Sat, Apr 09, 2011 - Page 9 News List

Radical reforms needed in urban public healthcare

By Pedro Malan

The forces that drove the growth of European and North American cities in the 19th and 20th centuries are now driving urbanization in Brazil, China, India, Mexico, Russia and other emerging-market countries. Because the growth of these cities has been accelerated and magnified by productive technologies, rapid internal migration and high net reproduction rates, many have reached unprecedented sizes at breathless speed. Indeed, all but three of the world’s 20 largest cities are in emerging markets.

Many forecasts suggest that by 2030, the four largest emerging-market economies will have overtaken the G7 in combined size, and that by 2050, today’s emerging-market economies will represent more than half the global economy and an even larger share of the world’s population. These forecasts all assume that economic growth will be generated in cities.

But will emerging-market cities be healthy enough to drive rapid economic growth? The issues that preoccupy health policymakers and practitioners in Lima, Cairo, Kolkata and Jakarta reflect contrasting climates, geographies, histories and cultures. Each city is ultimately a special case, but they share some generic features.

One is that the urban disease burden is shifting from infectious to chronic diseases — the so-called “diseases of affluence.” However, the urban poor, faced with bad housing, limited infrastructure and meager services, are vulnerable to epidemics, malnutrition-based childhood diseases, HIV/AIDS, malaria, tuberculosis and mental disorders. They are also likely to be hardest hit by natural disasters, such as the floods and mudslides that devastated parts of Rio de Janeiro in January.

A second generic feature of emerging-market cities is that dense concentrations of poverty help create fragile environments that spawn civil disorders, resulting in death and injuries. However, a recent symposium at Oxford University concluded that emerging-market cities could improve and maintain urban health by capturing the inherent advantages of concentration, coordinating health policies and programs, adopting successful innovations, reforming health education and training and developing improved planning processes.

Indeed, many potential solutions stem from opportunities for innovation created by the physical concentration of people and economic activity. It is invariably more efficient to build and maintain health-related infrastructure, such as water supply and sanitation systems, clinics and hospitals, and deliver specialized health care, where population densities are highest and to create affordable-care networks of community health workers using low-cost technology. It is invariably easier to capture economies of scale and operation in public-health programs where those economies are greatest.

Moreover, while the health of urban populations is directly or indirectly affected by actions taken (or not taken) in almost every branch of government, few emerging markets have acted to improve horizontal coordination within national or city administrations. Fewer still have addressed the need for vertical coordination between national and city governments. Tailored solutions are required — what works in one city might not work in others — but, because problems arising from weak or absent coordination are widespread, emerging markets should consider governance models that vest accountability for urban health outcomes — together with the authority to shape them — in city governments.

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