URBAN HEALTH AND UNIVERSAL HEALTH COVERAGE

Disclaimer: The views expressed in this paper/presentation are the views of the author and

do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its

Board of Governors, or the governments they represent. ADB does not guarantee the

accuracy of the data included in this paper and accepts no responsibility for any

consequence of their use. Terminology used may not necessarily be consistent with ADB

official terms.

Asia and the Pacific is rapidly becoming urban (Source: WDI Online)

Country Urban

population

Urban growth

(%) Megacities & rank in 2015

China 742,299,307 2.82 Shanghai (6); Beijing (8);

Guangzhou-Foshan (10)

India 419,234,061 2.38 Delhi (3)

Indonesia 134,868,666 2.69 Jakarta (2)

Pakistan 70,877,513 3.27 Karachi (7)

Bangladesh 53,316,419 3.51 Dhaka (16)

Philippines 44,104,820 1.27 Manila (4)

Urban Health Systems

• 40% of the population in ADB DMCs are now living in urban areas

• Extent health systems in urban areas can provide quality services will be a key in achieving universal health coverage.

UNIVERSAL HEALTH COVERAGE

Ensuring that all people can use the promotive,

preventive, curative, rehabilitative and

palliative health services they need, of

sufficient quality to be effective, while also

ensuring that the use of these services does

not cause the user financial hardship

Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality

and affordable essential medicines and vaccines for all

5

Operational Plan For Health (OPH) 2015-2020 2.5% of total ADB portfolio invested in health in 2015

but pipeline plateauing

Million $

ADF and OCR

• Increase health lending from

<2 to 3-5% ($ 700m-1b) by 2020

• Focus on 9-12 DMCs

Support DMCs to achieve

Universal Health Coverage

(UHC)

Expand health sector team

Leverage partnerships with

Centers of Excellence 0

100

200

300

400

500

600

700

800

2014 2015 2017 2018 2019 2000

LEARNING FROM OUR INVESTMENTS IN URBAN HEALTH

ADB investments in urban health

• ADB’s support for development projects in urban areas, include direct investments in urban health and indirect investments in urban heath-related sectors (water and sanitation, clean energy and infrastructure).

• Direct urban health interventions in three developing member countries (Bangladesh, India, and Mongolia)

• All three urban health interventions: – support quality primary services – strengthen health system, including governance, health information

systems, and capacity building – modality of service provision ranges from entirely public sector, to

partnerships with both not-for-profit and for-profit providers.

Investments in urban health systems

Developing Member

Country (DMC) DMC 1 DMC 2 DMC 3

Governance

Framework developed

to regulate private

sector

Urban health program

delivered through

Ministry of Local

Government

Standards of Quality

Assurance, Public-

Private Partnerships

(PPP) and Health

Management

Information System

developed

Service provision

Primary care

strengthened through

PPP model

Developing model

hospital for secondary

care with established

referral network

Primary care for

maternal, child health

and communicable

diseases delivered

through PPP with NGO

Strengthening of city

planning to identify

health facilities which

require upgrades

Investments in urban health systems

Developing Member

Country (DMC) DMC 1 DMC 2 DMC 3

Financial protection

Strengthen district

hospitals to avoid self-

referral to tertiary

facilities

The poor are pre-

identified and given

cards

Provision of free

health services

supported

Social participation:

Involve community

groups in urban

planning

Inter-sectoral action

Primary clinic PPP are

monitored in part by

local government

Urban clinics managed

under urban local

bodies

Common challenges

Governance

• Lack of coordination between government health system across different national ministries and sub-national government units

– Partly due to the absence of a policy framework on health service delivery.

– Resulting to a number of ministries/government bodies in charge, in one way or another, in a particular segment • In most instances, several agencies are separately in charge of

primary care, hospital care, women and children. • each actors’ role is not explicitly defined, resulting to redundancies

or nonexistence of necessary services.

Common challenges

Governance

• Poorly regulated private sector results to:

– weak information systems that are unable to capture the true disease burden or strain on health service delivery.

– limited control results to limited means in ensuring the quality of care provided

Common challenges

Service Delivery • tolerance of low quality health services, and switching of

providers resulting to limited care continuity and non-functioning referral of patients between providers – lack of standardized tools to communicate and document referrals – poor coordination and linkages within and between facilities – non-compliance with referrals – weak referral monitoring systems – inadequate referral infrastructure and financing

• self-referral is common among patients—perceived poor quality of primary care facilities in the urban areas pushes them to seek medical care in tertiary facilities – BUT underdevelopment of primary care in urban centers may have

contributed to the abundance of tertiary hospitals in the same area.

