DEVELOPMENT AND IMPLEMENTING URBAN HEALTH EQUITY INDICATORS IN TEHRAN URBAN HEART- TEHRAN On behalf of Urban- HEART Team Tehran CAPACITY BUILDING WORKSHOP ON HEALTH SYSTEM DEVELOPMENT
What is Urban HEART The Urban Health Equity Assessment and Response Tool aims at directing local/ national policy-makers to Identifyy the differences between the health of people living in disadvantaged urban areas and the general population Decide what strategies, interventions/actions should be used to reduce health equity gaps
Content of the original tool 27 indicators in 4 policy domains Physical and infra-structure Social and human development Economic (health) Governance
How disparities are demonstrated in UH? 1. Urban health equity matrix Shows disparities among regions 2. City Health Equity Performance Monitor Describes the trend of an indicator over the year Compare the status of the city with national targets
Workshop on Urban HEALTH, Tehran- April 2008
Indicators Urban Health Equity Assessment and Response Tool in Tehran (Urban HEART) Urban HEART Domains: 1.Physical and infra-structure: 10 indicators 2.Human and social development: 18 indicators 3.Economic: 10 indicators 4.Governance: 8 indicators 5.Health: 10 indicators 6.Nutrition: 9 indicators
Indicators of UH-Tehran Physical and infra-structure 1.Safe drinking water 2.Accidents and injuries (5 indicators) 3.Air pollution 4.Noise nuisance 5.Access to public transport 6.Solid waste management 7.Health centre utilisation Economic development 1. Employment 2. Residency in normal home/ Person/ room 3. Fair Financial Contribution Index (FFCI) 4. Household costs 5. Absolute/ Partial poverty 6. Social Welfare Index 7. Human Development Index Human and social development 1. Education: NER/ GER/ primary school completion/ Higher education (5 indices) 2. Violence: domestic, street 3. Smoking/ addiction 4. Smoke-free places 5. Mental health 6. Social capital Governance (Municipality) 1. Annual reports 2. Contracts transparency 3. Satisfaction 4. Responsiveness (Hot Lines) 5. Community participation (local elections) 6. Lawfulness 7. Standard activities Health 1.Safe delivery 2.Vaccination 3.Early pregnancy 4.Breastfeeding (excl & 24m) 5.IMR/ U5MR/ MMR 6.HRQL 7.Disability Nutrition 1. Calorie poverty 2. Wasting 3. Stunting 4. LBW (IUGR/ NMR) 5. BMI: obesity 6. Food diary 7. Food costs 8. Cereal costs
Main survey Sample size calculation based on pilot findings: 960 households per district: 21120 Training surveyors: 390 in two 2-day sessions Assigning 15 academics for supervision Last for 55 days Data entry completed and editing/ processing is ongoing; mostly delivered to working groups
Home owner
Person per room
Smoking rate among families 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Energy Intake 45% Above 110% calorie 40% 35% 30% 25% 20% 15% 10% 5% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Traffic accidents Percentage
Illiteracy rate Illiteracy 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Distribution of University Education in Tehran?@AB CDEFGH?BIJIK LMNO
Severe violence rate (per 1000) 16 14 12 10 8 6 4 2 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Voluntary help to close family 0.95 0.9 0.85 0.8 0.75 0.7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Divorced women 0.018 0.016 0.014 0.012 0.01 0.008 0.006 0.004 0.002 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Mean Family costs (Non-Food) 12000 10000 8000 6000 4000 2000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
13+ months children with full vaccination 100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Assets Matrix District Home owners Pc Family size Piped water Landline Bath Kitchen Toilet Cell phone Freezer Car Gas supply 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Urban HEART- Tehran
Health Matrix 22 Distri ct Exclusive BF rate Under y Married Suspected to mental disorder Vaccination Over rate U- MR NMR IMR Disabilit y rate Quality of life (Physical) Life expectanc y at birth Safe delivery Early pregnancy -. / 0 1 2 -. / 0 1-2 - -- Urban HEART- Tehran
