Helen Elsey, professor in global public health at the University of York in the UK, is a researcher focused on urban health, particularly in lower and middle income countries where rapid urbanisation is happening. She is especially interested in understanding what drives inequalities in health in cities and how to strengthen health systems to address these challenges. Professor Elsey discussed urban health, challenges, opportunities with Bal Krishna Sah of The Himalayan Times. Excerpts:
What is the purpose of your visit to Nepal?
I am co-director of a research consortium, 'Community-led Responsive and Effective Urban Health System (CHORUS)', which aims to strengthen urban health systems to improve urban health equity.
The consortium has partners in universities and research organisations in Nepal, Bangladesh, Ghana, and Nigeria. One of our partners, HERD International, is leading this work in Nepal. So, I'm here to work with the research team developing plans for the next phase of our work with Pokhara Metropolitan City. We will also hold a workshop for our researchers in Bangladesh and Nepal to come together and write academic publications of our work so far.
Why do you feel it is important to research urban health and how is urban health linked to universal health coverage?
Universal health coverage requires that all individuals have access to quality essential health services without suffering financial hardship. However, there are many challenges in achieving universal health coverage within the urban context. As people move from the rural areas - often due to economic challenges and climate change - to the city, we see rapid urbanisation particularly in South Asia and sub-Saharan Africa.
By 2025, 75 percent of the urban population will be in the global south, that's an estimated urban population of 3.75 billion. This rapid urbanization has put a great strain on the fragile city infrastructure not designed for the growing population. This is true for health services, as well as for housing, transport, waste and water management. This pressure on services is exacerbated by increase in non-communicable diseases such as diabetes and heart diseases. This means that health services - already overstretched in the urban context - are having to adapt so they can respond to these long-term chronic conditions.
What are the additional factors that make urban dwellers vulnerable in terms of health?
The rise of non-communicable diseases is the major risk riven by the changing living patterns in cities. People have less access to fresh fruits, vegetables, and physical activity than in rural areas and this, coupled with increases in alcohol, tobacco and substance abuse are increasing risk of developing noncommunicable diseases.
There are other factors in the urban environment that fuel both communicable and non-communicable diseases. Let's take the example of Kathmandu, where air pollution has been a significant problem, with estimates of 222 per 100,000 deaths due to air pollution in Nepal each year. This highlights how much health in cities is dependent on what happens in sectors other than health. For example, building adequate housing with access to clean water and sanitation or developing a good public transport system and encouraging people to walk or cycle, will have the most impact in improving urban health.
In fact, when we talk about 'health systems' in cities, we have to think beyond the 'healthcare system'. The urban health system must include all sectors, from transport to education or development.
Another challenge we have found is that the urban poor are often not captured in the data available on health in the city. There are several reasons behind this, but as many informal settlements are not legally recognized, they may not appear in surveys, and as the urban poor mainly use private providers, they are not captured in routine public health service data. This makes it very hard for city governments to plan and target the urban poor population.
Would you provide an overview of your current CHORUS research consortium on urban health?
We realized that these challenges are common, not just in Nepal, but in other rapidly urbanizing countries. So, our consortium, funded by the UK government, brings together researchers from Bangladesh, Ghana, and Nigeria as well as Nepal in a six-year program to find solutions to improve urban health, particularly among the poorest.
We have a number of studies in each country that aim to address health system challenges by identifying problems, co-designing - with city governments, health providers and communities - and then evaluating interventions that can strengthen the urban health system to reduce inequities in urban health.
How does your research address the unique challenges and opportunities of urban health you mentioned in these diverse regions?
Our research on urban health focuses on four areas: linking different types of service providers such as public and private; engaging with multiple sectors in a collaborative manner; responding to the double burden of communicable and non-communicable diseases, and identifying, reaching, and engaging the urban poor.
Let's take the example of Nepal where most people in urban areas use pharmacies or private providers. So, we are looking at ways to link public and private providers. We are working across different sectors to address some of the wider issues that are driving poor urban health and inequalities. Given the challenges of finding the health needs of the urban poor through available data, within CHORUS we have designed our studies to include close engagement with communities, using participatory methods to understand the challenges they face with their health and with access to care.
As an expert on gender and intersectionality, how do you think the gender dynamics intersect with urban health issues, and how it should be considered to achieve better health outcomes?
When we're talking about intersectionality, it's not just about whether you're male or female or third gender, it's about how other factors, like your level of wealth or education or disability, can combine with gender, often having a greater negative impact. For example, studies have shown that men will often wait until their condition is really bad before seeking care.
This means that conditions such as diabetes or hypertension get much worse. Whereas, many poor, married women may not be able to access money and take the decision to seek care without asking their husband's permission. So understanding how gender and these intersecting factors influence health and health-seeking behavior is really important when shaping the health system to meet everyone's needs equally.
So how does the research in urban health promote gender-responsive health services?
Our study provides evidence that can guide the government in addressing the diverse needs of individuals to ensure that healthcare services are accessible to all.
For instance, the government can adjust the opening hours of health facilities to accommodate daily-wage earners working long hours or make healthcare facilities physically accessible for people with disabilities.
In Bangladesh, our research focused on the transgender community in Dhaka, a group often under-represented in research. We were able to hear their stories of discrimination when trying to access primary care or pharmacies. Recognizing these challenges is essential to transform healthcare services into a more inclusive and respectful environment.
Health system strengthening is vital to achieve universal health coverage. In the context of Nepal, how can your research provide the most valuable insights to inform policies aimed at strengthening the urban health system?
In Nepal, like many countries, historically the focus has been on health in rural areas. It is only fairly recently that government, donors and researchers have really started to focus on health in urban areas. In fact, Nepal is leading the way as highlighted by the urban health policy introduced in 2019, this is groundbreaking, considering that many countries lack such a framework. Our CHORUS work in Pokhara metropolitan city led by HERD International assessed all health facilities and identified health health-seeking behavior of communities. Our approach is to work hand-in-hand with the local government. So, rather than just writing a weighty research report that goes unread, we developed fact sheets for each ward showing the health facilities and indicators in their area.
This helped ward chairpersons have a comprehensive understanding of health in their jurisdiction. Our findings showed that people are predominantly using private pharmacies so, we are now working with the metropolitan city to build linkages with private pharmacies so they can address hypertension and diabetes through the provision of health advice, screening, and referral to the public sector. Working in partnership and finding solutions grounded in the realities of city health systems is crucial to achieving universal health coverage and improving our cities for everyone.
A version of this article appears in the print on September 21, 2023, of The Himalayan Times.
