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Addressing health inequalities: why neighbourhoods should be front and centre of building a fairer world

(This blog was published on the SHLC's website prior to putting it here)

The emergence and spread of Covid-19 all across the globe has meant that more than ever, we have realised the importance of the context and place we live in.

We have become more appreciative of the accessible and adaptive physical and social features of our local neighbourhood. Liveability and sustainability of our neighbourhoods and cities determine our health and wellbeing and lately, with the impacts of Covid-19 felt throughout every community, this has received significant attention. Our work at SHLC is exploring how sustainability can be achieved at a neighbourhood level.

A year ago, a colleague and I argued how a bottom-up approach (neighbourhoods to local governments and above) is crucial in the race to manage the fast-spreading pandemic. As the virus has embedded, COVID-19 has highlighted the limitations we have in our system and has also brought to the surface the resilience built up from the neighbourhoods and communities that have helped us to keep going.

Most importantly, this pandemic has exposed how inequalities in health happens in cycles. The impact is disproportionate and those living in vulnerable circumstances are bearing most of the disease and associated socio-economic burden. It is clear to see, as the World Health Organization emphasises, “our world is an unequal one.

This year’s World Health Day focuses on a campaign to build a fairer and healthier world. The constitution of the World Health Organization enforces health as the basic and fundamental right of every human being, which is to be experienced without distinctions in any form. The envisioned fairer and healthier world is achieved only when there is equity in accessing the services and equality in the outcome. Inequalities in health is a global issue and not just for resource-constrained countries. COVID-19 has further highlighted this gap, which is mostly attributable to wider socio-environmental conditions where people are born and/or spend their time – what is most commonly referred to as ‘the social determinants. Cities host more than half of the global population and during this pandemic, the health of our urban population is bearing a detrimental impact.

Private health facility on the fringes of Kigali, Rwanda. Credit: Ramjee Bhandari, University of Glasgow
Determinants of urban health

The determinants of urban health are multi-sectoral and multi-level in nature. The role of sectors other than health, which integrate, overlap and coordinate are crucial in shaping the health outcomes in our changing urban context (see Figure below). A supportive social environment, healthy physical attributes and responsible politics all interact together to create healthy cities. While the importance of these social and environmental determinants of health is now uncontested, the rapid and often unplanned urbanisation in developing country cities has strained the ability of governments to build healthy and liveable neighbourhoods.

The syndemic of COVID-19, non-communicable diseases (NCDs) and the social determinants of health

  (Bambra et. al., 2020)
Unfair neighbourhoods

While cities bring opportunities for better health, they also bring many challenges if they are unplanned or unregulated. It is essential to recognise the social differences in our cities and to act to mitigate these differences in fair and just approaches. Compared to rural or non-urban areas, cities tend to have more health and social services. There is, however, a marked inequity in access and take-up of these services. In health sectors, the introduction of the private sector/market has resulted in wider availability of healthcare services, but the cost associated with it creates inequality and excludes certain populations who do not have the resources to access it.

These services are often placed near high-income neighbourhoods, providing significantly less benefit to those who cannot afford to pay. For example, in Khulna city in Bangladesh, the ratio of public, private and nongovernmental organisation (NGO) health facilities in Purba Sonadanga (a planned high-income neighbourhood) is 14:79:7 versus a ratio in Lobonchora (a low-income organically established neighbourhood) of 0:75:25. Though a diversity of service providers has increased available options, in developing country settings, the private providers are often poor and not adequately regulated.

For sectors other than health, there are similar issues of accessibility, affordability and usability. Education is another key social determinant impacting urban health that also has issues of structural inequity and quality to contend with.

We often see cities within cities, with distinctive urban conglomerates of planned and informal/unplanned/organic areas found side by side. While planned neighbourhoods have access to better urban services, informal settlements often lack the provision of basic amenities. The proximity of features such as a public open space is often associated with where you live, if you live in a deprived neighbourhood, these spaces are less likely to be accessible to you and you are less likely to use them. Urban residents living in deprived communities are more at risk of being impacted by events such as the current pandemic or other economic shocks. Building a safer city thus requires having a safety net to protect the vulnerable groups.

Public sports facility in Batangas City, the Philippines. Credit: Ramjee Bhandari, University of Glasgow
Way forward

To address urban health inequalities and end discriminatory practices, a coordinated approach is required. A proper alignment of population distribution and amenities, health services along with others, necessary for neighbourhoods is possible with proper planning. The role of governments and stakeholders at all levels are key to the protection of basic human rights in health and creation of a better environment where everyone can enjoy the best possible health outcomes.

Considering the impacts all sectors have on health, it is imperative to recognise health in all policies. As cities start to recover from Covid-19, there is also an urgency to rectify the systemic health gap this pandemic has brought to the surface. Without further hesitation, we need to move faster to create healthy and equitable neighbourhoods by realising that the health of its citizens is the most important asset any city can have.

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