Building Healthy Cities – Urban Planning
as a Tool for Health
Fifth Global Symposium on Health Systems Research
October 9, 2018
Dr. Damodar Bachani, JSI India, BHC Deputy Project Director
Dr. Ahmad Isa, IOM Makassar, National Migration Health Officer
Kim Farnham Egan, JSI, BHC Program Officer

Outline
• Introduction to Building Healthy Cities
• Engaging the System: A systems mapping approach
to increase data use and inform planning
• Indore, India
• Makassar, Indonesia
• Q&A
• Group activity
• Facilitated discussion of group activity outcomes
• Closing

USAID’s Building Healthy Cities
Project: Urban Planning for
Health

Building Healthy Cities Project
• Three Year Learning Project (2017 – 2020)
• Partner Smart Cities:
• Indore, Madhya Pradesh, INDIA
• Makassar, South Sulawesi, INDONESIA
• Da Nang, VIETNAM
Evaluating and Documenting a New Model for Urban
Health

Expected Inputs & Results
IR1: Increase opportunities for
all citizens to voice demand
for healthy cities
IR2: Increase availability
of data influential to
policy decision-making
IR3: Create a health-
aware management
model across sectors
IR4: Document how
replicable & sustainable this
model is for other cities
Increased equity of city
services
More SDH-sensitive city
plans, policies, funding
Greater citizen
engagement in building
healthy communities
Usable, relevant
information on
scalability

Healthier urban environments improve citizens’ quality of life, reduce
health costs and mortality
Clean & Rapid Public
Transport Green Built Environment
Facilities for Physical Activity
Dedicated Pathways
Defining Smart, Healthy Cities

The Rainbow Model
What are Social Determinants?

Engaging the System:
A Systems Mapping
Approach to Increase Data
Use and Inform Planning

How We See Social Issues
Cloud-type Problems
(Disorderly & Irregular)
E.g. Problems are poorly
structured and still
emerging; many related
issues and limitations,
solutions not yet defined
and often a matter of
stakeholder judgment.
Clock-type Problems
(Predictable & Rational)
E.g. Problems are well
understood, there exists
clear steps for
diagnosing the
problem, and with well-
known best practices
for implementation.
Adapted from “Introduction to a Systems Practice” by The Omidyar Group Licensed CC BY-SA

Systems Practice Helps with Cloud
Problems
Resisting applying “clock-like” fixes to “cloud-like”
problems
Work across stakeholders to find methods and tools that
will describe the “cloud” problem and find effective
solutions
The challenge:
Adapted from “Introduction to a Systems Practice” by The Omidyar Group Licensed CC BY-SA

Narrow Individual vs
Broad and Public Health
Source: https://www.youtube.com/watch?v=t_eWESXTnic

So, What is ‘Systems Practice’?
Systems practice = the practice,
processes, and tools that allow
organizations (and cities) to effectively
address adaptive challenges in
complex environments.
Adapted from “Introduction to a Systems Practice” by The Omidyar Group Licensed CC BY-SA

Key Practices
Four practices will increase effectiveness
when working on adaptive problems in
complex environments:
Seek overall health, not just completed indicators
See patterns, not just problems
Unlock change, don’t force it
Plan to adapt, don’t stay the course if it isn’t working
Adapted from “Introduction to a Systems Practice” by The Omidyar Group Licensed CC BY-SA

Key Processes
Challenge
Build urban health strategies that can
work with complex city systems.
Approach
Find common incentives for
stakeholders to work together across
city systems.
Opportunity
Find agreement on the purpose,
process, and approach, while building
capacity across urban planning and
health.
Adapted from “Introduction to a Systems Practice” by The Omidyar Group Licensed CC BY-SA

Tools: Dynamic System Mapping
• This map can help to make sense of a huge amount of
information and how it all connects
• Help to develop a theory on where “best buys” interventions
might be (e.g. those that improve multiple issues)
• Help to establish a visual framework for shared activities,
learning and adapting
Adapted from “Introduction to a Systems Practice” by The Omidyar Group Licensed CC BY-SA

Systems Mapping
Experience:
Indore, India

Data Validation
& Systems Mapping Workshop

Steps in Systems Mapping
Community-based and qualitative assessments
• Health Needs Assessment
• Data Use & Access Assessment
• Political Economy Analysis
• NCD Risk Factor & Environment Survey
1. Share data validation cards: Barriers &
Enablers
2. Identify key barriers and enablers
3. Conduct upstream downstream analysis
4. Analyse and explain patterns and
connections
5. Construct systems mapping loops

