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Healthy urbanisation through a governance lensDr. Pat PridmoreInstitute of EducationUniversity of London

In 2007, for the first time, more people in the world lived in cities and towns than in rural areas. City life can bring benefits but rapid, unplanned increases in the urban population and poor governance has frequently increased social stratification.This has led to the growth of informal settlements and slums where there are high rates of ill health and malnutrition.These health disparities are inequitable because they are systematic, socially produced (and, therefore, modifiable) and unfair.

UN Habitat (2010) Hidden Cities

In Nairobi, 60% of the citys population lives in the slums

Child mortality in the slums is 2.5 times greater than in other areas of the city.

UN Habitat (2010) Hidden Cities

Definition of urban health governanceThe process by which individuals, government institutions and other public and private social organisations at the municipal level interact and relate to citizens in making the decisions needed to plan and manage the affairs of the city that influence health and health equity. Good governance to reduce inequities requires political commitment, strategic vision, institutional change and networks working towards the goals of:participation and voice, rule of law, transparency, responsiveness, consensus orientation, effectiveness and efficiency, accountability and fairness.SDH: mechanisms and pathways (WHO 2010)

SDH: urban mechanisms and pathways

Building good urban health governance: work in progress (www.nick.ioe.ac.uk)The Nick Project(Nutritional Improvement for children in urban Chile and Kenya)

11Central Research QuestionCan child malnutrition amongst families living in poverty in informal settlements and slums in Mombasa and Valparaso be reduced through

(i) broadening community and stakeholder participation and

(ii) doing action research to improve governance and change the social determinants of nutritional status?

Nutrition governance questionsDoes the government publicly take responsibility for addressing the challenges of malnutrition and provide leadership and resources for the response?Is there clarity (in legislation and in practice) over roles and responsibilities for providing leadership, co-ordination and services?Is there a comprehensive nutrition strategic action plan for the city, (covering demographics, epidemiology, assessment, response, govt responsibilities, infrastructure)?

Is there a good quality resource mobilisation plan for funding child nutritional needs in the city? Are there publicly committed targets, objectives, rights and responsibilities for programmes and services to address malnutrition and mitigate impact on young children?Are appropriate and sufficient indicators being monitored with robust systems to measure child malnutrition and guide the response at municipal level?Is nutrition integrated into the city development plan and mainstreamed across sectoral development plans for the city (i.e. with situation analysis, impact assessment, activity plans, and resources)?

Are there specific municipal programmes within strategies of MoH, NGOs and key development partners?Has the municipality exploited opportunities to partner with other community stakeholders, including business, to deliver programmes and services.How effective is the municipality's co-ordination and partnership with other national and international bodies, including MoH, development partners and INGOs

15Research strategy Phase 1 Situational Analysis; randomisation into experimental and control groups; baseline data collection; open- space meeting and formation of a multisectoral Urban Nutrition Working Group (UNWG). (0-8 months) Phase 2 The UNWG participate in 3-cycles of action research: Reflect-Study- Plan- Act (and monitor) (9-30 months ) to develop a multisectoral action plan (What needs to be done differently to introduce change?), implement, monitor and continually improve the plan. Phase 3 Follow-up data collection and analysis; writing up and learning lessons. (27-36 months)

The action research process is supported by a series of 4, 6-monthly workshops during which the UNWG are focusing on multisectoral governance actions to strengthenthe leadership and structures in place for innovative strategic planning to reduce child malnutrition,resource mobilisation and accountability, the governmental framework for co-ordinating the operational response through different agencies, sectors, non-state actors, and development partners.

Some of the questions addressed during the first action research workshopWhat are our values, beliefs, and priorities in relation to undernutrition? How can we make a difference? How can our actions be different when many others have failed to reduce under nutrition? What habits or ways of working do we want to change or transform?What do I have to do to make these changes?What does my institution have to do?What are the challenges for public policy on nutrition?

Some of the challengesBringing health-related ministries on board and ensuring participation of disadvantaged groups.Dealing with complexity and creating a safe space to produce innovation by acknowledging and understanding the dynamics of social structure. Clarifying the roles of different sectors and groups; agreeing the role of the health sector and agreeing how other sectors can benefit from work on social determinants, in terms of their own priorities?

Bridging differing understandings between sectors of child malnutrition - and the divergent "language" that different sectors use to describe the issue.Establishing meaningful partnerships for joint ownership of multisectoral work which is committed to the value of equity.Agreeing on what information should be collected to monitor implementation and evaluate outcomes in order to inform policy-making and build accountability?Thinking differently as opposed to doing something differently.

Levels of change It aims at thinking differently, as opposed to simply doing something differently.

Thinking differently requires -

Some of the governance strategies that might be adopted by the UNWG groupStrengthening existing and building new more effective institutions, partnerships and processes of governance and local stakeholder control so that sectors take responsibility for a fairer distribution of health outcomes and pursue health and wellbeing as a common goal: Health in all policies. Funding and minimizing legal barriers on NGOs and building their governance capacity to engage and act.Micro-governance initiatives and institutional innovations that devolve power to stakeholders and mobilize the resources and capacities of communities that currently have no real access to governance.

Networking governance institutions to increase resources and power of advocacy (and shaming) and using these strategies as well as regulations and taxes and the media to combat the power of the multinationals and influence up-stream national policies (e.g. to reduce poverty, raise womens status, increase food security and access to public services) and resources.Having a responsive regulatory strategy based on responding to peoples problems, environments and demands, which has the capacity to learn and openness to new information. This requires human resources with appropriate skills and knowledge, and a learning environment to allow policy innovation and resolution of conflicts.

Thank you

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