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Convergent multisectoral action
Epidemiology has long debated the multifactorial causes of disease and the relationship between socio-economic factors and health. McKeown brilliantly demonstrated the link between socio-economic development and health effects by a now wellknown analysis of mortality statistics for England and Wales from 1838-1841 to the 1970s . Similar observations have been made using United States statistics . McKeown's effort clarifies, among other things, the likely respective influences on health status of socio-economic development and of conventional health service activities. The result is to recognize the importance of socio-economic changes on the basis of facts and to strengthen the theoretical basis for multisectoral intervention in health.
The appeal and feasibility of the multisectoral approach, and the confidence that it commands, particularly at community level, are demonstrated by the number, variety, and continuing proliferation of such projects. In both rural and urban areas an attempt is being made to look at health problems not through the distorting effect of disciplinary or sectoral considerations but on the basis of their true determinants, their relative importance, and their chronological relationship. In fact, the primary health care philosophy and strategy evolved relatively recent initiatives along these lines [56, 57].
In the case of an urban population in general and of the urban poor in particular, the linkages between social, environmental, and economic conditions, individual and community behaviour, health status, and general well-being are so intricate and all-pervading that no lasting solution to the prevailing problems can be envisaged that does not give due weight to all the elements in proportion to their importance.
Forty per cent of the urban population of Ethiopia live in Addis Ababa. About 80% to 90% of the city population are below the poverty line and live in crowded, low-grade settlements deprived of essential services. An urban upgrading programme, based on surveys carried out with the participation of the University in 1977, was initiated in Addis Ababa, with its main emphasis on mothers and children in the most deprived districts . The programme includes supplementary feeding, promotion of childcare and day-care centres, training of day-care instructors, development of small-scale poultry farming, market gardening, and integrated slum rehabilitation. Several national and international organizations participate under the co-ordination of the Ministry of Labour and Social Affairs. Women's organizations play a fundamental role. Progress is being made in spite of the constraints experienced, such as shortages of personnel, equipment, educational material, and finances, and a steep rise in prices after 1978.
Hyderabad is one of the 14 cities in which the Indian government has undertaken experimental urban community projects after a decision in 1966 to shift from slum eradication to slum improvement. Hyderabad has experienced a rapid population increase and is now the fifth largest city in India, with an estimated population of 2.5 million, of whom 500,000 live in slums. The project is a comprehensive one and includes environmental sanitation, construction of self help houses and water improvements, family welfare, immunization, health and first-aid classes, family planning, cooking and home marketing demonstration, supplementary feeding, special nutrition and midday-meal programmes, recreational and cultural activities and youth programmes, crèches, primary and night schools, vocational training, and economic activities such as bank loans and sewing cooperatives. Special emphasis is placed on the participation of women, on income-earning activities for women, and on the inclusion of women in the project staff. In spite of the usual problems related to management and the scarcity of personnel, the project is expanding and is being replicated in other states.
The Sang Kancil project was started in 1979 in Kuala Lumpur, Malaysia, to meet the numerous health problems caused by the large squatter population, which has risen dramatically during the last 10 years [58, 59]. A 1978 census of the squatters recorded 48,709 households distributed among 148 squatter settlements and comprising a population of at least 234,000 (out of a total of about 1 million in the city). A consultative seminar in 1978 concluded that there was a high risk of communicable diseases in the squatter communities, with fewer than 30% of the children being immunized and a high prevalence of worm infections; that the care of poor children should be closely linked to that of their mothers; that there were high rates of emotional problems, truancy, and drug addiction among schoolchildren; and that a high proportion of working mothers had to leave their children with neighbours, with other children, or alone. After extensive consultation, the Sang Kancil project opted to focus on preschool education, maternal and child care, and income-generating activities. Community centres were constructed in two areas with the intention of having 20 such centres by 1985. Two kinds of personnel have been trained: nurse-practitioners and community preschool teachers. Income-generating activities were the most difficult to develop but were considered a very important component, because the relationship between income and health was well understood. A first step was the establishment of a "mini-factory" where squatter women learned needlecraft and tailoring, and manufactured batik garments and soft toys and were thus able to increase their income by 25%.
