WHO Urban HEART Consultation Day 3

I've been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on Day 3 of the Consultation, there are also posts on Day 1 and Day 2.

Workshop 3: Review of Urban HEART guidance

There was a widespread view that the current Urban HEART guidance works quite well but that there are a few areas where it might be enhanced. There was discussion about the selection of interventions and responses being difficult in practice, and that it involves considerable negotiation. There wasn't agreement about the best ways to reflect this in the guidance but it was a recurrent theme, and one that's familiar in the context of HIA and negotiating recommendations.

Community participation is another aspect of Urban HEART that has been difficult to provide guidance on. Participatory rapid assessments, health assemblies, surveys, workshops, and the use of mobile and electronic engagement tools were all discussed as ways to involve communities in Urban HEART processes, though these were all recognised as having limitations.

There was quite a lot of discussion about the extent to which HIA might be integrated into Urban HEART, though it was agreed that Urban HEART and HIA are complementary rather than being processes that could be integrated. This is because Urban HEART helps to identify needs and areas for action at the city level, whereas HIA is most useful where there is a proposal or a limited set of options to assess. So whilst there are procedural similarities they serve quite different purposes and integrating them might complicate things rather than helping. The diagram below from the Urban HEART User Guide shows how WHO conceptualises Urban HEART's role in local planning cycles. Some related procedures like multi-criteria decision analysis and equity lenses were also discussed, and how they might be integrated into Urban HEART.

An important issue that was discussed was that we need to focus on enhancing the equity focus of Urban HEART rather than simply improving the technical aspects of the process. The value of Urban HEART is its equity focus rather than its health focus, and we need to prioritise that in any revisions. This is something I hadn't really considered before and I think it poses a challenge to the HIA practitioners: beware focusing on improving technical aspects of the assessment process at the expense of an equity focus. Technically perfect assessments won't necessarily result in inequities being better addressed.

The need to demonstrate economic effectiveness/cost-benefit was also discussed. This is familiar territory for HIA practitioners! I confess that I have mixed feelings about this. Whilst I can see that there are benefits to even limited economic approaches to describing the economic benefits of HIA or Urban HEART (willingness to pay analyses, estimated savings based on case studies, etc), ultimately Urban HEART and HIA are about informing and improving planning and decision-making. They're not readily comparable to other health interventions because they're fundamentally different types of interventions.

The need for an online guide, repository and clearinghouse for evidence was discussed. We're very fortunate in HIA to have the HIA Gateway. The consensus was that something similar is required for Urban HEART.

City case presentations

Madeleine Ntetani-Nkoussou discussed the use of Urban HEART in Brazzaville, Congo. There's a number of issues in Brazzaville associated with informal settlement/slums and rapid urbanisation. The physical and service infrastructure has struggled to keep pace. Potable water access and access to water sealed toilets remain big issues, as is food security. urban HEART helped the city identify the four arrondissement that required greater activity, in particular around the provision of health services and prevention activities.

Plenary discussion: Next steps

One issue that was raised is whether there a need or mechanism to involve state and national governments in Urban HEART? Though this approach would have relevance to them, a big part of the appeal of Urban HEART is the clarity of the indicators and its applicability at the city level.

The distinction between Urban HEART as an indicator/diagnostic tool and a framework to guide implementation came up a few times. It's intended to be both, but there's a tension, which most HIA practitioners would have encountered as well

There was quite wide-ranging and detailed discussion about approaches to building capacity for Urban HEART, which I won't describe in detail here because I'm not able to do justice to the range of issues discussed. Some of the broad topics touched on included:

• capacity building
• sharing best practice, particularly in the form of brief case studies focused on key learning
• building Urban HEART into WHO and country-level work plans 
• linking to professional groups/associations
• ensuring the health sector comes along the journey and that Urban HEART doesn't become the sole responsibility of cities/other sectors
• how often does Urban HEART need to be revisited/redone
• how can we make Urban HEART sell itself, i.e. so it doesn't need much ongoing support
• compendiums of best practice and then thinking how some of these best practice cases might be synthesised
• how to advance an equity agenda in settings where it's not on the political agenda

These issues are all eerily familiar to people who've worked on HIA! It was an excellent Consultation with plenty of food for thought that also highlighted how well-designed Urban HEART is and how much work has gone into its development. I plan to do another post in a few days that brings together some of the critical points and what the implications might be for HIA.

