REGIONAL COMMITTEE Fifty-third Session
Provisional Agenda item 8.1 SEA/RC53/19 2 September 2000
RECOMMENDATIONS ARISING OUT OF THE TECHNICAL DISCUSSIONS ON HEALTHY SETTINGS
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1.
INTRODUCTION
The Technical Discussions on Healthy Settings were held on 31 Aug ust 2000 under the chairmanship of Dr B.D. Chataut, Director-General, Department of Health Services, Ministry of Health, Nepal. Mr Ibrahim Shaheem, Director, Disease Control and Prevention, Department of Public Health, Ministry of Health, Maldives, was elected Rapporteur. The agenda and annotated agenda (SEA/PDM/M eet. 37/TD/2.1 and SEA/PDM/Meet.37/ TD/2.2 respectively) and the working paper for the Technical Discussions (SEA/PDM/Meet.37/TD/2.3) formed the basis for the discussions. A set of six discussion questions was also circulated which helped in the furtherance of discussions on Healthy Settings. 1.1 Introductory Remarks by the Chairman While welcoming the participants, representatives of the nongovernmental organizations and all others present in the me eting Dr B.D. Chataut, Chairman, highlighted the importance of the subject in the present day context. He said that health is not limited to one sector only; it encompasses environment, education, sanitation and hygiene, advocacy and public awareness programmes etc. He recognized the “healthy settings” viewpoint as a more inclusive way of looking at the present WHO assisted community development programs being promoted in the different countries. He then gave the floor to the participants and representative s of the NGOs for self-introduction. 1.2 Presentation by Dr A. Sattar Yoosuf, Director, Sustainable Development and Healthy Environment, WHO/SEARO Dr A. Sattar Yoosuf (SDE), presented the working paper and introduced the subject. He highlighted the importance of the subject, especially to the developing countries of the Region. He hoped that the topic would be discussed threadbare and the meeting would come out with recommendations in the light of the prevalent situation in the countries of the Region. Dr Sattar in his informative and elaborative presentation explained the meaning of ‘setting’ as a physical or geographically demarcated location, where people live and work. Healthy setting is an approach. A healthy setting is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to support each other in performing all the functions of life and in developing themselves to their maximum potential. He mentioned that “Hea lthy setting” is merely a generic term that takes into consideration the many types of community development actions being undertaken in society at large; which in effect are actions being carried out in community settings. It was mentioned that the health status of any setting is determined more by the quality of the environmental conditions and risk factors than by the health care facilities that are provided. He also clarified the hierarchical nature of settings; one being a subset of the other. These ma y be called contextual and elemental settings respectively. Betterment of health and well-being of community thus become one of the goals of community development. Community development action could be undertaken being either issue -based or target population based, in the form of campaigns, donor
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initiated development projects, government programmes, NGO community efforts or combination of one or more. Target population based community action can be viewed in the form of community development programme, taking up of a slum area, mother and child health, disadvantageous group etc. It will depend upon the needs of the country and how policy makers see the problem. South-East Asia Region has undertaken various community development programmes in the form of (a) metropolitan environment improvement programmes; (b) Sarvodaya in Sri Lanka; (c) Adipura in Indonesia; (d) model village in Bhutan,; (e) basic minimum needs action in Thailand; (f) cooperative group housing; (g) Grameen bank and other micro-credit in Bangladesh; (h) Gonashasthya Kendra in Bangladesh; (i) Sulabh in India etc. The concept of healthy settings is of concern to WHO due to public’s health, urban health and various managerial factors. Health promotion constitutes a preponderance on the public’s health rather than on individual health; focus on causes of ill health; use of multitude of approaches; active participation of public, and ensuring the critical role of PHC staff. The success of the programme will largely depend upon the good strategic planning, and issue prioritization, effective managerial mechanisms, and involved community participation. Certain constraints were seen in the proper implementation of the healthy settings. They included lack of awareness of concept, weak planning and management, weak coordination and team-work, low advocacy focus, unrealistic time frames, turnover of government staff and NGO-Government distance. The other constraints to sustainability included non-involvement of the community, lack of external resources, over-dependence on specific individuals, and the project-based nature of work. The challenges beyond the technical aspects relate to the lack of political commitment, partnerships and decentralization. The overall aim of a “healthy district” approach would constitute strengthening the country capacity for integrated management, promotion of health systems research and demonstration of the effect of technical inputs being used. 2. DISCUSSIONS
Ø It was agreed by the participants that a resolution on the Healthy Settings approach to health promotion should be proposed for adoption by the 53 rd Regional Committee meeting.
