Dr Helen Elsey is from the Nuffield Centre for International Health and Development, University of Leeds. In this HEART Talks she talks through the urban health HEART reading packs that she has put together with Dr Siddharth Agarwal from the Urban Health Resource Centre in India. The three reading packs are: A) Data and evidence, B) Improving population health – strategies for inter-sectoral action, and C) Interventions and pro-poor service provision.
The world is urbanising. Globally, more people live in urban areas than in rural areas. By 2050, it is expected that 66% of the world’s population will be urbanites. Africa and Asia are urbanising the fastest. By 2050 56% will be urban in Africa and 64% in Asia. There are currently 28 mega-cities (i.e. with a population of 10 million or more). By 2030, the world is projected to have 41 mega-cities. However, the fastest growing urban areas are medium-sized cities and those with less than 1 million inhabitants located in Asia and Africa. UN-Habitat estimates the number of people living in slum conditions is now 863 million; growing from 760 million in 2000 and 650 million in 1990. Cities are at the forefront of ‘disease transition’ with malnutrition and obesity occurring simultaneously. Water and sanitation provision is grossly inadequate in urban slums. Tobacco consumption is a major concern among urban poor men, and increasingly women; a risk factor for both NCDs and TB. There are multi-sector influences on urban health.
Local governments are key to coordinating inter-sectoral action. Donors are increasingly working with local government to strengthen capacity to plan, manage services, link with sector ministries, enforce public health legislation and establish local level governance structures.
There is a need to coordinate health services between local government and health ministries. The urban public health service is woefully inadequate. There has been underinvestment due to years of the perceived ‘urban advantage’. Responsibilities for staff, their training, equipment/drugs, and facilities often fall between the Ministry of Health (MOH) and the Municipality. The poor are left with little option but to use meagre resources on private facilities resulting in high levels of catastrophic health expenditure. There are poor referral mechanisms due to the plethora of NGO and private providers. There is a need for monitoring and enforcement of quality standards among providers and pharmacies. Secondary care is insufficient with maternity hospitals not open all hours and weak services. Tertiary hospitals are overloaded and not easy to access for the poor.
Public Private Partnerships (PPPs)
There are challenges with different forms of PPPs, private for-profit and not-for profit forms. For-profit PPPs have no incentive to reach out to the urban poor. They are not keen to partner for outreach care which is the key to preventative healthcare and the most crucial for urban deprived communities. Non-profit agencies tend to have few resources. Bangladesh’s Urban Primary Healthcare Programme uses partnerships with NGOs, private clinics and government health centres to expand services to slum and vulnerable communities. There are still challenges with monitoring, quality, and referrals between providers which covered in some detail by in the reading packs.
Helping people remain healthy and not in need of health services is a fundamental goal of any urban health strategy. There is a lack of evidence on which health promotion approaches are likely to be effective in changing ‘lifestyle behaviours’ such as tobacco use, diet, and exercise among the urban poor. Encouraging waist measurement, desired diet, physical activity and mental wellbeing at community level; peer education approaches to nutrition, physical activity, and promoting optimal behaviours in schools have shown some success. Community healthworkers (CHWs) have been effective at changing behaviours in Bangladesh, India, and Ethiopia. CHW and slum women’s groups promoting peer-to-peer health promotion shows promise. Mass media through mobile phones, print, radio and television have wide audience reach in urban centres, but it is hard to compete in the cluttered media environment. Instant messaging for skilled birth attendants is more effective in urban areas. There has been increases in zinc treatment awareness following TV, radio, and newspaper media campaign in urban areas.
Water, sanitation and hygiene (WASH)
WASH needs to be promoted in households and schools to improve, health, nutrition and education. The three interventions of the WASH sector (hand-washing, food storage, garbage disposal) – depend on one another for full realisation of their benefits. For example most sanitation systems cannot function without water. School WASH impacts education outcomes, especially for girls. Menstrual hygiene and girl friendly toilets in schools affect school attendance of girls and reproductive tract infections. Hand-washing with soap and water and other personal hygiene practices have the potential to substantially reduce within household transmission of diarrhoea and improve nutrition. Promoting practices such as hand-washing with soap and water, and safe disposal of child faeces benefit health and nutrition and can be incorporated in a wide range of public health strategies at low cost.
Participatory neighbourhood mapping
Participatory mapping has been used in India to expand the reach of urban services. Slum women’s groups use hand drawn maps to ensure that no family is left out from municipal/NGO lists used for housing, sewage systems, toilets, and entitlements. They are also used to track access to health services eg. immunisation, antenatal care, and delivery. The maps help identify recent migrants for linkage to services and entitlements. Gentle negotiation is occurring through collective petitions. Inclusive urbanisation requires disadvantaged communities to actively participate in governance.
Pressure from real estate developers, poor governance and corruption undermines local government’s role in controlling urban development to keep healthy places within the city. Access to green spaces reduces mental illness and has been shown to reduce inequities in cardio vascular disease and all-cause mortality in high income countries. Green spaces are rarely considered in controlled and uncontrolled expansion of urban areas. Urban agriculture can make an important contribution to household food security, especially in times of food crisis or food shortages. This needs support and regulation so food is grown in healthy environments.
Health and safe places for children
Urban poor women are more likely to work outside the home than other women in urban or rural settings. Working outside the home provides opportunities to improve income and increase self-esteem and gender equity. However, there is a lack of childcare and supervision for children. This could be solved with early childhood development opportunities. An NGO mobile crèche run day care centres in partnership with government’s National Creche scheme and with support funding agencies in India. Day care centres operate in coordination with builders and contractors near construction sites.
Transport and communications
10 billion trips are made every day in urban centres around the world. An increasing proportion of urban trips are using high carbon and energy-intensive private motorised vehicles. The urban poorest are disproportionately affected by key negative externalities generated by transport, including road accidents, air pollution and displacement when transport developments are occuring. Regulation to improve road safety can make a substantial difference to accidents. For example regulation of ‘matatus’ (mini-buses) in Kenya was introduced where drivers had to increase their driving and safety skills. This legislation resulted in a 73% reduction in accidents. Keeping cities compact, with opportunities for walking, cycling and public transport reduces emissions and support public health.
All of these issues and more are covered in the reading packs which point out key resources.