Social Matrix 23 District Violence rate Severe violence rate Addiction rate Higher education Illiterate!"+ Traffic accidents Percentage Voluntary help Collective activities Trust Friendship and unity Respect to values -. / 0 Urban HEART- Tehran 1 2 -. / 0 1-2 - --
Mental Health and Smoking 24 District Family Smoking rate Male current smoking rate % Female current smoking rate % Female Youth current smoking rate (.-) % Male Youth current smoking rate (.-) % Suspected to mental disorder Somatisati on Anxiety Functioning Depression! & ' ( " ) * +,!-!!!&!'!(!"!)!*!+!, &- &! &&
Economic situation 25 District Male!-+ Unemploym ent rate Female!-+ Unemploym ent rate!--!" Employme nt rate FFCI Catastrophic costs Un-insured family head Non Food Costs Food costs Proportion of Non-Food Costs to total costs Person per room Area per capita Resident in normal home -. / 0 1 2 -. / 0 1-2 - -- Urban HEART- Tehran
Urban Governance 26 District Satisfaction with Municipality services Responsiveness Hotlines Transparency Participation Lawfulness -. / 0 1 2 -. / 0 1-2 - -- Urban HEART- Tehran
Nutritional Matrix 27 /! "# $ % &' 161 29 22 283 479 351 277 01 130 32 26 353 574 390 267 02 166 36 21 361 645 361 246 03 134 35 33 329 548 393 324 04 132 35 29 304 562 309 330 05 149 30 28 378 657 394 286 06 145 40 26 327 483 375 298 07 115 36 27 270 512 370 320 08 109 48 31 296 536 447 350 09 145 54 35 261 424 400 348 10 113 38 27 304 385 362 337 11 143 47 32 286 480 368 332 12 116 38 27 295 462 282 330 13 106 45 26 325 453 305 341 14 116 54 39 262 455 424 341 15 121 42 32 253 347 320 369 16 116 45 37 256 444 357 391 17 130 43 40 227 450 348 389 18 123 49 34 315 498 352 386 19 136 43 30 236 460 356 380 20 139 35 27 287 395 388 390 21 161 41 40 333 597 387 355 22 Urban HEART- Tehran
30 : : 18/5 ن: / : 28 17/8% 32/9% 24/4% 21/0% 32/5% 24/1% 35/1% 35/3% 42/3% 28/8% 36/9% 23/3% 21/5% 31/0% 32/4% 34/7% 33/0% 25/6% 27/0% 30/0% 38/0% 21/2% 45/2% 36/5% 41/1% 42/0% 38/6% 53/2% 35/1% 29/4% 37/2% 33/8% 44/0% 39/5% 45/6% 39/1% 34/1% 47/2% 45/7% 40/2% 41/9% 45/0% 40/5% 49/4% 35/6% 28/2% 34/4% 35/8% 25/3% 21/5% 29/9% 31/8% 19/2% 35/0% 17/9% 33/7% 31/6% 29/9% 30/0% 16/7% 20/2% 34/1% 29/7% 23/8% 21/5% 25/9% RSTUH TUV WX Y@SZB [\]^ WS_`S 1/4% 2/4% 0/0% 1/2% 3/6% 1/3% 0/0% 3/5% 1/3% 2/5% 1/2% 3/5% 1/3% 0/0% 3/5% 1/4% 1/1% 0/0% 1/4% 1/3% 0/0% 3/5%! " # $ %! " # $ %
<70% 70-90% 90-110% >110% 1 25 26.9 32 34.4 16 17.2 20 21.5 2 19 19.2 31 31.3 25 25.3 24 24.2 3 25 25.5 24 24.5 27 27.6 22 22.4 4 11 11.1 22 22.2 29 29.3 37 37.4 5 13 14.0 31 33.3 21 22.6 28 30.1 6 14 14.6 29 30.2 27 28.1 26 27.1 7 17 18.5 26 28.3 14 15.2 35 38.0 8 18 17.8 27 26.7 27 26.7 29 28.7 9 11 12.2 18 20.0 24 26.7 37 41.1 10 8 8.4 24 25.3 24 25.3 39 41.1 11 14 14.4 30 30.9 26 26.8 27 27.8 ن ن! RSTUH TUV WX Y@SZB [\]^ WS_`S 29 12 12 12.4 23 23.7 29 29.9 33 34.0 13 23 24.5 27 28.7 16 17.0 28 29.8 14 16 16.7 22 22.9 29 30.2 29 30.2 15 28 16.6 43 25.4 36 21.3 62 36.7 16 14 15.9 19 21.6 20 22.7 35 39.8 17 13 12.6 21 20.4 32 31.1 37 35.9 18 11 10.4 26 24.5 29 27.4 40 37.7 19 7 7.5 14 15.1 30 32.3 42 45.2 20 10 10.5 25 26.3 22 23.2 38 40.0 21 13 13.4 27 27.8 26 26.8 31 32.0 22 8 8.4 25 26.3 28 29.5 34 35.8 45 330 15.1 566 25.9 557 25.5 733 33.5
Response tool The second part in UH Response could be organised with several approaches: Evidence-based policy making (City Council, Municipality, The Higher Council for Health, The Cabinet, The Parliament) Evidence-based practice (district Mayors) Inter-Sectoral Collaboration Community Based Initiatives
Policy making City Council: During the endorsement of 5-year development plan of Tehran: 2 articles indicated annual assessment of inequalities, using Urban HEART The Parliament Presenting data has been scheduled for different commissions, fractions The MHME: involvement of different sections to extend the plan 40 cities in 2010 (Healthy Urbanisation by WHO) Development of a National Health Inequality Monitoring System Targeting the planning system to diminish disparities is the main intervention for inequality reduction: a major task of the Deputy Mayor for Research and Urban Planning
Following year (2009) district budget according to UH 1.2E+09 1E+09 80000000 60000000 40000000 20000000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Before After UH