How can health services keep pace with the rapid growth of cities? | Richard Vize

The relentless growth of urban populations is driving city and national governments to increase access to healthcare while tackling the root causes of poor health.

According to Oxford Economics [pdf], the world’s largest 750 cities will be home to 2.8 billion people by 2030 – more than a third of the global population. They will account for almost a third of the world’s jobs and more than half its consumer spending. More than a dozen cities will have populations greater than 20 million.

Rapid, uncontrolled urbanisation strains many aspects of city life that determine health. Traffic, factories, generators and construction poison the air, meanwhile water supplies can become contaminated, poor housing harms the health of children, and food supply and quality can be compromised.

Unplanned urban growth drives poverty. About 900 million people worldwide live in urban slums, where overcrowding encourages the spread of infectious diseases such as tuberculosis, dengue fever and cholera. The United Nations estimates that by 2030, roughly 60% of city inhabitants will be under the age of 18, which puts huge numbers of children at risk from illnesses such as diarrhoea and pneumonia, the leading causes of global childhood death.

Health services, particularly in developing countries, are concentrated in cities. As Mark Britnell notes in his study of global healthcare, many developing countries such as China, Indonesia and India suffer from a chronic shortage of health workers. This creates big disparities in care between cities and the countryside; doctors are reluctant to work in rural areas because pay is poor, career choices are limited, hospital facilities are often inadequate and primary care tends to be underdeveloped.

Meanwhile, in the cities, hospitals become overcrowded because patients know that is where the best doctors, research and technology are found. The dominance of hospital care in cities often means primary care is neglected, which according to the World Health Organisation (WHO) [pdf] can lead to unregulated, unsafe and ineffective private services. In some African cities, public primary healthcare has almost disappeared.

Britnell highlights some of the efforts being made to bridge the shortfalls. Brazil has announced new medical schools to train thousands of additional doctors, and training is being extended to include two years working in public service posts. This could add up to 36,000 working students to the system by 2021. Compulsory training in public hospitals was inspired by the NHS.

In addition, Brazil has recruited at least 10,000 doctors from Cuba to work in the poverty-plagued favelas on the peripheries of cities, as well as in remote areas.

The chronic shortage of clinicians is encouraging countries to make better use of volunteers and community workers. India is trying to boost its services in slums through the National Urban Health Mission, which emphasises reproductive health and works with women’s health committees.

Toronto [pdf]has been trying to bring together its primary and hospital services to provide joined-up care for patients with several health conditions. This includes individual care plans, one point of contact, and multidisciplinary teams supporting high-risk patients after they have been discharged from hospital. The city’s Ageing at Home programme aims to make it easier for older people to continue to live at home after illness.

Toronto also provides impressive support for people living on the streets with mental illness. Its Streets to Homes programme includes incentives for private landlords to offer accommodation. Several thousand people have moved into their own home since 2005, and about 80% of them remain there for at least a year.

Yet for many people, access to healthcare depends on the ability to pay, which excludes swathes of the population. Increasingly, countries such as China, Thailand and Indonesia are addressing this problem by pursuing universal healthcare. At present around two in five countries have some form of universal healthcare.

Britnell argues that its expansion is being driven by two opposing forces: capitalism and globalisation have grown a middle-class demanding more from governments, while about 1 billion people lack access to basic healthcare and 100 million are impoverished every year through catastrophic healthcare costs. Providing more equal access to health services strengthens social cohesion and promotes economic growth.

But while developing countries are increasing the proportion of their wealth spent on healthcare, urban populations are expanding so quickly that it is all but impossible to provide the health infrastructure and staff to keep pace.

Faster progress can be made, however, in improving the environment, such as providing cleaner air and water. For this reason, the WHO believes local government – and particularly executive mayors – are central to improving city health.

Beijing and Shanghai, for example, have introduced tough anti-smoking laws. In 2013 Mexico City became the first in the world to levy a tax on sugary drinks, which had been a factor in Mexico having among the world’s highest obesity and diabetes rates. Kuwait City has reduced salt content in bread to tackle high blood pressure. London and Paris were among the first cities to attempt to cut traffic pollution and increase exercise by offering free bicycle use.

Poor road safety takes many urban lives. Fatal traffic accidents [pdf]cost about 21 lives per 100,000 population annually in Brasilia and 18 in Nairobi, compared with 1.3 in Tokyo. Cutting road deaths depends on many factors – higher population density actually reduces deaths compared with sprawling areas. São Paulo (Brazil), Bogotá (Colombia) and Accra (Ghana) are among cities pursuing safer road design.

The health of city populations is becoming a central concern of local and national governments and international institutions. Affordable access to health services is just part of the story. Local government in particular recognises that improving the health of city populations depends on everything from ensuring water quality to designing safe roads and controlling air pollution.

But there is a chasm between cities where growth is controlled and those where the relentless quest to find work is creating polluted, overcrowded slums.

• Richard Vize provided editorial support to Mark Britnell for his book In Search of the Perfect Health System, which won the health and social care prize at the BMA Medical Book Awards 2016.

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How can health services keep pace with the rapid growth of cities? | Richard Vize