Framing concepts and debates: urbanisation, migration, urban health equity and HIV

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Framing concepts and debates: urbanisation, migration, urban health equity and HIV

  1. 1. Framing concepts and debates:urbanisation, migration, urban health equity & HIV 5th Annual HIV-In-Context Research Symposium Urbanisation, Inequality and HIV School of Public Health, UWC, 13th March 2013 Jo Vearey, PhD Liz Thomas, PhD African Centre for Migration & Society Centre for Heath Policy, Wits University of the Witwatersrand Medical Research Council jovearey@gmail.com liz.thomas@wits.ac.za
  2. 2. Aims1. To explore the interlinked challenges of urbanisation, migration, inequality and HIV in South(ern) Africa: key concepts, trends.2. To apply a social determinants of health lens to unpack the complexity of the urban context: upstream determinants and downstream consequences.3. To provide suggestions for developing improved responses to urban health: a focus on understanding and responding to the complexity of the urban context.4. To summarise the key issues for consideration in this symposium.
  3. 3. The social determinants of health:socioeconomic and political context; structural determinants; intermediary determinants HIV Migration and mobilityUrbanisation The urban poor Overlapping vulnerabilities: gender; food insecurity; lack of cash; living on the periphery; struggle to meet basic needs Inequality Inequity in the city in the city Access to positive determinants of health in the city: basic services; healthcare; housing; education; secure livelihood activities; food security Governance (response): healthy urban governance; intersectoral action; health in all policies; developmental local government
  4. 4. What is urban?• No standard definition of urban• Countries differ in the way they classify population as "urban” – Population size • A population of > 2,000 is often considered urban. – Population density – Provision of public utilities and services – Percent population not dependent on agriculture – Type of local government – Presence of administrative centres
  5. 5. What is urbanisation?• Growth in the proportion of a population living in urban areas: 1. Rural to urban migration. 2. Natural population growth of existing urban population. 3. Reclassification of rural areas into urban ones (changing definitions).• Urban v’s rural in South Africa – Lack of clarity – Continuum v’s dichotomy – Population density; access to services; economic activities • Urban, semi-urban, peri-urban, rural
  6. 6. Urban Agglomerations in 2009 (proportion urban of the world: 50.1%)Source: United Nations, Department of Economic and Social Affairs, Population Division: WorldUrbanization Prospects, the 2009 Revision. New York 2010 6
  7. 7. Urban Agglomerations in 2025 (proportion urban of the world: 56.6%)Source: United Nations, Department of Economic and Social Affairs, Population Division: WorldUrbanization Prospects, the 2009 Revision. New York 2010 7
  8. 8. Urbanisation levels per province (2001) Kok and Collinson, 2006
  9. 9. South(ern) Africa is associated with historicaland contemporary population movements. – Internal > cross-border – Heterogeneity – Spatial variation
  10. 10. 44% of 28.1% of 4.4% of the Gauteng’s Western Cape’s South Africanpopulation were population were population were born in a born in a born outside of different different South Africa province province 2,199,871 people were born outside of South Africa Census 2011
  11. 11. Percentage of international migrants living in urban settlement by District Municipality
  12. 12. 7,4% of Gauteng’spopulation are non-citizens3.3% of Western Cape’s population are non-citizens 3.3% of theSouth Africanpopulation are non-citizensCensus 2011
  13. 13. HIV Migration and mobilityUrbanisation The urban poor Overlapping vulnerabilities: gender; food insecurity; lack of cash; living on the periphery; struggle to meet basic needs Inequality Inequity in the city in the city
  14. 14. The urban poor (Mitlin & Satterthwaite, 2004: 15) • Inadequate and often unstable • Inadequate provision of basic income; services, including health services; • Inadequate, unstable or risky asset • Limited or no safety net, such as base; access to grants*; • Poor-quality and often insecure, • Inadequate protection of poorer hazardous and overcrowded housing; groups’ rights through the law; • Inadequate provision of ‘public’ • Poorer groups’ voicelessness and infrastructure (as this increases the powerlessness within political health burden); systems and bureaucratic structures.* It is important to recognise that the South African situation is different to many low-income country contexts. InSouth Africa, a social welfare system exists that includes: disability grants, child support grants, child foster caregrants, care dependency grants and old-age pensions.
