of garbage is left uncollected daily Sixty-three percent of new construction is built without functioning licenses 5.7% of the population between 6 and 17 years of age do not go to school 36

37 Montevideo City Photo by Gustavo. Creative Commons BY-NC-SA. 37

38 Rural and Urban Limits in Montevideo Within city boundaries, there are still rural structures and contexts Majority of urban development is located in the center city Source: Unidad de Información Geográfica Intendencia Municipal de Montevideo. 38

39 Unemployment Rates Montevideo average: 16.4 % Fuente: Elaboración en base a la ECH. Montevideo Observatory of Social Inclusion. 39

40 Poverty Distribution by Neighborhoods Montevideo average: 33.6% Fuente: Elaboración en base a la ECH. Montevideo Observatory of Social Inclusion. 40

41 Zones of High Exclusion Housing problems are more universal throughout the city Fuente: Consulta a actores locales Montevideo Observatory of Social Inclusion. 41

42 Montevideo: A New Form of Local Governance City campaign to encourage participation across zones and sectors Yellow circle: Political arm of government (policy making) Orange circle: Institutional arm (implementation of policy) Green circle: Community arms (participation and community organization) 42

43 Section C Trends and Networks

44 Trends and Networks Trends in urban health The Healthy Municipalities, Cities and Communities (HMC) Movement in the Americas The network of HMC of the Americas 44

45 Reflections on Tendencies Participatory processes are fundamental, but sometimes they lack full representation, there are gaps in information, and they grow in uncoordinated ways Citizens demand security, and reports to police increase Among the main determinants of urban health are poverty and inequity Mutual support and joint action is more frequent Health promotion, as a strategy for improving urban health, is a process of social production with responsibility 45

46 Construction and Development of Capacities Incorporation of urban health into development plans with local governments using all possible networks Institutional strengthening Intersectoral committees with social participation Create and articulate entities that work to promote health and quality of life 46

47 The HMC Movement in the Americas PAHO introduced the strategy in the region in the 1990s Main objectives are to Promote health, together with people and communities, in settings where they study, work, play, love, and live Establish and strengthen a social pact among local authorities, community organizations, and public and private sector institutions Use local planning and social participation in management, evaluation, and decision making 47

48 HMC Movement A municipality begins the process of becoming healthy when its political leaders, local organizations, and citizens commit themselves to improving the health and quality of life of all of its inhabitants. Pan American Health Organization. (2002). Mayor s guide for promoting quality of life. 48

49 The HMC Movement in the Americas In 2007, 18 of the 38 countries in the region actively involved with the HMC strategy South America Argentina Brazil Ecuador Guyana Paraguay Peru Uruguay Central America Costa Rica El Salvador Honduras Nicaragua Panama North America Canada Mexico U.S.A. Caribbean Cuba Dominican Republic Trinidad and Tobago Countries in orange have national networks. Those in yellow are not implementing the HMC strategy. 49

50 HMC Network of the Americas: Vision The HMC Network leads the development and strengthening of the HMC strategy and positions health promotion on the political agenda of the member countries in order to contribute to sustainable local development, improve the social determinants of health, and strengthen the conditions of equity and peace in the region of the Americas 50

51 HMC Network of the Americas: Mission That the HMC Network of the Americas constitutes the main and model advocacy forum of the region of the Americas for healthy public policies, strengthening partnerships at continental level, articulating HMC networks activities, and promoting the sharing of experiences and solidarity among its members, thus ensuring the sustainability of achievements, improving conditions of equity and quality of life, and facing new challenges 51

52 HMC Network of the Americas: General Objectives Promote the creation and the strengthening of national HMC networks in the Americas with a health promotion perspective Promote healthy public policies, decentralization, and democratization of local governments Improve local capacity for the implementation, management, and evaluation of HMC initiatives Integrate the work of subregional networks with other initiatives linked to integration, political, economic, and social processes, seeking joint efforts and consolidation 52

53 Countries with National HMC Networks Argentina Costa Rica Cuba El Salvador (recently established) Mexico Paraguay Peru Other countries, such as Brazil, Canada, and the U.S., have various regional networks 53

54 Section D Lessons Learned and PAHO Resources

55 Lessons Learned and PAHO Resources Participatory evaluation empowers Lessons learned from application of participatory evaluation methodology PAHO HMC resources 55

56 Empowerment and Local Transformation Lessons learned through participatory evaluation of healthy municipalities, cities, and communities 56

57 Domains of Evaluation Values Equity, empowerment, diversity, solidarity Pillars Policies Participation Sustainability Intersectoral Structures Priority area Processes and contexts Conditions/ determinants Material/physical Individuals Norms/capacities 57

58 Domains of Evaluation Values Equity, empowerment, diversity, solidarity Pillars Policies Participation Sustainability Intersectoral Structures Priority area Processes and contexts Conditions/ determinants Material/physical Individuals Norms/capacities 58

