Urban Health Networks

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The Urban Health Networks initiative aims to reduce social and territorial health inequalities and to improve access to health services in low-income neighborhoods. The networks bring together a wide range of public and private actors involved in the provision of health and social care around small-scale targeted projects.

Purpose of health policy or idea

The objective of the Urban Health Networks (Ateliers Santé Ville, ASV) initiative is to reduce health inequalities at the local level by providing tailored solutions to health problems of communities living in the most disadvantaged neighbourhoods. The initiative brings together all of the local health and social actors concerned. The networks then develop local targeted health projects for the priority groups and assure the coherence of different policy actions to improve access to prevention programs and other required health services. They aim to include the local population and different actors in identifying problems and solutions.

Main points

Main objectives

The ASV have been given by law several specific objectives. They are expected to: 

• Identify at the local level the specific health needs of the most disadvantaged population as well as the risk factors (linked to the life style) which need to be tackled;
• Mobilise and coordinate different actors by creating and supporting medico-social networks;
• Propose new means of intervention given the local health problems observed;
• Make sure that those in need have access to public health and social services
• Develop active participation of the local population to all phases of program development (identification of local health issues, definition of priorities, plans and evaluation) as well as all other local actors ranging from general practitioners to different social and health institutions as necessary.

Type of incentives

Urban Health Networks are financed jointly by local authorities and by the State (federal government). They can also look for additional funding from local community groups.

Groups affected

Residents of the neighbourhoods, local level actors involved in health and social care, local policy makers

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

At the end of 2008 there were about 300 health networks in France. They become an icon for the urban policy. Nevertheless, the question of how to find sustainable funding is still not resolved. In a context of cost transfer from state to local authorities, financing provided for these networks remains insufficient and irregular. That is the main problem for ASVs to become a durable mean to fight against health inequalities. 

Political and economic background

France compares badly to many other European countries in terms of social inequalities in health and health care use. In particular, people in precarious situations (unemployed, homeless, etc.) and those living in low-income communities have worse health status than the general population while having less access to health services. 

The majority of "disadvantaged neighborhoods" are city housing developments with a relatively precarious population where income and schooling levels are low, unemployment is high and housing and urban environment are poor. Since the mid 1990s, the core target of French national urban policy are these neighborhoods classified officially as critical urban areas (Zone Urbain Sensible, ZUS). There are 751 critical urban areas in France with about 4.5 million inhabitants (more than a quarter of which live in the Parisian metropolitan area). 

The correlation between socio-economic level and health is explained by differences in the level (and continuity) of health care consumption, prevention and screening (in particular for cancer and sexually transmissible diseases). 

Until the late 1990s, the logic of "territorial action" was not very well developed. But the repeated failure of centrally-organized measures called for an integrated approach to health problems within a local territory as the unit of action.

The local (regional) level cooperation between different institutional actors for mobilizing available resources to improve the health of the most deprived population has been encouraged by several legal initiatives (see below).

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The finding that people who are on or below the the poverty line, those in marginal situations (homeless, singe mother, irregular work, etc) or those who live in poor neighbourhoods have health outcomes that are notably poorer compared with the rest of the population is not new. In 1998, a specific law on the organisation of actions against exclusion gave the responsibility for developing specific Regional Programs for Access to Prevention and Care (PRAPS) to the regions (Loi n°98-657 of July 1998). 

In parallel, improving health in disadvantaged neighborhoods has been one of the priorities of the urban policy "politique de la ville" which concentrates on critical urban areas with a particularly poor housing and sanitary situation. The Urban Health Networks were first inspired by the Regional Programmes for Access to Care and Prevention (PRAPS).

The Inter-ministerial Counsel of Cities (CIV) decided to create a mechanism at the local level to ensure the coherence and effectiveness of local policies to improve health of the most vulnerable part of the population.

Initiators of idea/main actors

• Government

• Providers

• Others

Stakeholder positions

For most of the municipalities, health networks are an appreciated tool to improve local health policy. However, some hesitate to develop these networks because they think that the State's financial commitment is not sufficient to sustain this policy.      

For health care providers, health networks raise the question of how to situate local health actions with respect to the national policy. They are not feeling sure about the local priorities identified and projects developed, since sometimes local problems may not be in line with national priorities.

Actors and positions

Government
Ministry of Health	very supportive		strongly opposed
Providers
health professionals	very supportive		strongly opposed
Others
local authorities	very supportive		strongly opposed

Influences in policy making and legislation

Following the recommendation from the Inter-ministerial Counsel of Cities (CIV), the Urban Health Networks (ASV) were created by a decree in 2000 (DIV/DGS, June 2000). The objectives of the networks and how they should function are defined by this decree. 