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WHO Urban HEART Consultation Day 1

I've been invited to participate in a WHO Consultation on Urban HEART in Kobe. This is a post on some of the issues discussed on Day 1, with some of my thoughts and reflections scattered throughout. There are also posts on Day 2 and Day 3.

Urban HEART grew out of the Commission on the Social Determinants of Health's work and dates back to 2007. Early activity on piloting and developing a tool were led by a few countries, notably Iran. The final report from the CSDOH gave further impetus and led to more piloting of Urban HEART in more cities. After piloting Urban HEART was extensively reviewed and Version 1 was published in 2010.

Urban HEART is conceptualised by WHO as a tool for assessment and response to health equity issues at the city level. Urban HEART was designed to meet four criteria:

• ease of use
• comprehensive and inclusive
• feasible and sustainable
• links evidence to action

It's a stepwise process with a lot of similarities to HIA. In contrast to HIA it doesn't need a proposal (even a general one or options) to assess. Rather it allows municipalities to identify issues for action and responses at the city level, and in that way it's more like a needs assessment or planning activity. It's useful where some willingness to act on health already exists, so Healthy Cities is a useful basis for action. Higher-order support is always required (which may be less true for HIA?).

Data that informs Urban HEART is almost always spread across agencies - no single one holds or reports on even the core indicators. This means multiple permissions and interagency liaison is often required, which reiterates the need for higher-order permission and negotiation at the earliest stages. Whilst this is undoubtedly desirable for HIAs as well it hasn't always been possible in my experience and HIAs often fly under the radar, at least in the early stages. I'm not sure that would be possible for Urban HEART but I'm not sure that's a bad thing. The under-the-radar HIAs I've been involved in have often encountered resistance when their recommendations are presented. A clear, unambiguous mandate and imprimatur as a basis for proceeding isn't a bad thing.

A survey of Consultation participants that was conducted in advance found that most participants thought Urban HEART works well overall, is easy to use and successfully links evidence to action, but is less successful at being comprehensive and organisationally sustainable.

Case studies from the City of Paranaque in the Philippines, Tehran in Iran and Indore in India provided a range of useful, practical lessons on the use of Urban HEART (and they were quite inspirational). The Inore case in particular modified the indicators in a way to suit the local context, in their case by ensuring that the indicators were all meaningful and comprehensible to anyone, from residents to national bureaucrats. The case studies also highlighted the need for Urban HEART to not be a one-off activity but as an activity that needs to be revisited/undertaken semi-regularly.

Megumi Kano from the WHO Centre for Health Development gave an overview of the synthesis of evaluations of Urban HEART.  The synthesis was only of Kobe Centre-funded pilots in developing countries and may not reflect all use. The synthesis showed that "core indicators" (see Urban HEART User's Guide) were not used in all cases, in fact some of the "suggested indicators" were used as often. All case studies used the matrix, though data validation was rarely mentioned. Another difficulty was the lack of not only disaggregated sub-city level data but trend data over time. Interventions tended to focus on physical environment and infrastructure and social and human development, rather than economics or governance.

How should we stratify/disaggregate equity analyses?

One issue that was identified at the Consultation is whether looking at geography and sub-municipal spatial areas as the unit of analysis always appropriate? For example might gender, poverty or age at the city level be a more appropriate way of analysing health equity issues? This is a recognised tension because all health equity analyses should use gender and SES for stratification but cities are often focused on neighbourhoods and a spatial approach. In many ways it points to a bigger, perhaps more overtly political discussion about what do we mean by health equity?

