Creating stronger urban health systems in the Global South
With primary health services stretched to the limit, could new healthcare models developed with international partners provide life-saving capacity?
Cancer, heart attacks, diabetes and stroke: we think of these as afflictions of the developed world, exacerbated by our lifestyle, diet and lack of exercise. But these conditions are becoming more and more prevalent in low and middle-income countries too, particularly in cities, whose populations have swelled in recent decades. And while our health systems have had the time and resources to adapt, theirs have not.
In the past, many countries in Africa and Asia focused on developing state-run health services for their rural populations — particularly primary care and community services in local hospitals and healthcare centres. While urban populations have easier access to the big hospitals and specialist services, primary care — the front door of any healthcare system — is usually less well-established, often provided by the private sector or charities.
As more people have moved to the cities for work, these primary care services have been stretched to the limit. At the same time, their caseload has changed from treating predominantly communicable diseases such as malaria and tuberculosis to managing non-communicable diseases such as cancer and diabetes.
New models for primary care
A new six-year programme, funded by the Foreign, Commonwealth and Development Office, is aiming to help redress the balance. The team — involving researchers from Bangladesh, Ghana, Nepal, Nigeria and the UK — is developing projects that will pilot new ways of delivering primary care services to poorer communities in large and medium-sized cities in each country.
With policy makers involved in the process from the outset, the plan is that, if proved successful, each project can be rolled out more widely across the country and — where appropriate — across the wider region.
The seven organisations involved in the project have all worked together before, with each bringing different expertise to the table. For example, the ARK Foundation, based in Bangladesh, is very experienced in working around gender and equity issues, while the University of York has expertise in systematic reviews and the University of Leeds and HERD International, based in Nepal, have particular strengths in quantitative and qualitative research respectively.
Project co-director from the University of Leeds, Professor Tim Ensor, explains: “Having such a strong partnership is crucial, as projects in each country are able to benefit from this combined knowledge and expertise. Having worked together before also makes the collaboration run much more smoothly, with distance and the necessity for online communication being no real barrier.”
One of the first projects to kick off will be in Bangladesh, led by the ARK Foundation, and BRAC University, based in the capital Dhaka. The team are adapting the World Health Organisation Package of Essential Non-communicable disease interventions (WHO PEN) to the particular circumstances in Dhaka — and later the smaller city Khulna — with an initial focus on state-run primary care.
They are looking at which non-communicable diseases — those not passed from person to person — are most prevalent in the city, how they need to be treated or managed and what resources are required, including healthcare staff. They also plan to address how patients are referred to hospital if their condition worsens, and what information systems and care records are in place to enable that transition.
In Nepal, a similar project, led by HERD International, will work with private sector and not for profit providers of primary care, in Kathmandu and Pokhara.
Integrating informal healthcare
The project in Nigeria, led by the University of Nigeria, is taking a slightly different approach. In slum communities in Nigerian cities, people use informal routes for their healthcare, such as small drug stores, self-trained ‘doctors’ without professional qualifications, and traditional medicine practitioners.
Professor Ensor explains: “The problem with such informal providers is that there is very little consistency or quality control. But at the same time, there’s no point simply telling people not to use them. So we’re aiming to engage with these healthcare providers, find out what they provide and assess the quality. If the healthcare is acceptable, then our aim is to work with them to improve it and try and integrate them into the formal systems.”
The Ghanaian project will work in two districts of Accra, adapting a system of community health practitioners that is used successfully to deliver primary care in rural areas. These health workers travel around villages to deliver care outside the main health facilities, and have a far greater reach and impact as a result. The project, led by the University of Ghana, will aim to do the same in the districts of Ashaiman and Madina, focusing not only on treatment of non-communicable diseases but also on their prevention, by promoting healthier lifestyles, diet and exercise.
The Community-led Responsive and Effective Urban Health Systems (CHORUS) programme runs until 2026.
More information about the programme can be found at chorusurbanhealth.org. Follow CHORUS on Twitter.