  15. 15. Urban inequality: urban inequities in health 0.76 0.75 0.75 0.74 0.74 0.74 0.73 0.72 0.72 0.72Gini coefficient 0.72 0.7 0.68 0.67 0.66 0.64 0.62 rg n rg th an n d wn ia ei do an bu bu e or b nt To ab on ur R et es itz fo iz e D Pr st L nn m ar ap El Ea st oe m ha C Ea rt er Bl Po Jo et Pi (Figure adapted from UN-HABITAT, 2008: 72)
  16. 16. Urban informal settlements and HIV
  17. 17. Percentage of households by dwelling type What’s missing? How to define informal: land tenure? Access to services? e.g. GP – 5% drop in informal (24% - 19%) StatSA, 2012
  18. 18. Urban informal settlements
  19. 19. Urban informal settlements:overlapping vulnerabilities = inequities in health food fragile insecurity livelihood activities HIV gender access to housing services density
  20. 20. Higher HIV prevalence in urban informal settlements25201510 Urban Informal Urban Formal 5 0 HSRC 2002 HSRC 2005 HSRC 2008 MRC MRC THUSA NW SA SA SA Buffalo City Capricorn Wkp EC DM Wkp Lp Thomas, 2011
  21. 21. HIV by quintile?• What do we know?• What are the implications for new policy and action?
  22. 22. HIV in urban SA by quintile100% 3 11 90% Richest 5 80% 70% 32 4 60% 3 50% 27 2 40% 30% Poorest 1 65% 20% 38 65% of the urban SA HIV 10% epidemic is in the 0% poorest 40% of the populationSource Cleary et al 2011 HIV
  23. 23. Developmental response to HIV requires:addressing understanding and act: upstreamNeed to the upstream drivers and the downstreamdrivers andconsequences of infection downstream consequences of HIV infection Upstream Downstream Consequences individual, of infection, household, HIV wellness, mitigate impacts community, macro - infection at individual, household, community, structural health system economy etc
  24. 24. HIV in slum settings (Grief et al 2010) Upstream Downstream issues / impacts Age of debut Wellness/ HIV Physical progression environment Riskier Low sex Social condom WHY? Treatment use transmission environment Economic Rights and environment Dignity MSPSLUM SETTING Structural inequities Deprivations, gender, education, market forces ,global & macro policies
  25. 25. Ranking of urban HIV epidemics (ESA) among national epidemics Est. number Adult Est. number Adult PLHA (2007) PLHA (2007) 1 South Africa 5,400,000 21 Ghana 250,000 2 Nigeria 2,400,000 22 Myanmar 240,000 3 India 2,300,000 Maputo Maputo 220,000 Gauteng Gauteng 1,550,000 23 Carribean 220,000 4 Mozambique 1,400,000 24 Mexico 200,000 5 Kenya 1,400,000 Lusaka Lusaka 185,000 6 Tanzania 1,300,000 25 Angola 180,000 7 Zimbabwe 1,200,000 26 Chad 180,000 8 USA 1,100,000 Nairobi Nairobi and Dar 180,000 9 Zambia 980,000 Dar Es Salaam 180,00010 Russian Fed 940,000 27 Swaziland 170,00011 Ethiopia 890,000 28 Colombia 160,00012 Malawi 840,000 Port Elisabeth Port Elizabeth 155,00013 Uganda 810,000 29 Italy 150,000 Durban Durban 730,000 Addis Abeba 150,00014 Brazil 710,000 30 France 140,00015 China 690,000 31 Spain 140,00016 Thailand 600,000 32 Central African Republic 140,00017 Cameroon 500,000 33 Rwanda 130,00018 Ukraine 430,000 34 Argentinia 120,00019 Cote dIvoire 400,000 35 Burkina Faso 120,000 Cape Town Cape Town 315,000 36 Togo 120,00021 Vietnam 290,000 Kampala Kampala 110,00022 Botswana 280,000 East London 105,00023 Indonesie 270,000 …20 Lesotho 260,000 Pakistan 94,000 Harare Harare 260,000 Bulawayo 90,000 UK 77,000 Source: Luanda 70,000UNAIDS 2009 Henk van Renterghem
  26. 26. Nairobi, Kenya Inner city variation / epidemic patterns Higher prevalence in more densely populated neighborhoods / slumsKibera : estim.HIV prevalence16% 19/03/2013 HIV and slums UNAIDS and UN-HABITAT discussion paper CHP Academic meeting Jan 2011 27
  27. 27. Clinics in Buffalo City – percentage of all HIV tests positive varies within city –(green circles) shown with population