Services for Underserved Populations
Enablers
• Informal settlements located close to
middle-class neighborhoods benefit
from improved city services and
infrastructure.
• Social protection schemes including
ration cards, old age pension, Aadhar
program, health schemes, employment
schemes, housing assistance, skill
training, disability pension.
• Interest in participating in community
incentives for physical activity/exercise.
• Smart Cities engaged community
groups on issues of waste management
and in some cases, sanitation.
Barriers
• Dangerous conditions in neighborhoods -
poor drainage and infrastructure for storm
and waste water, narrow roads and lanes,
unsafe pedestrian infrastructure.
• Lack of land rights for informal settlements
and housing tenure for those with
undocumented status.
• Low knowledge of social protection schemes
among lower income brackets.
• Many UPHCs and Anganwadi centers are not
accessible for these communities, due to
distance and operating hours.
• In informal settlements, focus on and
understanding of healthy environments was
limited to immediate risks.
• Understanding of the long term risks of
malnutrition, tobacco chewing, smoking, and
alcohol consumption was low.
• Lack of continuity of care and low
compliance with clinical care
recommendations for chronic disease.
Step 1
Data Validation Cards: Example

Groups write their responses to these questions
using worksheets:
Step 2
Identify Key Barriers and Enablers: Format

Rank Barriers n= 20 %
1
High vacancies among Urban PHCs, ASHAs and other primary
health workers.
16 80
2
Five sectors are not included in Smart Cities – 1) ICDS, 2) pollution
control 3) field publicity, 4) commerce, and 5) health.
12 60
3
Low understanding of the long term risks of malnutrition, tobacco
chewing, smoking, and alcohol consumption.
10 50
4 Lack of training for non-health workers. 10 50
5
Health and service performance data is not shared between
sectors nor is it made public.
9 45
6
Low knowledge of social protection schemes among lower
income brackets.
9 45
7
Dangerous conditions in neighborhoods - poor drainage and
infrastructure for storm and waste water, narrow roads and lanes,
unsafe pedestrian infrastructure.
9 45
8
Task based accountability for better coordination and
management.
9 45
Step 2
Identify Key Barriers and Enablers

Work fast to get lots of
ideas out:
•FIRST: what causes,
enables, amplifies,
bolsters, fosters, leads
to… (THEME)
•THEN: what is the effect
of, what does it lead to,
what results from…
(THEME)
Topic
Number
Team
Member
Names
Adapted from “Introduction to a Systems Practice” by The Omidyar Group Licensed CC BY-SA
Step 3
Conduct Upstream Downstream Analysis: Format

Theme: High vacancies of community health workers at Urban
Primary Health Centers
UPSTREAM DOWNSTREAM
• Overburdened job profiling
• Inadequate number of health
workers
• Lack of recruitment over the
years
• Existing staff over-burdened
• Inadequate incentives
(monetary/facilities)
• Quality of health services
affected
• Low production of doctors from
medical colleges
• Overall healthcare delivery
affected
• Long curriculum
#2
Step 3
Conduct Upstream Downstream Analysis: Example

Step 4
Patterns & Connections

Step 5
Construct Systems Mapping Loops: Example

Interactive map
available on Kumu

Action Points BHC Supported Activities
STRENGTHENING PUBLIC HEALTH
Strengthening Urban PHCs and civil
dispensaries
Mapping and situation analysis of primary health care facilities
Training needs assessment
Organizing and conducting training of health care personnel
Support ISCDL for developing
network of health ATMs
Identify strategic location of health ATMs
Tools for monitoring of their utilization
Universal health care for urban poor Participatory research in urban poor settlements
Screening for lifestyle diseases Identify public health care facilities for screening program
Training health care personnel on screening procedures
Plan and conduct screening of lifestyle diseases
EDUCATION
Developing health promoting
schools
Develop guidelines on health promoting schools
Prepare tools for assessment of health promoting schools
Baseline and post-training assessment of selected schools
Organize, conduct, and monitor training of teachers
PUBLIC AWARENESS
Developing messages and material
for public awareness on healthy
lifestyles, food hygiene, traffic rules
Organize meeting of experts to identify key messages dissemination
Engage an agency for development of public awareness material
Support ISCDL & health sector in dissemination of material
DATA MANAGEMENT
Improve data management and
analysis for effective monitoring,
planning, and decision making
Developing Hospital Management Information System
Analysis of water pollution data and water-borne diseases
Developing outcome and impact indicators for Smart City Mission
Analyze data to prepare report on health profile of citizens
OTHER ACTIVITIES
Organizing orientation workshop for other Smart Cities
Support for operational & health systems research
Using Systems Mapping in Project Planning & Implementation

Systems Mapping
Experience:
Makassar, Indonesia

Workshop and Agenda
• Held on 13-14 September 2018 in Makassar, Indonesia.
• Attended by 41 participants from 29 departments/organizations.
• Purpose: to hold an interactive discussion among stakeholders
to validate findings from BHC assessments, explore enablers and
barriers, and explore healthy system mapping through upstream
and downstream analysis.
• Sessions: Sharing research findings through a Gallery Walk,
Interactive quiz, Group work.