A project in poor areas (called young towns) of the southern zone of metropolitan Lima, Peru, was initiated in 1978 to cover 45 neighbourhoods with a population of about 550,000 [60, 61]. Its objective is integrated health care for children and families at the primary level, through co-ordinated action by services and institutions and through the participation of organized communities. The conditions in which the people of the young towns live are extreme, characterized by underemployment, malnutrition, occupational difficulties, little access to basic services, and so on. Fifty-four per cent of the population have no stable employment, and almost 60% suffer from malnutrition, being unable to obtain more than 80% of their caloric needs. Malnutrition is due to a lack of food, not to irrational selection. Infant mortality is quite high, and medical services for the young are insufficient. Because there is no garbage collection, almost 6,000 tons are dumped each month at the periphery of the settlements, producting unhealthy conditions. Only 7% of the population have access to drinking water and sewage services in the home. Conditions for women are particularly bad, largely because of the traditional attitude that women should not study or work outside the home.
Because of the size of the settlements and the high proportion of the total metropolitan population living there, these socio-economic and physical conditions present a major policy problem for the country and the government. The project activities consist of mother and child care, including nutrition and oral health; water and environmental sanitation; early stimulation and non-formalized initial education of children; basic education and training of women in matters such as making clothes and shoes, food processing, carpentry, and other skills; and training block monitors, health promoters, and midwives. The project is based on a thorough analysis and relies on local community organizations. It initially covered 46 young towns and is being expanded to other areas.
Rocinha is one of the largest but not one of the worst favelas of Rio de Janeiro . It is rather heterogeneous, with some semi-legalized areas and, especially on the steep slopes, areas where the population lives under precarious conditions of extreme indigence. The most striking feature is the accumulation of human waste and garbage, with all the consequences of insect and rodent infestation and disease prevalence. The area has a history of community organization, with some local services being supported by community groups. Components of the programme are water supply and sanitation, informal education and community schools, day care, and primary health care. Progress is being made in all components. A notable degree of community participation has been achieved, and the programme has demonstrated that community resources and public support can produce favourable results. The work is being extended to other favelas using the methods developed in Rocinha.
Other examples are available from the Mathare Valley in Kenya; Rosso, Mauritania; Maxquene, Mozambique; and various districts in Dar es Salaam, Dakar, and elsewhere.
All these projects play an important part in changing attitudes and priorities, provided several specific requirements are met: They must be planned with a long-term perspective (e.g., a 10-year horizon). There has to be considerable initial investment of staff, time, and skills to bring the projects to the point of take-off. There must also be a real involvement by the communities served, who must understand and support the project. Political leaders must be able to assess for themselves the nature and impact of the projects. Finally, the start-up projects should, from the beginning, be first steps in a strategy for large-scale action to provide good coverage for all those who have previously been ignored.
Non-health activities sectorally implemented may also have a substantial effect on health . The link with education is well known and important. It is associated with lower fertility levels [63, 64] and increases the efficiency of family planning programmes. Education of low-income women will help them to appreciate the benefits of breast-feeding, of a balanced uncontaminated diet for their children, and of personal hygiene. School feeding programmes are not only an incentive to the enrolment of children in schools but also a means to better health, increased attendance at school, and the ability and motivation to learn [65, 66]. There exists an important web of interrelationships between education, health, nutrition, and family planning in which women play a fundamental role. Of particular importance is the concept of basic education, which differs from conventional primary education in that it attempts to satisfy the minimum needs of specifically identified groups, not only children but also youths, adult men and women, and selected rural and urban groups. The effects of improved water supply, sewerage, and solid-waste disposal have been discussed extensively. Mention should also be made of housing, the transportation system (which influences access to health and family planning centres), the development of urban agriculture (as in Lusaka), job availability, and income in its two-way relationship with health, nutrition, fertility, and (once again) education.
Convergent action by different programmes and sectors entails an effort in intra- and inter-sectoral articulation. The point is not so much to contrast the vertical and the horizontal approaches as two conceptually different modes of service delivery, but to decide for what purposes or at which stage each is better suited or more cost-effective, and when one should naturally evolve into the other. It is a matter of awareness and co-ordination: awareness of how to mobilize the most appropriate resources to cope with a given problem (irrespective of disciplinary considerations, organizational location, or managerial responsibility) and ability to coordinate them all, so that those who can make a useful contribution are involved, gaps are not left, the work is done efficiently, and the objectives are met.
In urban health development, where the improvement of the environment, behavioural changes, and the satisfaction of basic needs have such fundamental importance, the application of knowledge about the close links between health and development can bear important and long-lasting fruit. Thus, it is through multisectoral action and intersectoral articulation that the evolution from "medical services," dominantly curative and disease-oriented, to "health systems," emphasizing health promotion and disease prevention, can be concretely realized.
