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Municipalization and Urban Health: Tendencies in
the Americas, Lessons Learned, and Challenges
Marilyn Rice, MA, MPH, CHES
PAHO/WHO
Section A
Urban Trends
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
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 http://www.ifpri.org/2020/focus/focus03/focus03_09.pdf
5
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
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
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
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
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
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
Municipalities in the Americas and Europe
Region
Territory
(thousands of km2)
Population
(millions of
inhabitants)
Number of
municipalities
Latin America
21,000
450
16,600
Canada
6,100
30
4,657
U.S.A.
10,000
250
19,200
Europe
24,500
575
122,682
Source: Carvajal, Palma E. (1998). El nuevo municipio latinoamericano:
descentralización y democracia. ILPES, LC/IP/R 135.
12
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
Source: Retrieved from http://www.citypopulation.de/World.html
Guatemala 1
Haiti 1
Mexico 11
Nicaragua 1
Panama 1
Paraguay 1
Peru 1
Puerto Rico 1
United States 53
Uruguay 1
Venezuela 5
13
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
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
Urban Public Health
Concentration of populations in
urban areas
- 1990—67%
- 2005—72%
- 2007—78%
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
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
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
New Topics
Social innovations
Reduction of poverty and hunger
Violence
Obesity
Sedentary lifestyles
Mental health
19
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
Section B
Urban Examples
Examples of Urban Context
Selected cities of Latin America
- Asuncion, Paraguay
- Buenos Aires, Argentina
- Lima, Peru
- Montevideo, Uruguay
22
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
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
Community-Identified Needs
Need for more urban planning
Flooding
Garbage
Housing
Social participation
Education
Health
25
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
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
Economic Distribution of Population
Ciudad de Buenos Aires: Distribución de la Población Ocupada por Actividad Económica
Adapted by CTLT from EPH Indec, 2004
28
Allocation of Resources
Adapted by CTLT from EPH Indec, 2004
29
Indigent Population and Poverty
Adapted by CTLT from EPH Indec, 2004
30
Indigent Population and Poverty
Adapted by CTLT from EPH Indec, 2004
31
Metropolitan Lima
43 districts
Extension: 2817.30 km2
Population: 7,496,831 inhabitants
32
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
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
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
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
Montevideo City
Photo by Gustavo. Creative Commons BY-NC-SA.
37
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
Unemployment Rates
Montevideo average: 16.4 %
2001-2003
Fuente: Elaboración en base a la ECH. Montevideo Observatory of Social Inclusion.
39
Poverty Distribution by Neighborhoods
Montevideo average: 33.6%
2001–2003
Fuente: Elaboración en base a la ECH. Montevideo Observatory of Social Inclusion.
40
Zones of High Exclusion
Housing problems are more universal throughout the city
Fuente: Consulta a actores locales 2004. Montevideo Observatory
of Social Inclusion.
41
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
Section C
Trends and Networks
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
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
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
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
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
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
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
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
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
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
Section D
Lessons Learned and PAHO Resources
Lessons Learned and PAHO Resources
Participatory evaluation empowers
Lessons learned from application of participatory evaluation
methodology
PAHO HMC resources
55
Empowerment and Local Transformation
Lessons learned through participatory evaluation of healthy
municipalities, cities, and communities
56
Domains of Evaluation
Values
Equity, empowerment, diversity, solidarity
Pillars
Policies
Participation
Sustainability
Intersectoral
Structures
Priority area
Conditions/
determinants
Material/physical
Individuals
Norms/capacities
Processes and
contexts
57
Domains of Evaluation
Values
Equity, empowerment, diversity, solidarity
Pillars
Policies
Participation
Sustainability
Intersectoral
Structures
Priority area
Conditions/
determinants
Material/physical
Individuals
Norms/capacities
Processes and
contexts
58
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
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
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
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
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
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
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
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
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
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
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
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
HMC Resources
HMC listserves (English and Spanish) with over 300 members from
various countries in the Americas
- http://listserv.paho.org/archives/red-mcs.html
HMC newsletter published every trimester in English and Spanish
with articles submitted by countries
- http://www.bvsde.ops-oms.org/bvsdemu/bolmunici/
bolmunici.html
HMC Web site at Virtual Library
- http://www.bvsde.ops-oms.org/sde/ops-sde/bvmunicipios.shtml
71