Scaling up

It was noted that approaches scaling up Urban HEART might not be the same in all cases because it's so linked to the scope and role of government, so this will vary markedly. Encouraging progress has been made internationally, as the map below illustrates.

Map of countries who have built capacity to use Urban HEART, 2008-2011

Questions arising from Day 1

• How can we promote Urban HEART better?
• How can we involve NGOs or the private sector? Should we?

My general reflections

1. An issue I have encountered is the limited availability of *any* health indicators at the city/local government level, let alone sub-city levels, given that cities can be quite small in scale with limited resources in Federalist systems.
2. The health sector will always need to be involved in the use of Urban HEART in some capacity because they hold the data, or some of the data, but they needn't be a roadblock. A pragmatic approach to getting the best available data but to focus on response strategies and interventions helps.
3. In some ways the most useful thing that health systems can do is to regularly report on a broad range of health indicators at city and sub-city (disaggregated) levels, so cities can pick up Urban HEART and other related approaches and run with them.

Cross-posted on my HRH blog

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Japanese Health Impact Assessment Practice

Guest post by Michiko Hoshiko

Health Impact Assessment (HIA) is not yet a routine part of public decision-making in Japan, though there are an increasing number of examples of HIA’s use.

Before any regulatory assessment measure can be adopted in Japan it’s necessary to demonstrate its economy, efficiency and effectiveness, so this forms the focus of much current HIA activity. In 2011 the Japanese Public Health Association produced guidance on HIA ¹⁾, focusing on how to do it.

The Kurume University School of Medicine and the University of Occupational Environmental Health have been centres for the development of HIA in Japan to date. The case studies below describe some of the HIAs and research that has been conducted.

Kurume University School of Medicine

1) Health impact assessment of the transition to a core city in Japan²⁾

The city of Kurume became a core city in 2008, which is a more autonomous level of regional government that some cities in Japan are eligible for. A core city requires a population at least 300,000 people and allows the transfer of administrative authority from prefecture to more independent municipal government. A rapid HIA was conducted on the transition to a core city because potential health impacts were identified for public servants in Kurume as well as residents.

2) Assessing the validity of health impact assessment predictions regarding a Japanese city’s transition to core city status: A monitoring review³⁾

The validity of health impact assessment predictions has not been accurately assessed comparing predictions with subsequent data. An HIA into the transition of Kurume to a core city was conducted before the transition, but the recommendations were not accepted and adopted by city officials. A monitoring review was performed one year after the transition to guage the accuracy of the HIA predictions by evaluating the correlation between the predicted impacts and what ended up happening.

3) Prioritization of health impact assessment on the management transformation of a municipal hospital in Japan

Municipal hospitals in Japan are currently facing a serious eonomic management crisis because of operating deficits and doctor shortages. Unprofitable departments, including obstetrics and paediatrics, have been closed at some hospitals, which has caused controversy in a number of local communities. The aim of our study was to examine the health-related impacts of management and service changes at a municipal hospital close to the Kurume University School of Medicine on residents, patients, and hospital staff.

4) Development of a Health Impact Assessment Screening Tool for Use at the Municipal Level⁴⁾

The aim of this study was to make an HIA screening tool for use at the municipal level in Japan. The HIA screening checklist is versatile and applicable across a range of projects. The intended users are municipal officers and as such we wanted it to be short and usable.

University of Occupational Environmental Health)

5) Development of HIA screening tools for policies and projects⁵⁾⁶⁾

In screening you try to identify as many potential health impacts as possible. This should include not only scientific knowledge but also “lay knowledge” that incorporates information such as the anxieties and fears of stakeholders. This screening tool allows stakeholders to participate in the identification of potential health impacts and to characterize them in terms of being positive and negative, as well as their potential severity. This is then used in the decision to proceed with the HIA or not.