The background document for the technical discussions of the 1986 World Health Assembly  states that it is in the slums of cities in emerging nations that a well-conceived health development policy can prove itself by "giving the poor access to resources and economic opportunities, raising educational levels, ensuring availability and distribution of food, improving the status of women and providing the basic infrastructure and other public amenities."
Unfortunately, because health planning continues to be influenced by the perception that health is mainly the result of medical services, it cannot be said that a comprehensive intersectoral policy has emerged in most cases.
Community organization and self-reliate
The extremely high rates of population growth; the multiplicity, nature, and scale of the needs; the apathy, hostility, and neglect often exhibited by governments; and the insufficiency of the resources engaged all suggest that it will never be possible to grapple with the problems of the poor in slums and squatter settlements without the initiative and the active participation of the people themselves. In many instances little will be done for them unless they call for action, and in almost every case no lasting benefit will ensue without their active support, understanding, and participation. But will they respond? In rural areas, community organization is a historical phenomenon, based on solid cultural foundations. It remains reasonably efficient and largely taken for granted. All this is lost with the influx to the cities, at just the time when a reference point for protection and direction is most needed. Having once been lost, the delicate connective tissue of social organization has somehow to be reconstructed so that people can find themselves again: on the one hand, to discover and realize the potential of the community and, on the other, to attract the attention of politicians, governments, and other powerful organizations. Yet the conditions to redevelop social organization are difficult to establish. in the new slums and squatter settlements little is generally done to guide rural migrants when they arrive or to help them through the transition from rural to urban life and through the various "rings" of the city to a point where they can feel that they belong in anything more than a superficial and temporary sense [681.
In contrast to the relatively stable and homogeneous rural village, migrants find themselves in a society that is culturally and linguistically very heterogeneous, transient and mobile, opportunistic and restless, too preoccupied with individual survival to be concerned with solving collective problems or with finding mechanisms to face them, and collectively unaware of the ways of life in the new environment. At the same time, they find themselves caught up in a continuous, often unconscious, battle against the ignorance, prejudice, and hostility of the more fortunate. While these features of the urban society are divisive, some people nevertheless feel united by inhabiting the same place, by sharing poverty, and by enduring a number of pressing common problems to which some solution must be found. It is neighbourhood awareness, with different names in different places, that provides the basis for the social organization of the urban poor and thus for some improvement in their living conditions.
Contrary to the long-established assumption that low-income urban populations typically lack social organization and are apathetic, their initiative and resourcefulness are increasingly recognized by planners and other government officials. There is of course an implicit danger that an overemphasis on community action may be used as a pretext for withholding government support, but, in practice, experience has shown that neither the exclusively community-managed self-help programme nor the paternalistic government-sponsored and imposed community programme is viable. Success is more likely to occur when a partnership between community and government is established, entailing recognition of what self-help can do, respect for the individual, and willingness of the government to cooperate with popular action .
A UNICEF review based on information from 70 countries and case studies prepared on 9 of them, concluded that the community-based approach is viable and has been increasingly adopted. It enables services to reach further out to the poorest families; to be designed in explicit response to needs that people have themselves articulated, and thus to be better understood and supported; to be more valued and better maintained by the community; and to be less expensive while permitting broader coverage. Social action is not only a result but also a way of achieving social cohesion.
There are different methods of implementing this partnership, and the examples do not lend themselves easily to any simple classification. But viability seems to be enhanced if the involvement of the community originates from a clear understanding of the problems being faced, or from initiatives taken from within the community.
Developments that result from a true dialogue between government and communities, where the respective contributions are mutually acknowledged, are difficult to cite. The community development in Rocinha, Rio de Janeiro, already mentioned, may be such an example. Residents formed a health group, a sanitation group, and a school group and worked together with the Municipal Secretariat for Social Development first at a survey and later at joint planning of the programme based on the survey. The resulting activities included child and adult education, sanitation, and health services. The main sewer system was established through a mutual-help process, and secondary connections were built by the community. Community agents have been trained to monitor the growth of children under five years old and to form women's health education groups. The programme and its methodology have been institutionalized, and the possibility of expansion to other areas is being considered.
In some cases the initiative comes entirely from the community, which creates and maintains the organization and infrastructure to bring about the improvement it has defined. Sometimes unbearable conditions, or the threat of slum clearance and eviction, lead to an open clash with the government: such was the case of the Hong Kong boat people and the Tondo residents in Manila. This type of reaction, although often effective, does not create an atmosphere of trust between slum people and the authorities; nor, in general, are the results conducive to large-scale replication.
