Moving forward health equity: implementation research on governance for health equity at local level.

Abstract

BACKGROUND: Urbanization is one of the leading sociodemographic trends of the 21st century, which makes urban areas one the most important settings for tackling current and new global challenges. In fact, the importance urban health has been increasingly recognised for its central role shaping public health globally. In this context, an equity-promoting urban governance offers a window of opportunity not only to face these challenges, but also to be part of the solution. Policy coherence, accountability and social participation have been identified both as drivers of health equity and key dimensions of governance for health equity.OBJECTIVE: The fundamental question that underlies this research is how local health strategies can drive forward an equity-promoting urban governance for health. This thesis aims to describe the urban governance for health context in three urban case studies, and to appraise and comparatively analyse how the key dimensions of governance for health equity have been incorporated within local health strategies. Moreover, the thesis assesses the main barriers and facilitators of the implementation of equity-promoting local health strategies. ,METHODS: This is a qualitative-based implementation research, which employs a multiple case study method to in-depth examine the local health strategies of Bilbao, Barcelona and Liverpool. Participant observation, document analysis and 27 in-depth semi-structured interviews among technicians, managers, decision-makers and other local actors were conducted. The key dimensions of governance for health equity were assessed: 1. Policy coherence was analysed using an adaptation of the Storm's Maturity Model for HiAP; 2. Accountability was assessed using the Ebrahim and Weisband¿s proposal and the corresponding domain of the PAHO Equity Commission's rubric for accountability; 3. Social participation was analysed using the Health Canada¿s Public Involvement Continuum model. To assess the barriers and facilitators of the implementation processes the Consolidated Framework for Implementation Research was used. In addition, to contrast and validate the comparative analysis results, 16 experts in the field of governance for health, health equity and implementation science were interviewed.RESULTS: There were significant variations in the levels of maturity of policy coherence, accountability and participation across the local health strategies explored, being more developed in the cases of Barcelona and Liverpool, and somewhat more incipient in Bilbao. The heterogeneity of the governance for health strategies revealed that there is no one-size-fits-all type of strategy that fosters health equity. However, there are elements in common that can act as enablers of an equity approach.Regarding policy coherence, the results suggest that a democratic and socially progressive political environment supports the integration of health and equity as a shared value. Likewise, the establishment of legal and regulatory frameworks such as public health laws or strategic government plans can provide an umbrella for the institutionalization of a social model of health. Specifically with regard to local health strategies, these seem to be more operative when they involve multi-level policies, as they enable more easily the establishment of structures and resources for intersectoral action for health, the use of decision-support tools, and the development of individual and institutional capacities, which are key elements for its implementation. Building synergies with other programs and networks can also foster the implementation of policy coherence at the local level.With regard to accountability, a human rights-based approach to health combined with structures, mechanisms and processes for accountable governance can foster transparency and answerability, but also compliance and enforcement. Accountability in local health strategies can be operationalized through Public Health Observatories with a technical profile and a sufficient degree of autonomy from the political level. Ensuring continuous and inclusive monitoring and evaluation, an availability of openly available disaggregated local data as well as the generation and transfer of applied knowledge are also key enablers of accountability at the local level.Regarding social participation, a more horizontal model of governance involves promoting deliberative capacity and the decentralisation of power through the establishment of a variety of processes, mechanisms and instruments that encourage the participation of all social groups. It is key ensuring an inclusive and representative participation and incorporate social participation as an essential part of the whole policy circle. Local health strategies should strive for leadership by and for the community, including specific actions for the development of participatory skills and capacities for both the population and local government.CONCLUSION: The results highlight that progress in the implementation of equity-promoting local health strategies requires the inclusion of equity as a general value and as a specific policy objective through goals to reduce inequalities, but also through goals to strengthen and operationalise policy coherence, accountability and social participation. This implies moving from short-term, fragmented or isolated policies to a comprehensive set of policies that place equity at the centre. Effective policy action to respond to the global challenges cannot fit into low-cost policy options that fits within electoral cycles. Health inequalities will only be reduced as a result of substantial political change; moving forward policy coherence, accountability and social participation into local health strategies can foster the creation of arenas to challenge the distribution of power.