Common challenges

Financing

• limited financial protection brought about by the charging

of user fees, and limited “coverage” of government-run health insurance systems

• Presence of an poorly regulated private sector contributes to high out of pocket expenditures

Common challenges

Social participation and inter-sectoral collaboration

• low social participation compounded by lack of information

on available government health services

• minimal inter-sectoral collaboration and cooperation leading to missed opportunities for synergies between health and other sectors (education, infrastructure, others)

Challenges

– Political commitment and strategies for improving health in urban areas, however, often lack evidence about how to design, implement and monitor large scale interventions.

– Urban health in low and middle income countries tend to be

eclipsed by larger rural development health programs.

– Missed opportunities in urban areas to link health sector

programs with other social sectors interventions

– Urban health systems further complicated by large private

health service delivery sector , and multiple layers of government service delivery (primary, secondary and tertiary together with medical education) under different government ministries/bodies

2016 GLOBAL REPORT ON URBAN HEALTH

Points to Ponder

• Disaggregated data helps

• Build on urban capacities

• Work with other sectors

• Build on financing that works

Points to Ponder

• Disaggregated data helps

• Build on urban capacities

• Work with other sectors

• Build on financing that works

Bangladesh

Bangladesh

Cambodia

Cambodia

Indonesia

Nepal

Nepal

Pakistan

Pakistan

Philippines

Viet Nam

Viet Nam

Points to Ponder

• Disaggregated data helps

• Build on urban capacities

• Work with other sectors

• Build on financing that works

Urban capacities

• Well resourced with: – Health workers – Financial resources – Facilities

• Stable electricity and refrigeration

• Stronger supply chain management

• Population Density enables mobility and access at scale for reaching

health care providers

• Numerous information media and outlets

More resources, mobility and information -- better access and availability

But bad for Non-communicable Diseases

• Greater consumption of unhealthy food, use of tobacco and alcohol, physical inactivity due to:

– Over-reliance in motorized transport

– Availability of unhealthy food

– Longer working and commuting time

Points to Ponder

• Disaggregated data helps

• Build on urban capacities

• Work with other sectors

• Build on financing that works

Colombia/Mexico

• Communities close off streets to cars and open them on cyclists and pedestrians

• Promote community engagement and exercise

Wales

• Data from police reports are combined with the emergency department records

• Predict and prevent violence

Local Governments

Policies and environments that affect peoples’ health are determined by a variety of local government entities, including:

• City Councils

• Zoning Boards

• School Districts

• Transportation & Planning departments

• Parks & Recreation departments

Local Governments

Local government officials can enact policies that support the control of obesity

– For example, local zoning ordinances & economic incentives affect the presence and absence of: • Parks and open spaces for recreation

• Bike facilities

• Mixed use developments

• Healthy food retailers &

farmers markets

West Palm Beach, Florida : BEFORE

• two-way traffic

• wide shaded sidewalks

West Palm Beach, Florida : AFTER

• raised intersections • shortened pedestrian crosswalks • narrowed streets • on street parking

West Palm Beach, Florida : AFTER

• Renovated abandoned buildings for mixed use development

West Palm Beach, Florida : AFTER

West Palm Beach, Florida : AFTER

• Goal: Decrease consumption of Sugar Sweetened

Beverages among children age six and under.

• Policy Change: The NY City Board of Health amended

its health code to prohibit serving beverages with added sweeteners and places limits on beverages served in licensed day care facilities.

– Limits the serving size of 100% fruit juice to 6 oz per day for children 8 months and older

– When milk is served, children 2 years of age and older must receive low-fat 1% or non fat milk

– Water must be readily available throughout the day

New York City

Points to Ponder

• Disaggregated data helps

• Build on urban capacities

• Work with other sectors

• Build on financing that works

• NATIONAL HEALTH INSURANCE – Tax financing combined with health insurance

premiums from formal sector

– NOT YOUR USUAL SOCIAL HEALTH INSURANCE

China

Two urban schemes

Iran

Thailand

Moving forward

• Craft urban health plans with explicit roles and accountability for government and private sectors – Re-designing government service delivery framework

• Invest in Health information systems that routinely capture both the health

status of communities and health service delivery across both public and private sectors – And can disaggregate data into urban/rural and quintiles

• Consider national health insurance systems which pool tax financing and

formals sector insurance premiums, and can purchase from the public and private sector in a way that increases health system efficiency leading to better outcomes for the patient – Government into a purchaser of outputs and outcomes rather than inputs

• Encourage urban local authorities to promote convergence and dialogue with

other sectors – demonstrate evidence of health impacts

YOUR THOUGHTS?