Ø Participants considered that although the term "Healthy Settings" is new, the concept and practice of the elemental components of healthy settings has already been demonstrated in numerous health promotion projects in countries of the South-East Asia Region, such as healthy cities projects, healthy schools projects, healthy islands, healthy marketplaces, healthy workplaces etc. Therefore the concept is already well known and widely accepted at the country-level.
Ø It was discussed that a district is the lowest politically demarcated geographical entity with its distinct administrative infrastructure and
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decentralized government, where peripheral development sectors are present. A district will encompass various smaller settings such as villages, markets, schools, hospitals, health centres, offices, etc. Therefore, a healthy district could be an umbrella for various healthy settings.
Ø It was agreed that political commitment, partnerships between governmental and non -governmental organizations, and community participation are necessary for the success of healthy settings-type projects.
Ø There should also be proper coordination mechanism between the different stakeholders in healthy settings projects and programmes. Sanitary engineers, scientists, media people, architects, community at large, politicians, religious leaders, etc. should as such meet regularly for achieving the planned goals.
Ø It was agreed, however, that the goals of healthy settings projects and programmes cannot usually be achieved within a short timeframe. Sustained effort over a prolonged period of time is required.
Ø Participants discussed that in many countries, decentralization facilitates local collaboration in healthy settings projects. Model village or model basti projects have been successfully implemented in a number of countries. Integrated mangement and coordination of larger scale projects, such as healthy cities projects, is more complex and requires greater effort.
Ø Many developing countries also face, participants were aware of the various difficulties in adopting the healthy cities concept as it is practiced in the European Region. European cities generally enjoy more developed physical infrastructure and a more stable population base. It is easier to achieve a healthy supportive physical environment since this is largely a matter of single-sector infrastructure development. Building supportive social environments requires multi-sectoral collaboration.
Ø Some of the common challenges that have been noted in healthy settingstype projects in SEAR countries include high turnover of government personnel, a culture of verticalism and weak coordination, insufficient community participation, poverty and ignorance.
Ø Countries will require external support in order to strengthen and expand the healthy settings approach to health promotion. Such support should be primarily technical.
Ø
While initial seed money from donors may be useful in initiating projects, other fund raising mechanisms should be sought for sustaining projects. Dependency on donor-financing compromises the sustainability of projects. Sometimes, fee for services, charity and donations, private sector support, self-help approach, cross-subsidies, establishment of cooperatives and micro-enterprises, micro-credit, and volunteerism should be considered.
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Ø Although many healthy settings-type projects have been implemented and are on -going in SEAR countries, the aim now should be to institutionalize the concept as a national programme in all countries.
Ø Participants agreed that basic water supply and sanitation is a priority issue in virtually any setting in SEAR countries. A diagnosis of needs in most healthy settings projects and programmes will inevitably give emphasis to this area.
Ø Participants also agreed on the extreme importance of air pollution issues in creating healthy settings, not only with respect to urban air quality but indoor air quality in rural settings even more so. Other health issues considered by the participants to be important for achieving healthy settings in SEAR countries include food safety, vectors control, solid and hospital waste management, malnutrition, diaerroral diseases, illicit drug use, alcohol and tobacco use, HIV, TB, etc. However, these have to be addressed on priority basis. 3. RECOMMENDATIONS
Ø Member states should each identify a pilot district where a Healthy District project may be undertaken using the Healthy Settings concept, and should establish the necessary infrastructure to manage such a project by the end of year 2001.
Ø Member states should give priority to strengthening human resources capabilities for managing Healthy Settings projects, and should advocate intersectoral action for health towards strengthening future application of the primary health care approach at the district level.
Ø Member countries should strengthen the capacity and active involvement of communities, NGOs, the private sector towards healthy settings approach, particularly in the areas of priority settings, monitoring and evaluation of projects.
Ø Member countries should build an existing mechanism of local intersectoral management approach such as municipal councils, district and community development committees, for the planning, implementation, monitoring and evaluation of healthy district projects.
Ø WHO should provide technical support to Member States in advocating healthy district using healthy settings approach at national level. Strategic advocacy will generate collaborative supports from national level to the implementations at district level.
Ø WHO should provide necessary technical support to Healthy District projects in countries, particularly in the areas of project planning, capacity building, monitoring and evaluation. A priority action should be to extract lessons learned from current healthy settings-type projects, both successes and failures.
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Ø WHO should support the development of healthy settings management information systems and assist with networking among the various Healthy District programmes in the member states.
Ø The 53rd Regional Committee meeting should consider a Resolution in support of the foregoing recommendations.