Urban Health in Developing Countries

by Paul Freeman (freemp@uw.edu)

Needs

Some lessons learned

If time-achievements Manoshi

URBAN HEALTH IN DEVELOPING COUNTRIES

Typical Scene in the Korail Slum.Dacca

This is how over ONE Billion people (150 million children) live

Source: United Nations Population Division, World Population Prospects, The 2008 Revision.

World Population Growth Is Almost Entirely Concentrated in the World's

Poorer Countries.World Population (in Billions): 1950-2050

Urban PopulationPercent

29

15 17

53

47

37 37

76

55

42

74

85

54

61

82

World Africa Asia Latin Americaand the

Caribbean

MoreDeveloped

Regions

1950 2000 2030

Source: United Nations, World Urbanization Prospects: The 2003 Revision (medium scenario), 2004.

Trends in Urbanization, by Region

Much of growth in midsized cities/towns not just megacities

World Urbanization Prospects, the 2009 Revision

Urban and rural population by development regions (in millions)

Source: United Nations, Department of Economic and Social Affairs,2010

World Urbanization Prospects, the 2009 Revision

Urban and rural population, African Region in millions

World Urbanization Prospects, the 2009 Revision

Urban and rural population by city size class (in millions)

World Urbanization Prospects, the 2009 RevisionUrban Agglomerations in 2025 (proportion urban of the world:

56.6%)

Source: United Nations, Department of Economic and Social Affairs,2010

Intra-Urban and Urban-Rural Variation in IMR and U5MR: Nairobi, Kenya

Location IMR (per 1,000 live

births)

U5MR(deaths per

1,000 children)

% prevalence of diarrhea in children

under 3

Kenya, nationwide 74 112 3

Rural Kenya 76 113 3

Urban Kenya, excluding Nairobi 57 84 2

Nairobi – all areas 39 62 3

High income area <10 <15 --

Informal settlements 91 151 11

---Kibera settlement 106 187 10

---Embakasi settlement 164 254 9

Source: Patel, Ronak, Burke, Thomas. (2009). Urbanization – An humanitarian disaster. New England Journal of Medicine, Vol. 361, No. 8, p741-743. Original source: Population and health dynamics in Nairobi’s informal settlements: Report of the Nairobi Cross-sectional Slums Survey (NCSS) 2000. Nairobi: African Population and Health Research Center, 2002.

Urban-Rural Mortality Variation: Bangladesh

U5MR is 57% higher than national and 20% higher than rural poor

Source: Saha, Subir Kumar . Presentation: Poor rich inequalities in the health and survival of urban children in Bangladesh. Presented at the International Conference for Urban Health, Baltimore, MD , Nov. 1st, 2007. Concern Worldwide.

Urbanization and Poverty

Source: Mercado, S., et al. Urban Poverty: An Urgent Public Health Issue. Journal of Urban Health, Vol. 84, No. 1 (May 2007 Supplement).

• The global slum population is 1 billion; estimated to be nearly 2 billion by 2030

• In sub-Saharan Africa, 67% of the urban

population live in slums…

Urban Causes of Child Mortality are Similar to Rural: Kenya

Source: The burden of disease among residents of Nairobi's informal settlements. APHRC No. 1, 2008, Policy Brief.

Pneumonia, Diarrheal Diseases, and still births* account

for nearly 60% of the mortality in children under

five in these slums.

*This study took place in two urban slums, Korogocho and Viwandani, with a population of about 56,000 persons.

Top five causes of premature mortality among children under the age of five years ranked by percentage contribution to the total years of life lost (YLL) in the Nairobi DSS (2003-2005)

Causes YLL % YLL

Rank

Pneumonia 3463 22.8 1

Diarrhoeal Diseases 2969 19.5 2

Stillbirths 2480 16.3 3

Malnutrition and Anaemia 1275 8.4 4

Birth Injury and/or Asphyxia

661 4.3 5

Source: Ezeh, Alex. Population Growth, Poverty & RH: Revisiting The Urban Advantage. African Population and Health Research Center. Presented at the Foundation Presidents Meeting, Population and Reproductive Health, in Seattle, WA. 10 Jan. 2008.

Natural Increase is the Major Cause of Urban Population Growth

Urban Mental Health

• Widespread needs all common manifestations including child neglect and failure to provide normal nurturing.

• Need both community based and oriented approaches & drug treatments

• See Vikram Patel “Where There Is No Psychiatrist” and clinical trials. Lancet

Scaling up Project Lessons Requires

Health System Strengthening

Source: D.Silimperi MSH

Urban Health System Strengthening:Health Service Delivery- also differences from Rural

• Limited primary health infrastructure; role for urban CHWs (consider CareGroups)

• Dependency on hospitals for PHC • Variety of providers, delivery

sites—choice, mobility• Major role of private sector • Quality of care—magnitude of

variation

• Role for regulation—licensing,

accreditation, • Heterogeneity complicates

health promotion, communication • Large scale implications Source: D.Silimperi

New Urban Health Paradigm*

• Recognizes multiple causations• Includes both social and economic determinants• Incorporates concepts of inequity and social capital• Considers the city as a whole• Integrates social science, epidemiology, public health,

urban planning and policy• Takes into account the pluralism of providers• Builds multi-sector partnerships

• *Trudy Harpham, ICUH 2008

Illustrative Evidence-based Urban Research Agenda to Reach MDGs 4 and 5

• Expand information base on the “urban poor”

• Undertake systematic studies of urban morbidity and mortality

• Cost and evaluate integrated urban MNCH package delivery

• Document quality of care • Evaluate diverse incentives and

payment with regard to outcome• Evaluate public-private health

partnerships• Evaluate how best to implement

CBPHC and involve community

Lessons Learned from Successful Urban Health Projectswith Documented Improvements in MNCH and FP/RH (1)

1. Recognize and ensure community involvement, empowerment, and harness local initiative

2. Coordinate across multiple stakeholders; opportunity for innovative partnerships

3. Invest in local analysis, mapping, and data collection

4. Adapt interventions to local needs—no simple solutions or standardized delivery

5. Plan for sustainability, financial and institutional

6. Build management that is accountable for results

7. Undertake advocacy and policy reform along with implementation

Source: D.Silimperi MSH

Lessons Learned from Successful Urban Health Projectswith Documented Improvements in MNCH and FP/RH (2)

8. Incorporate intersectoral collaboration and cost-sharing, cross-cutting support systems

9. Recognize and utilize urban networks and diversity of communities

10. Leverage urban advantages Source D.Silimperi MSH

Invest in people and relationships

Possible visions. Wompa! Tjinuru!

• Plan for a manageable scale, diagonal PHC approach• Address problems prioritized with communities incrementally as

practical --health care, public health, health determinants.• Begin only with early adaptor stakeholders-community, govt and

provider by-in that is maintained by facilitators as a priority• Develop, with local communities & government on the basis of

ongoing evaluation of process and outcomes, a workable model for a reasonably sized community. Design in sustainability from the outset. (Later this community could become a community for innovation and learning for others)

• Repeat this model with local adaptation to other similarly sized communities as they buy-in.

• Vision ahead and add innovation and change incrementally as available, affordable and needed by changing scale as population coverage increases.