  28. 28. 12 Urban focussed strategies 100.0 districts Very high HIV and high 12 districts Low HIV and High urbanisation eg Metros urbanisation – many in – mainly Gauteng and Response to HIV in urban TARGET INFORMAL SETTLEMENTSandUrban 80.0 Western Cape - strategy KZN- prevention areas needs to vary based on prevention mitigation – urban informal focus the characteristics of the 60.0 district : Series4 6 districts Population shifts , HIV 21 districts 40.0 epidemic, informalRural Low HIV and low Very high HIV and low settlements, poverty, econom in urbanisation – Northern urbanisation – many Cape - strategy KZN rural – prevention 20.0 prevention y – ie KYE mitigation/ rural and development Rural focussed strategies 0.0 Low 0.0 5.0 < 25 ANC HIV prevalence > 25 10.0 15.0 20.0 25.0 30.0 35.0 High 40.0 45.0
  29. 29. The social determinants of health:socioeconomic and political context; structural determinants; intermediary determinants HIV Migration and mobilityUrbanisation The urban poor Overlapping vulnerabilities: gender; food insecurity; lack of cash; living on the periphery; struggle to meet basic needs Inequality Inequity in the city in the city Access to positive determinants of health in the city: basic services; healthcare; housing; education; secure livelihood activities; food security
  30. 30. The social determinants of health Living environmentUrbanisation Broad social and economic determinants Inequality Socio economic status, eg HIV social class Behaviour Medical interventions Migration gender, education, income etc Treatment Source: Closing the Gap: policy into practice on Social determinants of Health , 2011, Brazil, quoting from Solar and Irwin 2010
  31. 31. The social determinants of health:socioeconomic and political context; structural determinants; intermediary determinants HIV Migration and mobilityUrbanisation The urban poor Overlapping vulnerabilities: gender; food insecurity; lack of cash; living on the periphery; struggle to meet basic needs Inequality Inequity in the city in the city Access to positive determinants of health in the city: basic services; healthcare; housing; education; secure livelihood activities; food security Governance (response): healthy urban governance; intersectoral action; health in all policies; developmental local government
  32. 32. Healthy urban governance• What’s needed? – A clear understanding of HIV as a development issue – Need for integrated prevention strategies and responses at multiple levels – Intersectoral action (ISA)• Missed opportunities? – National Planning Commission – National Strategic Plan: SANACs; PAC; DACs; LACs – Integrated Development Plans – District Health Plans – Developmental local government
  33. 33. Urbanisation, inequality and HIVUnderstanding the complexity of Responding to the complexities of the urban context the urban context • Healthy Urban Governance• HIV as a developmental issue – More than government – Interdisciplinary research – An enabling policy environment – > biomedical response – Developmental local government – Address inequity• Social determinants of health – Overlapping vulnerabilities • Multi-sectoral action and multi- level responses – Short-term (humanitarian); long-term• Spatial approach (developmental) – Different spheres of government – Intra-urban – Who takes a lead? Role of health sector? – Urban penalty v’s urban advantage – Alignment of sectoral plans: common understanding to inform responses• Know your epidemic; Know your response (KYE, KYR) – Local responses
  34. 34. The social determinants of health:socioeconomic and political context; structural determinants; intermediary determinants HIV Migration and mobilityUrbanisation The urban poor Overlapping vulnerabilities: Commission 3: gender; food insecurity; lack of cash; living on the periphery; spaces of vulnerability to meet basic needs struggle Inequality and opportunity Inequity Commission 2: Commission 1: in the city falling city in the people on the between the move cracks Access to positive determinants of health in the city: basic services; healthcare; housing; education; Commission 5: secure livelihood activities; food security dignified Commission 4: politics human of participation and representation Governance (response): settlements healthy urban governance; intersectoral action; health in all policies; developmental local government

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