Key Sectors
Government
Health Institutions
• Health department
• Health service providers
• National health insurance
provider
Non-Health Institutions
• Regional planning agency
• Communication and
informatic department
• Social department
• Civil and registration
department
• Environmental department
• Education department
• Transportation department
• Disaster management
• Community empowerment
office
• Garbage management
• Public works department
• Statistical bureau
Private Sectors
• Communication company
• Property company
• Entrepreneur association
• Health provider
Academia, Researchers, and
Professionals
• University
• Research institution
• Journalist
• Police
Community Representatives
• Community leader (formal and
informal) from sub-district, village,
and remote island
• NGOs and faith-based
organizations
• Diffable association

What worked well?
Workshop Experience
What could have worked better?
• IT support
• Time extension
1. Interactive quiz to gather
participant input
2. Health campaign - stretching
exercise during work
3. Gallery walk to explore different
angles
4. Upstream and downstream
analysis
“Now I understand how systemic
approach and mapping work. We
can explore any health issue deeper,
broader and more comprehensive
considering including socio-cultural
aspect” - Participant from Research and
Development Agency of Makassar City
(Balitbangda Makassar)

What surprised us?
• 83 enablers and 78 barriers explored during gallery walk.
• Data-related issues and health awareness were the barriers participants
most agreed with.
• Public-private partnerships and demand on data and information were
the enablers participants most agreed with.
• Most groups did not agree that the high prevalence of NCDs was
related to lack of knowledge on risky behaviors (smoking, alcohol, etc.).
• Integrated data system (house of data) already
Built, but still empty.
Participant Observations

Barriers and Enablers
Top 3 enabler factors, as prioritized by workshop participants:
1. Collaboration of government, private sector, and communities to support Smart
Cities.
2. Healthy lifestyle movement (Gerakan Masyarakat sehat “Germas”) has been
regularly promoted.
3. Use of technology-based data for decision-making in government institutions
and communities.
Top 9 barrier factors, as prioritized by workshop
1. Lack of awareness of healthy behaviors.
2. Complicated procedures for accessing data.
3. Problems with quality, completeness, and timeliness of data.
4. Low participation in Musrenbang in the neighborhood.
5. Lack of community knowledge (lower income) about health insurance scheme.
6. Lack of data integration between departments and dashboard.
7. Lack of data storage and analysis.
8. Lack of ICT use in remote areas and vulnerable communities (disability, slum
area, poor area).
9. Not all people have easy access to clean water.

Causal Effect - Example 1
Upstream Downstream
Theme: Lack of awareness of healthy behavior
Lack of supporting policies on health
issues
Lack of facilities and infrastructure
Lack of people compactness in the
neighborhood
Lack of knowledge about health
Lack of socialization from government
Social and economic issues
Low level of education
Government program
related to health are not
running well
Uncomfortable environment
(garbage, etc.)
High risk of disease
Lack of accessing health
facilities
Lack of willingness to
behavior change and new
approach adaptation

Upstream Downstream
Theme: Lack of awareness of healthy behavior
Lack of supporting policies on health
issues
Lack of facilities and infrastructure
Lack of people compactness in the
neighborhood
Lack of knowledge about health
Lack of socialization from government
Social and economic issues
Low level of education
Government program
related to health are not
running well
Uncomfortable environment
(garbage, etc.)
High risk of disease
Lack of accessing health
facilities
Lack of willingness to
behavior change and new
approach adaptation
Causal Effect - Example 1

Upstream Downstream
Theme: Lack of awareness of healthy behavior
Lack of facilities and infrastructure
Lack of knowledge about health
Social and economic issues
Low level of education
High risk of disease
Lack of willingness to
behavior change and new
approach adaptation
Causal Effect - Example 1

Theme: Lack of awareness of healthy behavior
Lack of facilities and infrastructure
Social and economic issues
Lack of knowledge about health
Low level of education
High risk of disease
Lack of willingness to
behavior change and new
approach adaptation
Causal Effect - Example 1

