Surinder Aggarwal, University of Delhi, Delhi, India

Presentation Title: Acting on social determinants of health to promote healthy urban settings




Urban areas in developing countries are developing quickly and in a haphazard manner, with little care for resulting environmental and social damages. Accompanied with these impacts are critical changes in lifestyles, social fragmentation and the growing burden of urban poverty. As a consequence, urban residents suffer from the burden of communicable and non-communicable diseases. Health outcomes of such changes are clearly reflected through changing health transitions and rising health inequities. The challenge lies in taking the appropriate actions to promote healthy urban settings. In this study, the Social Determinants of Health (SDH) approach, promoted by the WHO in 2008, was applied to address such health issues, as well as the urban HEART method to tackle health inequities in the urban settings of selected Southeast Asian cities and India in particular. With the case study of Ahmedabad, India, this study demonstrated how empowerment of poor, self-employed women translates into better health outcomes through environmental improvement, better housing, and low-cost health care.

Key Lessons Learned

  • Action on social determinants of health (SDH) is an approach for achieving health equity within and among countries.
  • The study on Self Employed Women Association of India (SEWA) in Ahmadabad was considered a good example of how empowerment (as a major social determinant) of more than one million slum women in India and abroad brought structural changes in their living and working environments, income generation, child enrollment in schools and health situations through this approach.
  • Understanding the structural pathways of empowerment such as distribution of power, income, goods and services, circumstances of people’s lives (access to health care, schools and education, conditions of work and leisure, state of housing and physical environmental changes) and their links with health outcomes is crucial for producing and creating good health. Social justice is a matter of life and death for the vulnerable communities living in informal settlements. These emerge as the best determinants of health from the SEWA study while capacity building, partnership, networking and self-reliance remain the primary instruments of change.
  • Providing financial security, basic health insurance, intersectorality, community participation, social networking, institutional building like forming cooperatives (housing, health, environmental), building alliances with different stakeholders and self-reliance can deliver low-cost health solutions.
  • Committed and well-managed institutions like SEWA can mitigate environmental change-linked health impacts on marginalized communities living in hazardous settings. Their approach and actions of 'empowerment and capacity building' can be aptly applied towards improved health outcomes under GEC scenarios.

Knowledge Gaps and Needs

  • Emphasis is needed on issues of linking health with degraded and/or shrinking urban ecosystems.
  • How to promote and regulate Asianurbanization, especially in China, to make it environmentally sound and socially inclusive?
  • To understand the specific impacts of the activities of institutions like SEWA, a more comprehensive and scientific study with a large database and more spatial coverage needs to be undertaken.
  • Is a holistic approach that links economic benefits with social gains like health more acceptable to poor families rather than a program that focuses on a single issue?
  • Promote the SDH approach and actions through evidence gathering, dissemination, monitoring and advocacy, and integration of health equity in all policies.
  • Engage researchers and research institutions to identify and measure health inequities using a Social Determinants Health approach in order to provide the critical evidence required by policymakers and funding agencies to take action.

Policy/Practice Implications of Research

  • Establish national institutional mechanisms to coordinate and manage inter-sectoral action for health, in order to mainstream health equity in all policies, and, where appropriate, by using health and health equity impact assessment tools.
  • Improve the technical capacity of municipalities and corporations to plan, implement, measure and evaluate health inequities and social determinants of health.
  • Develop, strengthen and reinforce information systems in various sectors and routinely generate data and produce evidence on health inequities (disaggregated by age, gender, ethnicity, etc.) and their determinants to keep the focus on, and monitor progress of, the implementation of policies and programs.
  • Report and share with different constituencies the evidence of health inequities on a regular basis, in order to advocate and sustain inter-sectoral actions.
  • Develop and promote a network of individuals and institutions to facilitate collaborative research, and the distribution of information, experiences and best practices.
  • Be aware of widening health inequities as a result of globalization and urbanization, and advocate for good governance and corporate social responsibilities at the local and global level.
  • Health development models and the Health Improvement Index, as developed in this study and based on the SEWA experience, can be adapted for other communities in different settings.
  • Social determinants of health need to be addressed through strong local governance.