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Rethinking health systems in the context of urbanisation: challenges from four rapidly urbanising low-income and middle-income countries
  1. Helen Elsey1,
  2. Irene Agyepong2,3,
  3. Rumana Huque4,
  4. Zahidul Quayyem5,
  5. Sushil Baral6,
  6. Bassey Ebenso7,
  7. Chandani Kharel6,
  8. Riffat Ara Shawon8,
  9. Obinna Onwujekwe9,
  10. Benjamin Uzochukwu10,
  11. Justice Nonvignon11,
  12. Genevieve Cecilia Aryeetey11,
  13. Sumit Kane12,
  14. Tim Ensor13,
  15. Tolib Mirzoev14
  1. 1Department of Health Sciences, University of York, York, North Yorkshire, UK
  2. 2Research and Development Division, Ghana Health Service, Accra, Greater Accra Region, Ghana
  3. 3Public Health Faculty, Ghana College of Physicians and Surgeons, Accra, Ghana
  4. 4Director, The ARK Foundation, Dhaka, Bangladesh
  5. 5Centre of Excellence for Urban Equity and Health, BRAC University James P Grant School of Public Health, Dhaka, Dhaka District, Bangladesh
  6. 6Research, HERDInternational, Kathmandu, Nepal
  7. 7Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
  8. 8Public Health Research, Centre for Injury Prevention and Research Bangladesh, Dhaka, Bangladesh
  9. 9Department of Pharmacology and Therapeutics, University of Nigeria Faculty of Medical Sciences, Nsukka, Enugu, Nigeria
  10. 10Health Policy Research Group, College of Medicine, Universiy of Nigeria, Enugu, Nigeria
  11. 11School of Public Health, University of Ghana, Legon, Greater Accra, Ghana
  12. 12Nossal Institute for Global Health Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
  13. 13Nuffield Centre for Health, University of Leeds, Leeds, UK
  14. 14Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
  1. Correspondence to Dr Helen Elsey; helen.elsey{at}york.ac.uk

Abstract

The world is now predominantly urban; rapid and uncontrolled urbanisation continues across low-income and middle-income countries (LMICs). Health systems are struggling to respond to the challenges that urbanisation brings. While better-off urbanites can reap the benefits from the ‘urban advantage’, the poorest, particularly slum dwellers and the homeless, frequently experience worse health outcomes than their rural counterparts. In this position paper, we analyse the challenges urbanisation presents to health systems by drawing on examples from four LMICs: Nigeria, Ghana, Nepal and Bangladesh. Key challenges include: responding to the rising tide of non-communicable diseases and to the wider determinants of health, strengthening urban health governance to enable multisectoral responses, provision of accessible, quality primary healthcare and prevention from a plurality of providers. We consider how these challenges necessitate a rethink of our conceptualisation of health systems. We propose an urban health systems model that focuses on: multisectoral approaches that look beyond the health sector to act on the determinants of health; accountability to, and engagement with, urban residents through participatory decision making; and responses that recognise the plurality of health service providers. Within this model, we explicitly recognise the role of data and evidence to act as glue holding together this complex system and allowing incremental progress in equitable improvement in the health of urban populations.

  • health systems
  • urban
  • non-communicable diseases
  • multi-sector
  • local government
  • nigeria
  • ghana
  • nepal
  • bangladesh
  • low- and middle- income country
  • urbanisation

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjgh-2019-001501

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    Footnotes

    • Handling editor Stephanie M Topp

    • Contributors The concept for the paper developed through discussions with authors HE, TE, TM, RAS, SB, CK and RH at the Health Systems Research conference, October 2018. All authors contributed to the concept of the paper and contributed examples and evidence from their country contexts. HE developed the draft of the paper. All authors provided multiple rounds of comments on the article text and figure. All authors approved the final draft and the supplementary material.

    • Funding The participation of authors in Health Systems Research Conference where the paper was conceptualised were funded by the following grants: Surveys for Urban Equity, GCRF MRC Foundation Award MO/PR24718/1; Healthy Kitchens: Healthy Cities, World Universities Network; and COMDIS HSD Research Consortium, Department for International Development and Urban Anchal, MRC PHIND MR/PO17037/1.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement No additional data are available.