Urbanization and the learning agenda for health systems research: insights from Future Health Systems
Projections about urbanization are staggering: 55% of the world’s population already live in urban areas, and by 2050 this is predicted to rise to 68% with almost 90% of the growth happening in Asia and Africa. The implications for health are huge, as is the learning agenda for health systems research.
Research on urban health is hardly a blank slate, but recent trends in urbanization are generating new interest and questions from a health systems and policy research perspective. Whether urbanization is a pathway to improved or worsened health is an old concern, but recent debates have centered on the question of ‘for whom’? What do we know about how the health risks and benefits of urbanization are distributed across individuals, neighbourhoods and communities, and cities; and, how can they be mitigated or harnessed? There is growing recognition that the health of people living in slum-like conditions and/or ‘informal settlements’ (e.g. 55% of urban populations in Sub-Saharan Africa), represents a major challenge about which existing knowledge and policy is ill-equipped.
When thinking of urban health it is often the large-scale disasters such as epidemics or floods which grab the attention. Just think of the Ebola epidemic spreading through Monrovia’s slums or the mudslide killing over 400 people in Sierra Leone. Dense settlements create conditions for high impact and high profile events, further exacerbated by urbanization processes which push people to live in risky and unstable areas. Indeed, much of the focus on urban health has been about disaster risk reduction. However, there is increasingly recognition that the everyday risks and health problems of people in urban settlements are undercounted and likely a far greater cause of premature death. Yet, the evidence is patchy. Statistics are rarely broken down beyond city-wide averages, and so conceal vast differences between neighbourhoods and between poor and wealthy populations. The simple fact is we don’t know enough about health outcomes and the delivery of health supporting services in diverse urban areas.
How adequate are existing health systems frameworks for understanding and addressing the complexities of urban health and life? At FHS we’ve been considering how insights from our previous research might be applied to urban settings, and what requires a re-think, for example:
- Health markets and informality - FHS work has highlighted the extent of informal health markets in LMIC health systems. In rural areas of Bangladesh, Uganda and India, informal health providers are often people’s first port of call. Operating beyond the scope of formal regulation the care they provide is easy to access but problems in quality persist. Research has focused on the performance of these markets and measures to improve their quality, for example training, partnerships with the formal system, intervening across the health value chain, or the use of mHealth to provide accurate health information. What does informality look like in urban settings, and where are the intervention points? What is the profile of urban health providers and how does it differ to those in rural areas? In rural areas, despite the absence of formal regulation, there are norms and practices which govern behaviour; what do these look like in urban areas where populations are denser and fast moving? What are the partnerships which would be appropriate e.g. between residents and health providers, city authorities or between communities?
- Equity and community capabilities - Much of the work on urban health so far has emphasized the need to go beyond city-wide averages. Urban environments are heterogeneous and even in ‘slums’ there are some very rich people. Inequity in access to services and people’s engagement with health markets is likely to be stark. An analysis of equity in urban areas needs to get to grips with how complex social, economic and spatial inequalities interact. For example, our research in Sierra Leone has shown that different settlements in Freetown face very different challenges based on local topography e.g. flooding risks, accessibility for waste collection, ambulance accessibility, the ability to dig safe pit latrines (depending on soil or rock etc). These more obvious differences intersect with more subtle ones of identity and social position (gender, age, religion, sexuality etc.). Previous FHS work on community capabilities has highlighted the way vulnerabilities and resilience intersect across all of these dimensions. The organisation of life in urban areas - where people living in the same area cannot be assumed to be connected, and where social ties and fault lines extend within and beyond the settlements - stretch the usual models of research and engagement to the extreme.
- Accountability – FHS research in rural communities has brought together communities, health providers and district management teams to improve health service accountability. In urban areas it is not immediately clear which institutions govern health-related services (see informality above!). There is likely to be a mix of utilities, central government ministries (health, land, environment etc.), municipal governments, and a major agenda is to work out how sectors and accountabilities intersect. How can these institutions be stimulated to work together in different settings? How can we design multi-sector interventions which go beyond the health system?
As policy interest in urbanization grows there is a real opportunity to bring together perspectives from urban planning and governance, with those from health systems researchers. Interdisciplinarity and multi-sectoral action will be key to ensuring resilient and healthy cities, communities, and individuals, and if the predictions prove true, it will represent a defining challenge of our time.
Photo credit: Annie Wilkinson