Getting attention to urban health issues – or not?

A personal look at the struggle to get urban health problems recognised and acted upon, and why priorities need to change.

David Satterthwaite's picture
Senior associate in IIED's Human Settlements research group
07 August 2023
The transition to a predominantly urban world
A series of insights and interviews designed to share the experiences of community leaders, professionals, researchers and government from the global South
Woman walking a flooded road with piles of trash bags next to her.

International support for urban healthcare is crucial for adequate sustainable urban development  (Photo: Betina Carcuchinski/PMPA, via FlickrCC BY-NC-SA 2.0)

Discouraging push backs

So how are urban health issues in the global South viewed and acted on by the UN and other international agencies that work there. Some have a clear position. The head of research at UN-Habitat said his agency does not ‘do’ health issues because that is WHO’s responsibility. Can it be true that the agency whose main focus is meant to be improving conditions in cities does not deal with city health?

Or WHO staff, including its then director general Gro Harland Brundtland (1998-2003), who prioritise health care yet give little attention to environmental and occupational health and safety, or their social determinants, in urban areas? And who hold this view despite the massive burden of disease, injuries and premature death that these generate?

WHO had set up the ‘healthy cities’ programme that acknowledged the need to work with urban governments and civil society across sectors. WHO’s regional offices in Europe and South-East Asia ran influential programmes, but WHO headquarters gave the initiative a very low priority.

Likewise, most aid agencies have given very low priority to basic health care and water and sanitation in urban areas over the last three decades – despite all the recommendations demanding that these get more support.

Difficulties to overcome

The myth of the urban bias

There are all the claims that urban populations benefit from urban biases so they should not receive priority – despite the lack of evidence. But what biases do informal settlement dwellers benefit from? And how would we know, given the lack of data?

It is true that separate discussions about urban and rural health are necessary because of the large differences in contexts, people’s livelihoods and the risks they face, and the range of social and environmental health determinants they live with… in governance structures and responsibilities, different government policies and different needs, all of which influence what should be done. But of course, urban issues need to be seen within the larger picture that includes rural/urban links too.

The disconnect between international discourse and local institutions servicing local needs

Government representatives to the UN and other multilateral agencies are concerned with national health issues, bypassing local ones and the local authorities under whose jurisdiction so many environmental and occupational health and healthcare services fall. Aid agencies are only as effective as the local intermediaries they use to implement their projects.

Aid agencies not knowing what to do, and what or who to support

Perhaps in part, the lack of attention to urban health is because they simply don’t know what they can do. Social housing is not the answer – except in a few instances. Serviced house plots or ‘core houses’ on which the occupants can build incrementally can work well if they are in good locations with access to infrastructure and labour markets – but getting such sites is difficult.

Informal settlement upgrading has proved successful in many nations when community-led, but most funding agencies find it difficult to work with grassroots organisations – just as grassroots organisations often find it difficult to work with external funders. 

Early discussions

We could have started this discussion in 1948 with the universal declaration of human rights: “Everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control (article 25).”

But the 1950s and 1960s brought very little international support for health care services or for action on social, economic and environmental health determinants.

A glimmer of hope?

The 1970s saw some rise in interest in urban health issues, including healthcare and addressing social and environmental health determinants, along with some interest in urban poverty. But there was surprisingly little explicit attention to health issues. And this interest was from very low base and mostly confined to the World Bank’s and UNICEF’s support for informal settlement upgrading.

There was more discussion of ‘basic needs’, including healthcare and provision for water and sanitation, and how these should have a higher priority. Barbara Ward’s 1976 book ‘The Home of Man’ has a chapter on ‘the costs of justice’ that spells out the funds needed for basic needs, including urban health.

The 1970s also brought a rapidly growing concern for the environment that can be seen in the UN’s 1972 Conference on the Human Environment, but with little connection to urban/environmental health.

The recommendations coming out of the first UN Conference on Human Settlements in 1976 included universal provision for water and sanitation and action on other key housing-related health determinants. These included the recognition that informal settlement upgrading done well can transform health and reach low-income groups.

The International Conference on Primary Health Care in Alma-Ata in 1978 demanded universal provision of primary health care along with support from sectors that influence health. There was no mention of ‘urban’ or of ‘rural’.

The 1980s – the lost decade

But these positive beginnings came to nought during the notorious 1980s – the lost decade. What was termed ‘selective primary health care’ dropped its strong community focus, and along with it funding for water and sanitation. But this was more about the lack of funding and the need to show effectiveness in the time of Thatcher and Reagan.

As noted above, a large and influential set of agencies not only opposed support for urban health, but opposed any attention to ‘urban’. Again, Mrs Brundtland comes into the picture. She headed the World Commission on Environment and Development whose 1987 report ‘Our Common Future’ helped get sustainable development back on the radar.

But even she tried to get the urban chapter deleted and it was only saved by her chef de cabinet, former Canadian government minister for urban affairs Jim MacNeill, saying ‘over my dead body’.