Background Paper on Improving Urban Population Health

This paper concerns urban health systems in developing counties (the South) and considers the determinants and outcomes of urban health and the activities that link them. It also identifies challenges for action and priorities for research. Because cities are particularly complex in terms of the range of poverty, environmental, social and service factors that can determine health, it helps to have a broad understanding of the health system, which is both multi-sector and multi-level (individual, household and community). The concepts of the double burden of disease and the urban penalty are discussed and research on social exclusion, resilience and the effectiveness of interventions is called for. Executive Summary This paper concerns the urban health system in developing counties (the South) and considers the determinants and outcomes of urban health and the activities that link them. It also identifies challenges for action and priorities for research. Because cities are particularly complex in terms of the range of environmental, social and service factors that can determine health, it helps to have a broad understanding of the health system. Essentially this breadth means thinking about determinants in both multi-sector and multi-level (individual, household and community) dimensions. The main intervention that tries to tackle urban health in an explicitly multisectoral way is the beleaguered Healthy City initiative. While it remains strong in Europe it has largely fallen by the wayside in the South. However, with the prominence of the current WHO’s Commission on the Social Determinants of Health, it might be due for a resurrection. In terms of multi-level analyses, we need to extend research that has mainly been done in the North, which shows the independent effect that place, or neighbourhood, often has upon both physical and mental health. However, such research needs to be particularly sensitive to the meaning of ‘community’ in low-income urban neighbourhoods. Recent evidence around these four groups of determinants (poverty, social, physical environment and services), gives some directions for action. For example appreciation of the spatial and temporal heterogeneity of urban poverty has implications for the nature of programme targeting. Greater understanding of urban livelihoods, particularly the role of social capital in protecting or promoting health, strengthens the need for truly inter-sectoral, or ‘joined up’ government activities. While there is much evidence on environmental hazards and the effect they have on urban health status we need more intervention research to inform us how to promote behavioural change in relation to the environment (eg hygiene, cooking, and waste disposal behaviour). In terms of health services, the urban poor remain under-served, particularly in relation to reproductive health. In considering urban health outcomes the double burden of infectious diseases and chronic diseases (including mental ill health) needs to be acted upon in any programme development. Whether the urban poor face an urban penalty (greater health problems than their rural counterparts, exacerbated by characteristics specific to cities such as over-crowding and dependence on a cash economy) is still debated. Even if they do not, the extent of health inequalities within cities themselves is a persuasive reason for prioritizing action for the urban poor. Some general regional patterns are: Sub-Saharan Africa: still lacking the basic physical, environmental-health-related essentials like safe and adequate water and sanitation and healthy housing (with electricity, piped water, insecticide-treated bed nets). Latin America: while the basic physical health problems are largely understood and many acted upon, the rising levels of violence and mental illhealth (possibly associated with the rising socioeconomic inequalities which are so evident in the cities) represent a big challenge. The need for ‘joined up government’ and for the health institutions to work with social and other sectors is a priority.