After a long period of experimentation between 2001 and 2006, the urban health networks were generalised by another inter-ministerial decree (bringing together Ministry of Employment, Social Cohesion, Housing and Ministry of Health) in September 2006 (n°DGS/DHOS/SD1A/2006-353). The same decree introduced "health" as one of the five priorities for urban policy to improve social cohesion by encouraging local actors to take into account difficulties of the local population in terms of access to health services and prevention. The municipal authorities are asked to develop contracts to encourage the development of urban health networks. 

The inter-ministerial decree of 2006 prepared the legal and financial ground for the development of urban health networks. The objective set for 2008 was to establish at least 300 ASVs in critical neighbourhoods.

Legislative outcome

success

Actors and influence

Government
Ministry of Health	very strong		none
Providers
health professionals	very strong		none
Others
local authorities	very strong		none

Positions and Influences at a glance

Adoption and implementation

Pilot networks were introduced in two regions in 2001. After a positive evaluation at the end of 2003, they have continued to develop in other areas. Despite this continuous development, they were not considered as "permanent initiatives" until recently.  Even after the decree of 2006, the people involved in the networks were not clear about the sustainability of the financial support given locally. By the end of 2007 there were large disparities in the deployment of these networks across France.

Monitoring and evaluation

There are two levels of evaluation. First each ASV is supposed to develop a specific participative evaluation procedure including the residents concerned. The network will be evaluated with respect to the number of projects carried out, resources employed and the results achieved given the initial health issues that were identified and objectives set. On a second level, these evaluations will be included in the national evaluation of "urban policy".

Results of evaluation

An official report evaluating the overall outcomes of the Urban Health Networks at the end of 2007 stated that despite large variations of projects (their scope, impact…) the networks, in most cases, had real observable results in terms of services provided to local residents. In general, all the local level actors (generalists, hospital staff, residents, voluntary associations, public employees…) were convinced by the specific and unique contribution of these networks. There appears to be particular satisfaction with respect to the participative method of identifying and proposing solutions. The report notes also the bottom-up effect of these networks as the regional public health programmes sometimes took into account the diagnosis and priority areas set by these networks.

It is difficult though to make clear cut stories as there is no framework for these networks to present their results and compare their actions. Despite the large number of documents on the internet by different networks, it is difficult to get an idea about "final" results.

At the beginning the "assessment" of health problems in the area was considered as a first output, now the projects developed are evaluated but there are little quantifiable results. One example is from Toulouse (cartier north). First, they identified that access to care was an issue especially for elderly immigrant population who do not know the importance of regular health check-ups and where/how to go. The network put in place an information campaign targeting this population to encourage them to have a health check-up. But there is no number on the % of population convinced. Second, to improve the quality and efficiency of care at home for elderly, the network put in place a "training course for nurses" and they prepared a repertory of available providers which is distributed to the health professionals. Third, to fight against obesity, they organise collective actions (pique nique in forest, cooking lessons, sportive activities, etc.).

But stories differ from network to network. In Midi-Pyrénées, the objectives were to improve breast cancer screening and to reduce teenage pregnancy. They have measured the results in terms of % of targeted population reached. 

Expected outcome

A commonly agreed statement about health care provision in France is that it is compartmentalised and that there is a lack of an integrated approach when dealing with people's health problems. While assuring a better case management and coordination of services is important for all, this type of coordination is likely to be more important for ensuring access for those with a low level of education/income who seem to be less well informed on care pathways. 

The Urban Health Networks contribute, although modestly, to introduce a more integrated approach to health of the local urban communities.

Outcomes from different projects show the value of collaboration between different actors and identify the scope for much more effective engagement to meet the common aims of improved community health and well-being. 

For these networks to be more effective, it is important to assure continuous evaluation to identify best practice and to provide better guidance for new networks. For the moment, there is not much support from the central bodies in that sense.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

 

References

Sources of Information

Inter-minsterial decree DGS/DHOS. Elaboration of local projects of public health and ASV development. September 2006. 

www.ville.gouv.fr 

Mannoni C. La démarche atelier santé ville. Des jalons pour agir, 2008/01, 218p., Professions banlieues ed.

Author/s and/or contributors to this survey

Or, Z. and V. Lucas

 

Suggested citation for this online article

Or, Z. and V. Lucas. "Urban Health Networks". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/fr/a13/3