There have been some community initiatives, however, if not yet many, that are not based on confrontation, although admittedly the stakes may not have been as high as in the preceding examples. One example is the creation community kitchens in the Kamanves slum in Miraj, India, which was initially part of a comprehensive effort to improve the nutritional status of the population and later was developed well beyond its original objectives. After a discussion of local problems in the community, a group of residents formed a committee that, after consultation with the Director of Community Health, started to work with the staff of the local hospital in a series of activities involving all community residents. An organization was established, a management committee was elected, and fees were collected from all members. The first initiative was a morning feeding programme for children, later expanded to cover very poor adults at a cost of 0.06 rupee per person. The kitchen, which was initially out in the open, was later provided with a shelter. Children attending were given a medical examination. The programme expanded to conclude training and income-generating activities. The health education programme was a most important one and led, among other things, to high immunization rates for diphtheria-pertussis-tetanus, polio, tuberculosis, and smallpox.
One purpose of the community organization is to enable slum dwellers to gain organizational and managerial skills, including the confidence to choose who should participate, to work with and use government and non-governmental organizations, and to build mechanisms that demand responsibility and accountability from the resource holders as well as from comunity beneficiaries. Nylon-a periurban slum area near the airport of Douala, Cameroon, that was estimated to have reached a population of more than 100,000 by 1980 and yet, until a few years ago, was marked on city maps as an uninhabited zone where the population had no legal existence- provides a good example of how the process can develop so that community goals can be met by the residents. Initially, in order to fight water and industrial pollution and growing vandalism, the three ethnic groups living in Nylon decided to join in a common effort to improve their condition. The area was divided into lots, blocks, sectors, and subdivisions, and "animators" were assigned to each unit, accountable to the corresponding person at the next higher level. The leaders then sought municipal assistance, organized a seminar on the urban environment Which attracted public attention to their problems!, and established a training programme for the animators. Official recognition was gained from the Ministry of Social Affairs. A community centre was constructed, and later a topographical survey was carried out and a master plan for development drawn up. Electricity was installed and, with foreign aid, the construction of a market place began. Community activities in Nylon gave rise to the concept of a "transitional urban economy," which is neither traditional nor modern and is characterized by predominantly unemployed people working in the informal sector, simple methods of production, and a complex network of ties with the modern sector, whose by-products and waste materials are exploited to the maximum. Food self-sufficiency was considered a prerequisite of the transitional urban economy, and so any available land was intensely cultivated, poultry was raised, and an experiment was initiated with a small food-producing industry.
Many other examples could be mentioned, and some have been included in preceding sections. They are all the result of community development, forming a fascinatingly diverse story in which the entry points and motivators are endlessly varied. The key stimulus can be community crisis, a health intervention, a government programme, the interest of a specific group such as women, an existing community structure, or a charismatic leader.
Failures occur also and are not unexpected. Indeed, the circumstances of the urban poor, some of which are listed at the beginning of this section, seem to make success much more surprising than failure. Paradoxically, the people in old established slums often experience more difficulty in working together for the common well-being than those in new slums and squatter areas. The main constraints rest with the poor themselves, who rarely have the social amalgam, confidence, skill, and experience to galvanize their own community, deal with government officials and NGOs, and, if the need arises, challenge other people's conservative, selfish, and hostile attitudes and actions.
Government collaboration with communities may be hampered by excessively scientific and technical approaches, poor mechanisms for social planning, insistence on too high standards, inappropriate legislation, administrative bottlenecks, and the inability of government officials to communicate with the community and to understand the dynamics of an urban slum. Similarly, NGOs may define health programmes in terms of their own perceptions, pursue short-term goals, and occasionally (and this also applies to governments) create dependent attitudes ("What's there for me this time?") that are not conducive to community initiative, organization, and action.
Before ending this section, three additional remarks should be made. The first is to emphasize the fundamental role of women in community organization and action. Women are principal actors and vital target groups in community involvement. They are close to the children, the most vulnerable group among the urban poor and at the most critical moments of their lives; they decide on contraception, breast-feeding, and the quality and quantity of children's food; they may make all the difference in the prevention of disease, and are likely to have to decide what to do and where to take children when they are sick; they keep the urban garden ( when there is space for it) and raise small animals; economically, they are the ones who have to make ends meet in the household; they are the responsible persons in most single-parent households and the ones to go to for complementary income; they benefit from, but also run, the community crèches and day-care centres for pre-school children. They are, no doubt, those in whom education money is best invested.