6) HIA of closing a research laboratory⁷⁾

Due to changes in the economic climate a major laboratory for an international corporation was closed. An HIA was conducted to look at the potential impacts on workers, who are both domestic and come from overseas.

7) HIA for introducing for reemployment system after retirement⁸⁾

Japan is facing a rapidly ageing population, with reduced birth rates and the retirement of the post-war Baby Boomers. A number of companies have reintroduced “re-employment” shemes for workers who have already retired to address workforce shortages. This HIA looked at the potential positive and negative health impacts of re-employment schemes.

References

1)      Public health monitoring report commission: Health Impact Assessment Guidance. Jpn J Public Health, 58:989-992, 2011 (in Japanese)   

2)      Hoshiko M Hara K, Ishitake T: Health Impact assessment of transition to a core city in Japan. Public Health, 123:771-781, 2009  

3)      Hoshiko M Hara K, Ishitake T: Assessing the validity of health impact assessment predictions regarding a Japanese city’s transition to core city statue: A monitoring review. Public Health, 126:168-176,2012

4)      Ishitake T: Development of a Health Impact Assessment Screening Tool for Use at the Municipal Level. HIA 2012 international conference in Quebec.

5)      Fujino Y, Nagata T, Kubo T, Uehara M, Kajiki S, Oyama I, Dohi K,

Mori K: Application of HIA for enterprise [1], Science for Labour 67(1)

32-35, 2012 (in Japanese)

6)      Nagata T, Fujino Y, Kubo T, Uehara M, Kajiki S, Oyama I, Dohi S, 

Mori K: Application of HIA for enterprise [2], Science for Labour 67(2)

40~43, 2012 (in Japanese)

7)      Nagata T, Fujino Y, Kubo T, Uehara M, Kajiki S, Oyama I, Dohi S, 

Mori K: Application of HIA for enterprise [6], Science for Labour 67(6)

26~29, 2012

8)      Tanaka H, Uehara M, Fujino Y, Nagata T, Kubo T, Kajiki S, Oyama I,

Dohi S, Mori K: Application of HIA for enterprise [7], Science for Labour

67(7), 38~42, 2012       

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Michiko Hoshiko: Researching the use of health impact assessment in Japan and Australia

I have been conducting research related to health impact assessment in Japan since 2008 at the Kurume University School of Medicine. As part of this I have been involved in several HIAs, for example our health impact assessment of the transition to a “core city” (core cities are cities of more than 300,000 people that take on greater governmental autonomy and some of the responsibilities of prefectural governments) and a HIA of the redevelopment of a major hospital site. I have also been involved in the development of a HIA screening checklist for use in government.

Following the completion of my PhD I have been able to pursue further research into HIA, through a fellowship based at the University of New South Wales in Sydney, Australia. My aims during the fellowship are:

1) Investigate the use of HIA screening checklistsI will investigate the use made of the NSW Healthy Urban Development Checklist as a tool for engaging with local government officials around population health issues, comparing it with the checklist I developed at Kurume University in Japan.

2) Investigate the use of health impact assessment in local governmentI will investigate the use of health impact assessment and related tools to improve the population health impacts of decisions made by local government. In particular I will investigate process and procedural aspects of HIA that are associated with impacts on local government decision-making and implementation.

3) Investigate the use of health impact assessment in urban regeneration projects and major projectsI will investigate the role of HIA in influencing the health impacts of urban regeneration projects, and its role in addressing health within major project assessment.

4) Investigate and compare the different barriers and facilitators for HIA’s use in Japan and AustraliaDuring my staying in Australia, I will conduct research on the different barriers and facilitators for HIA’s use, particularly on issues such as health service planning, urban sprawl, energy, and disaster response.

I hope to develop at least two academic journal articles on this program of research. If you’d like to find out more about my research or get in touch please email me at hmichi AT med.kurume-u.ac.jp

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