What is Health Infrastructure? And Why Does It Matter in Urban Health?

Conversations around health infrastructure often revolve around big-ticket items like hospitals, clinics, and a modernized healthcare system. Among urban centers in the Global South, however, the largest impacts on human health do not come from an absence of medical facilities but a scarcity of clean water and sanitation.

Prioritizing hospitals and healthcare systems, though critical infrastructure, ahead of adequate housing, clean water and sanitation, social services, and well-trained medical personnel, puts the proverbial cart before the horse. With limited resources, governments and NGOs must tackle the underlying causes of ill health first and then implement the big-ticket, headline-grabbing projects after – mirroring the earlier path of high-income countries.

Taking a more holistic approach to health infrastructure means appreciating the multifactorial social determinants of health. From inadequate educational opportunities to private toilets or latrines, poor health infrastructure impedes the health, life outcomes, and prosperity of billions in urban centres.

What is health infrastructure?

Health infrastructure is an all-encompassing term for the services and facilities that contribute to a population’s health. It includes elements of a healthcare system, like hospitals, vaccination programs, clinics, and the personnel who run the system (doctors, nurses, managers, pharmacists, etc.).

The term should not be defined too narrowly, however.

Tremendous advances in general health in high-income countries in the late 19th century were sparked primarily by improvements in sanitation. The Broad Street cholera outbreak of 1954, for example, saw a local water pump being identified as the source of the infection.

Such public health interventions heralded a new era for the grimy streets of Victorian England, as they can in the world’s urban centres today. As such, the term health infrastructure should also include:

• Clean water and sanitation,
• Robust, disease-free housing, and
• Social services

Broader still, we may include infrastructure like roads, communication systems, economic opportunities, planning rules, and a good education within the category, as these impede or enhance the health outcomes of populations. After all, poor health is inevitable if you live in a secluded village with no incoming roads, no significant local economy, and no ability to call ambulances.

UN Sustainable Development Goal 6: Why it matters

In 2015, the UN established its 17 Sustainable Development Goals (SDGs) – a “shared blueprint for peace and prosperity for people and the planet, now and into the future” – placing a firm emphasis on clean water and sanitation.

While SDG 3 (Good Health and Well-Being) formed the backbone of health goals, many of the targets, like ending preventable deaths in newborns and children or reducing epidemics of water-borne diseases, can only be accomplished through a holistic approach to health infrastructure.

SDG 6 (“Ensure availability and sustainable management of water and sanitation for all”) ambitiously targeted universal access to safe and affordable drinking water, adequate sanitation and hygiene, an end to open defecation, reduced water pollution, and more.

If met, these achievements could prove the single biggest improvement in health outcomes ever. According to the World Health Organization (WHO), currently:

• Over 1.7 billion people lack basic sanitation services, such as private toilets or latrines.
• At least 10% of people worldwide consume food irrigated by wastewater.
• Nearly 1 million people in low- and middle-income countries die from inadequate water, sanitation, and hygiene annually – 60% of diarrhoea deaths.

Building health infrastructure in an urbanizing world

Increasing urbanization poses an additional set of challenges for low-income countries, exacerbating and entrenching existing health inequalities as hundreds of millions migrate into overcrowded cities in the Global South. By 2050, it’s estimated that two-thirds of the world’s population will live in urban centers.

Despite the diversity among Global South nations, several broad trends are identifiable: a spike in megacities (> 10 million people); increased urban sprawl, often in the form of slums and shanty towns; growing intra-urban inequalities; and a rising disease burden.

The term “southern urbanism” was coined to describe this phenomenon, noted for its contribution to the complexity and growth of the disease burden.

“Noncommunicable diseases are also growing rapidly in the Global South, linked to changes in living conditions and lifestyle associated with urbanization. It is anticipated that the burden of disease in cities of the Global South will continue to increase as urbanization continues, as a result of increased traffic injuries and respiratory disease resulting from increased numbers of motor vehicles; growing levels of violence due to growing levels of poverty and inequality in many cities; growing obesity as a result of changing lifestyles associated with urbanization; growing numbers of unsafe settlements in hazardous areas; and a high risk of infectious diseases,” writes Warren Smit, Research Manager for the African Center for Cities.

Informal settlements, in particular, arise naturally as the urban pull factors outstrip the ability of governments, NGOs, and the private sector to build new infrastructure, be it housing, toilets, sewage systems, and more. Residents frequently do not have legal security, and dwellings rarely comply with planning and building regulations and therefore lack adequate services.

Moreover, nations find themselves hit with a double-punch of malnutrition and obesity, as urban poor populations become plagued by high food insecurity and low dietary diversity. Combined with indoor and outdoor air pollution, which causes approximately 2 million premature deaths annually, it is a perfect storm for worsening health outcomes.

What must be done?

We are in the last decade for realizing the UN’s Sustainable Development Goals. After the global pandemic further exacerbated health inequalities in the Global South, the urgency for change has never been greater. Indeed, as Smit notes, “Climate change is likely to exacerbate these risks.”

With Africa predicted to see 4 billion people by century’s end and India overtaking China as the world’s most populous country, nations in the Global South must take a holistic approach to health infrastructure. Housing, clean water and sanitation, economic investment, a reliable planning system, pollution regulations, and dietary diversity should form the backbone infrastructure for the new southern urbanism.

Global inaction simply isn’t an option.