An inclusive institutional mechanism, a Steering Committee, was designed by the DMQ Health Department to be a flexible mechanism to resolve issues that come up at the local level and keep communities informed on the work.
A broader intersectoral Technical Health Committee was established with DMQ and external stakeholders’ participation. The DMQ asked each internal agency and relevant departments for a delegate to this technical committee. The Ministry of Health delegated the District Director of Health Promotion,
responsible for work on the SDH; the DMQ Health Department and 20 agencies of DMQ, MoH and PAHO to be involved in the Technical Health Committee.
Community health work teams at the city and neighbourhood level are being formed and trained by DMQ to bring the voice of the local community to the processes. Work teams are made up of members of the neighbourhood (or geographic area selected) with representatives of the DMQ Health Department and the
Secretariat for Territorial Coordination and Citizen Participation. These teams aims to promote participatory work on healthy physical, economic, and social environments.
The community work teams represent the following five sectors of each neighbourhood (or geographical area) and include community representatives from:
1. The community: addressing SDH relevant to the entire community, such as access to natural foods, access to walkable or cycling spaces, smoke-free spaces, or personal safety.
2. Community institutions or organisations:
including those that provide social services such as day care centres, churches, senior centres, community centres, and universities.
3. Local health care: including all places where people come to receive preventive care or treatment or health-related emergency services such as hospitals, clinics, and doctors’ offices.
4. Primary and secondary education: including private and public schools.
5. Workplaces: including private and public workplaces.
Other sectors include opinion leaders of their sector (education, health, etc.) within the parish.
The selection process for interested candidates for the community teams is being led by the DMQ Health Department and is currently underway.
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Mechanisms and processes
The mechanisms are being set up within the context of Municipal Ordinance 102, which outlines the various mechanisms for citizen participation. The leaders of the parish (district/
neighbourhood) level assembly define the process for electing the representatives and the voice and capacity they have in the neighbourhood and district level assemblies.
The establishment of these assemblies was facilitated in Quito by the Secretariat for
Territorial Coordination and Citizen Participation.
There are 65 parish level assemblies that are required by municipal ordinance to meet three times per year.
To generate and implement policies and programs that address health equity in a holistic manner and with participation of the residents, the city is producing, gathering and processing information on health and the SDH to communicate with residents and hear their priorities on the state of health in the different neighbourhoods. Through intersectoral coordination, the existing databases of various DMQ departments are being reviewed.
Surveys are then designed and implemented to collect missing information. The findings are organised as accessible visual charts to show their importance for population health. The work has also used the United States Centers for Disease Control Healthy Communities program.20 DMQ staff are being trained on the methods and on initiatives that impact on health and are also developing a virtual platform to display updated and accurate health data and health determinants information disaggregated by districts of Quito, including slum neighbourhoods21, to make the information publicly accessible.
Residents are involved in and build ownership of the process through their own awareness raising and local ‘priority setting’ workshops that DMQ holds in local neighbourhoods. These workshops use the evidence gathered by DMQ but also address the issues identified by the communities. In 2017 DMQ will engage further with civil society organisations and explore
additional methods for participatory mapping and needs assessment by communities.
The workshops with civil society review the health evidence from DMQ, add or collect additional information of interest to residents, prioritise health problems in each locality and develop a road map with activities for both the neighbourhood and city level. The responses are organised in an intervention proposal that is presented to the mayor for approval and implementation.
Article 87 in the framework of Municipal Ordinance 102 includes a provision for the creation of ‘citizen observatories’. Citizen observatories are made up of groups of citizens or organised civil society from different sectors, for a period of time, with the purpose of evaluating and providing technical recommendations to promote, evaluate, and monitor public policies. This information then supports the policy-making and implementation processes of the different sectors within the municipality that have an impact on health.
DMQ supports the capacity of residents to generate these intervention plans, or Community Health Plans within their health teams (described earlier). The interventions chosen are those that are seen to have high impact, or that draw on examples of promising practices from the region and from national and international evidence, such as from the Ecuadorean Association of Municipalities, the Resilient Cities initiative and from PAHO. DMQ is providing incentive funds of between $2,000 and $5,000 on a competitive basis to promote community involvement in the development and implementation of plans and initiatives for health. It holds events to provide wider community awareness of the findings of the local health situation, and to launch the contest and award.