59 Take into Account Political Context and Timing Political context and timing was by far the most important factor affecting the implementation of participatory evaluation in the participating countries Election periods and political transitions often caused major delays (if not termination) of initiatives, shortage/change of personnel and funds, and great uncertainty about the future of the initiatives, and their evaluation This has consequences for the evaluation of programs under implementation, but especially for programs conducted by the previous administration and not continuing under the new one 59

60 Political Context Transitory nature of local and national political contexts can weaken programs and public policies, particularly when there is a change in political parties It is important to form a strong coalition among all sectors of society to strengthen and sustain the HMC initiatives and their evaluation, and to provide continuity during these transitional periods Rice, M., and Franceschini, M. C. (2007). Lessons learned from the application of a participatory evaluation methodology to Healthy Municipalities, Cities and Communities Initiatives in selected countries of the Americas. Promotion & Education (Vol. XIV, No. 2.). 60

61 Aim for a Truly Intersectoral Process Incorporating a variety of local partners (MOH, NGOs, universities, community members, community-based organizations, etc.) was important for the sustainability of the HMC initiative and its participatory evaluation in the countries It is crucial to get buy-in from the main stakeholders in order to begin and sustain the implementation of the participatory evaluation methodology Lack of support from critical stakeholders, such as municipal program managers or key personnel at public institutions, can seriously deter or isolate the advancement of the initiative 61

62 Conducting a Participatory Evaluation Takes Time But it is worth it Participatory evaluation process was lengthy and time consuming due to various factors Need to bring together and guarantee the buy-in from people from various backgrounds, sectors, and interests Stakeholders come with different perspectives and paradigms, and often from institutions and organizations with rigid and bureaucratic structures and work cultures Different levels of education among the community leaders 62

63 Time Is Needed Recognize the time needed for institutions, organizations, and individuals to adapt and accept a new methodology and paradigm that can greatly change how they function and work. Given the appropriate time and stimulation, people become motivated and apply dedicated efforts to implementing these new programs and methodologies. This initial process is an opportunity to strengthen alliances and trust among participants and their institutions (for example, municipal managers, representatives from the community, and NGOs) 63

64 Set Aside Resources for the Evaluation Lack of sufficient resources can limit or interrupt the participatory evaluation process Allocation of scarce community resources to conduct a participatory evaluation was a common problem that resulted from a general lack of understanding about the effectiveness and the usefulness of the results generated on the part of program managers and others responsible for funding and budget It is important to educate stakeholders on the benefits and the appropriateness of participatory evaluation in producing key information for decision making at all levels It is important to advocate for the establishment of a fund for health promotion evaluation from the initial planning stages of any initiative (PAHO, 2005) 64

65 Reach Consensus on Definition of Key Concepts There is a general lack of understanding about The concept of health promotion (often considered an approach to disease prevention) The participatory evaluation methodology which has a large qualitative component There are doubts about the benefits of conducting a participatory evaluation, mostly related to the time it takes to conduct the process and the usefulness of the data it will produce Resistance by those in key institutions is common 65

66 Address Concerns about Participatory Processes Concerns can arise related to Fears of receiving negative comments Prejudice against actions taken with too much input from community members Fears that the process would generate unrealistic demands on the part of community This can be particularly true of communities that are not well represented, in which, traditionally, programs and approaches are implemented from the top-down and truly representative and participatory mechanisms for community participation were scarce or non-existent 66

67 Institutional Context and Individual Factors Working with institutions with rigid and bureaucratic structures can be a major challenge for those engaged in conducting a participatory evaluation due to lack of institutional support, excessive bureaucracy, lack of coordination among public sector institutions, strict guidelines regarding the use of funds, conflicts between the different actors involved (federal, state, municipal) High turnover of personnel at all levels and institutions can be very disruptive and difficult to deal with since it can seriously impair the continuity, feedback, and appropriate application of the participatory methodology 67

68 Institutional Context On the positive side, working with institutions can open channels of communication with other levels and sectors, improve organizational climate, and open spaces for exploring new modes of multi-sectoral collaboration Working with institutions also offers the opportunity to regularize processes and methodologies within their work plans, programs, etc. 68

69 Strong Leadership Is Central Strong leadership is central to the sustainability of the evaluation initiative A common determinant of successful experiences with the participatory evaluation in the countries was the existence of strong, sustained, and dynamic leadership to take the process forward Active commitment and engagement from institutions both at the local and national levels is key to the success of the initiative, as is collaborative work among these institutions The role of national and regional HMC networks can be central in these efforts, providing the potential for far-reaching connections to municipalities throughout a country or region, as well as a connection with key stakeholders that can support the evaluation process 69

70 Participatory Evaluation Can Be Empowering Conducting a participatory evaluation can be an empowering process by itself There was an empowering effect of applying a participatory methodology communities and stakeholders were more willing and interested in participating and maintaining this participation The process provided a very rich opportunity to discuss, exchange, and reflect on countries experiences with the HMC strategy 70

71 HMC Resources HMC listserves (English and Spanish) with over 300 members from various countries in the Americas HMC newsletter published every trimester in English and Spanish with articles submitted by countries bolmunici.html HMC Web site at Virtual Library 71