Lack of Awareness of
Healthy Behavior
Causal Effect - Example 1

Upstream Downstream
# Theme: Lack of awareness of healthy behavior
Lack of supporting policies on health
issues
Lack of facilities and infrastructure
Lack of people compactness in the
neighborhood
Lack of knowledge about health
Lack of socialization from government
Social and economic issues
Low level of education
Government program
related to health are not
running well
Uncomfortable environment
(garbage, etc.)
High risk of disease
Lack of accessing health
facilities
Lack of willingness to
behavior change and new
approach adaptation
Causal Effect - Example 2

# Theme: Lack of awareness of healthy behavior
Lack of supporting policies on health
issues
Lack of knowledge about health
Lack of socialization from government
Government program
related to health are not
running well
Lack of accessing health
facilities
Causal Effect - Example 2
Upstream Downstream

# Theme: Lack of awareness of healthy behavior
Lack of supporting policies on health
issues
Lack of knowledge about health
Lack of socialization from government
Government program
related to health are not
running well
Lack of accessing health
facilities
Causal Effect - Example 2

Health Systems Mapping Workshop Makassar, 14 Sept 2018

Questions?

Group Activity

Instructions
• Time: 20 minutes.
• Divide into 3 groups - introduce yourselves and
identify a “reporter.”
• Theme with upstream (cause) and downstream
(effect) factors based on BHC assessments in Indore
and Makassar.
• Discuss and identify causes and effects, and draw
arrows to show your work.
• Add upstream/downstream factors as needed.
• If you have time, create a “loop” using your
identified causes and effects.
• Afterwards, your reporter will summarize your
discussion to the rest of the session (3 minutes).

Upstream Downstream
Theme: Lack of awareness for healthy behavior
Lack of supporting policies on health
issues
Lack of facilities and infrastructure
Lack of people compactness in the
neighborhood
Lack of knowledge about health
Lack of socialization from government
Social and economic issues
Low level of education
Government program
related to health are not
running well
Uncomfortable environment
(garbage, etc.)
High risk of disease
Lack of accessing health
facilities
Lack of willingness to
behavior change and new
approach adaptation
Example

Theme: Lack of awareness for healthy behavior
Lack of supporting policies on health
issues
Lack of knowledge about health
Lack of socialization from government
Government program
related to health are not
running well
Lack of accessing health
facilities
Example

Theme 1
Theme: Problems with data quality, completeness and timelines
UPSTREAM DOWNSTREAM
• Lack of real time data • Lack of data
• Limited data analysis
• Poor quality of data which
cannot be used/analyzed
• Manual data collection • Out of date data
• Poor/inappropriate data collection
system
• Programs inhibited
• Few training and guidelines for data
management
• Few documented activities
#1

Theme 2
Theme: Neighborhood environmental conditions - poor drainage,
infrastructure for storm & waste water, unsafe narrow roads & lanes
UPSTREAM DOWNSTREAM
• Lack of work at grassroots level for solid
and liquid waste collection and
disposal in some communities
• Water pollution and stagnation
leading to breeding conditions
for mosquitos
• Inadequate infrastructure for drainage
of storm and waste water
• Health problems related to
above conditions
• Value of water not understood by
citizens; Inadequate collection of
water after use
• Low coverage of beneficiaries
due to non-participation
• Encroachment of roads and lanes for
various purposes
• Obstacles in transport system
due to above conditions
further leading to air pollution
• Lack of planning for footpaths and
roads in residential settlements
• Poor drainage may lead to
injuries, accidents
#2

Theme 3
Theme: Low understanding of long-term risks of tobacco and
alcohol use
UPSTREAM DOWNSTREAM
• Illiteracy and lack of awareness about
harmful effects of tobacco/alcohol
• High use of tobacco and
alcohol
• Lack of information-education-
communication to control their use
• Rising prevalence of diseases
attributable to tobacco/alcohol
• Lack of media involvement in public
awareness
• Crime, domestic violence, road-
traffic accidents due to alcohol
• Peer pressure for their use (trial/regular)
• Unnecessary wastage of
resources
• Easy availability of tobacco/alcohol
throughout the city
• Economic loss
• Government considers tobacco and
alcohol products important sources of
revenue
• Lack of stringent enforcement of
regulations to market tobacco/alcohol
#3

Thank You!
Questions or comments? Contact us at:
Dr. Damodar Bachani damodar_bachani@in.jsi.com
Dr. Ahmad Isa aisa@iom.int
Kim Farnham Egan kfarnhamegan@jsi.com
Visit our website at jsi.com/buildinghealthycities