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)

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)

Country

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

Operational Plan For Health (OPH) 2015-2020

2.5% of total ADB portfolio invested in health in 2015
but pipeline plateauing

Increase health lending from

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

Million $
800
700

Focus on 9-12 DMCs

Support DMCs to achieve
Universal Health Coverage
(UHC)

600
500
400
300

Expand health sector team

Leverage partnerships with
Centers of Excellence

200

100
0
2014 2015 2017 2018 2019 2000
ADF and OCR

LEARNING FROM OUR

INVESTMENTS IN URBAN HEALTH

ADB investments in urban health

ADBs 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)

Governance

Service provision

DMC 1

Framework developed
to regulate private
sector

DMC 2

DMC 3

Urban health program

delivered through
Ministry of Local
Government

Standards of Quality
Assurance, PublicPrivate Partnerships
(PPP) and Health
Management
Information System
developed

Primary care
strengthened through
Primary care for
PPP model
maternal, child health Strengthening of city
and communicable
planning to identify
Developing model
diseases delivered
health facilities which
hospital for secondary through PPP with NGO
require upgrades
care with established
referral network

Investments in urban health systems

Developing Member
Country (DMC)

DMC 1

DMC 2

DMC 3

Financial protection

Strengthen district
hospitals to avoid selfreferral to tertiary
facilities

The poor are preidentified and given

cards

Provision of free
health services
supported

Involve community
groups in urban
planning

Social participation:

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 nonfunctioning 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 patientsperceived 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

West Palm Beach, Florida : AFTER

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

New York City

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

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?