Urban Health in Low- and Middle-Income Countries

Abstract

Over the next 30 years, low- and middle-income countries will cross an historic threshold, becoming for the first time more urban than rural. This chapter explores the implications for urban public health. To date, health research and policy discussions have been overly concerned with urban-rural differences in health, which generally favour urban areas except for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), and insufficient attention has been paid to the wide disparities in health that exist within urban areas. Empirical studies show clearly that the urban poor - especially those who live in slums, without adequate drinking water, sanitation, and housing - face health risks that are similar to and sometimes markedly worse than the risks facing rural villagers. The private sector is a more prominent element of the urban than the rural health system, and the monetary costs of care often cause the urban poor to delay or forgo needed treatment. In addition, although high-quality health care is in principle available in large cities, the quality of the basic health-care services accessible to the urban poor can be abysmally low. It is not so much the physical distance to services that matter for them, but the social, informational, and economic costs of access. A number of urban health risks warrant more attention: Women's mental health, which is doubtless a key determinant of self-efficacy and thus health-seeking behaviour; the incidence of intimate-partner violence and the risks of crime faced by the urban poor; injuries and deaths due to motor vehicles, typically ranking near the top of the urban burden of disease; tuberculosis and malaria (in sub-Saharan Africa and parts of Southeast Asia); the health threats posed by indoor and outdoor air pollution; and the risks that climate change will present for the cities of low- and middle-income countries, which are likely to experience increases in extreme weather in the coming decades. As national governments and health systems continue to decentralize, the health needs of smaller, secondary cities cannot continue to be neglected - it is in these smaller cities where the majority of urbanites live in most countries. To meet the health challenges of an urban era, the public health sector must engage in what Harpham (2007) terms 'joined-up government', forging partnerships with other urban agencies and sectors at the municipal and regional as well as the national level.