Second is to underline the ability of communities in many countries (this applies to urban and rural areas alike) to operate in terms not of stereotyped socioeconomic development plans of compartmentalized bureaucratic units but of community needs, basic causes, and convergent actions that can synergistically meet those needs. Indeed, the community level is where intra- and inter-sectoral coordination becomes natural and real.
Finally, a tribute should be paid to the initiative and resourcefulness of marginal urban communities, whose qualities are indeed being increasingly recognized by planners and other government officials. Frankenhoff notes, "It is essential to facilitate the involvement of the untapped resources of marginal communities into the process of urban development." There are political, social, and economic arguments in favour of this option. The political argument is that increasing the stability of these slum communities in terms of jobs, housing, education, and health will contribute to national political stability. The social argument is that the community that is helped to build itself will produce social benefits for the nation. The economic argument is that the slum community can generate significant consumer demands as well as capital formation. Houses, sewers, sidewalks, schools, and clinics can be built by such a community with a minimum of assistance.
Urban health development with a main focus on the poor must be pursued with continuity and determination in the developing countries. Responsibility must be decentralized to increase relevance. Services must be improved through the establishment of the necessary managerial processes. The infrastructure must be strengthened, expanded, and, where it is totally lacking, created. The referral system must be reorganized and the patient workload redistributed. All relevant sectors of socio-economic development must be mobilized and organized into functional networks to contribute to clearly defined health objectives. Communities must be involved, but the mistake must be avoided of only calling on the poor, as if other, more privileged strata of society were to be exempted from contributing extraordinary resources that instead are expected of the poor.
The urban turnaround observed in industrialized cities, it was pointed out at the 1984 conference on population in Mexico City, is for the time being unlikely to occur in most developing countries. Here, therefore, the problems will stay and grow, and must be faced. Several international organizations have led the way, and we all must follow and do things that will concretely help the poor.
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Trends in urban and rural food consumption and implications for food policies in Tunisia
J. Périssé and A. Kamoun
This study of the evolution of food consumption among urban
and rural populations in Tunisia is based on the results of
household consumption and budget surveys. To make sure that any
differences observed in such a sutdy actually reflect the
consequences of urbanization and are not attributable to mere
chance, it is essential that the surveys should meet a number of
-They should have a national sampling framework that ensures a proper distribution of households, taking into account both seasonal variations and geographical differences.
-Recording of household budgets, showing the amounts of money spent on foods, goods, and services, should be supplemented by actual weighing of food commodities on various days, particularly in those countries where home-produced, home-consumed foods are an important part of the diet.
-For any study of the evolution of consumption over time, the methods of data collection, the concepts followed, and the way of expressing the results should be identical from one survey to the next, lest distortions be introduced that might appear to reflect behavioural differences.
TABLE 1. Urban and rural population and growth rates in Tunisia,1975-1985
growth rate (%)
Tunisia is one of the very few countries to have carried out four such national surveys between 1965 and 1985. Of the four surveys (in 1965-1968, 1975, 1980, and 1985), conducted under the auspices of the National Institute of Statistics and funded by the government, the last three met the criteria listed above. This article compares them and comments on their results.
For the purposes of the present study, we have divided urban areas into two groups: one (U) comprising small and medium-sized cities with their own town councils, and another (C) comprising the major cities with over 90,000 inhabitants, such as Tunis, Bizerta, Sousse, Sfax, and, since 1985, Gabès. The rural areas (R) consist of villages, hamlets without any administrative structure, and scattered dwellings.
The evolution of the Tunisian population from 1975 to 1985 is shown in table 1 (based on the 1966, 1975, and 1984 censuses). The national population increased by 28% between 1975 and 1985 and is now above 7.2 million, as against 5.6 million 10 years ago. During that time the population of the urban centres, including both the smaller and the major cities (U + C), rose by 46% and that of the rural areas by only 12%.
For the first five years of the period under review, the rural population showed only a slight yearly rate of growth (0.8%) as the consequence of a marked exodus to the cities (and to foreign countries). The cities, on the other hand, had an annual growth rate of 4.6%. Tunisian cities are thus becoming overpopulated, and in 1980 contained the majority of the overall population: 52%, compared with 47% in 1975. Because employment opportunities in the cities have become scarcer, movement from the rural areas has somewhat abated since 1980: the rural population has tended to remain settled and increased twice as fast between 1980 and 1985 as during the five previous years (1.5% versus 0.8%). As a result, the growth of urban population slowed down (3.1 % versus 4.6% as previously).
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