The local health teams and wider community set their local plans for improvement of health in their neighbourhood, as proposed by key community stakeholders in the neighbourhood, sports associations, collective neighbours and neighbourhood committees. They then submit these to the competition. The district health
Healthy Neighbourhoods – closing the gap in health inequality, City of Quito, Ecuador
teams develop the criteria for receiving the seed funds based on the preliminary analysis of the health issues in their parish, and determine the winner. These funds support initiatives from the community to improve health and raise awareness, and benefit the wider community, rather than a small group of individuals. This initiative is being piloted in areas of the city where there is institutional capacity to implement the model and show results, but the intention is to target the funds towards, and stimulate participation in, those with higher health needs and where there is a need for support for participation in action on health issues.
Another element of the Healthy Neighbourhoods initiative is that of facilitating a community-led certification of ‘healthy spaces’ (such as in fresh food markets and schools) within the municipality. The criteria for school certification are developed by the DMQ Health Department in collaboration with the Ministry of Education, the Ministry of Health and PAHO. In the longer term it is intended that responsibility for certification of these healthy spaces will be delegated to the Community Health Teams.
For food markets, DMQ discusses the standards for health promotion and food safety, and the evidence available. Teams from the community, such as the users of the market from the community, the administrative staff, the workers and municipality assess the markets and develop work plans for health improvements on prioritised gaps in the standards. Similar work is done in schools, and for healthy public spaces selected by community teams such as equipped parks or streets in residential neighbourhoods.
In all cases the participatory action plans are implemented in coordination with relevant actors, and a participatory process is also used for the review.
The certification process aims to support the administrators and users of spaces like markets and schools to prioritise how to best invest limited resources to address those issues that are important to preserve and promote health and to address any gaps identified. It is expected that the initial effort around receiving
a certification will forge a working relationship between the relevant actors to ensure continued improvement of these spaces even after
certification.
The involvement of citizens in the policy-making process, of the different sectors of the City of Quito, creates a powerful incentive for sectoral policies to consider the full breadth of impact they have on Quito inhabitants. Citizens that are empowered with the tools and knowledge of how their environment is affecting their health support the health sector to ensure that policies work to improve health and the determinants of health.
The project works to identify allies for health and a base of supporters for healthy policies.
At times this may not be the most economically beneficial strategy, at least in the short run.
Establishing and maintaining partnerships
These processes being facilitated by DMQ are designed to empower and guide the different community sectors (education, health, community institutions) to act within their area of influence, so that they have the power to implement these changes. Out of this work DMQ expects to identify valuable input that informs the creation of public policy and guides the prioritisation of tasks for the municipal government. These tasks will be part of the agenda of the Secretary of the Health Department, who will in turn negotiate with the mayor’s office, other departments and agencies and the City Council on behalf of the community, to ensure inclusion in their plans, budgets, policies or ordinances. For the communities, these approaches resonate well with collective approaches customarily used for improvements that have wider social benefit. For health sector personnel, engaging communities and strengthening their understanding of the health implications of the decisions, activities and choices being made on priorities and resources is clarifying the health impact of people’s decisions and embedding health within their thinking and priorities. DMQ’s key role in promoting population health is accepted by the
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Ministry of Health and making the link between health and its determinants is strengthening health promotion and population health improvements within the community.
In addition to the partners already outlined, the DMQ also works in partnership with local universities and international organisations. DMQ has negotiated internships in the Metropolitan Health Units and graduate students have led workshops in physical activity. PAHO has supported the work through both international specialists and local teams, providing technical support and skilled facilitators for the work with the community. PAHO is also supporting efforts
to exchange best practices with other cities in the country and Latin America and Caribbean (LAC) region. For example, in October 2016 a meeting was held with several cities on Urban Health and Chronic Non- Communicable Diseases to share experiences with other cities in Ecuador and with Mexico City. In 2017 similar workshops are planned to share experiences.
DMQ also plans to hold meetings with other cities to share knowledge and local best practices that improve health. This exchange is important to strengthen and support local capacities and build networks for urban health.