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Presented by ADB's Eduardo Banzon on 25 April 2016 at the Asian Development Bank (ADB) Headquarters in Manila at the Health Talks Seminar Series.
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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?
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