Reframing urban health, reconnecting public health and contextualizing HIV. Lessons from South Africa

Despite the challenges of migration, rapid unplanned urbanization and increasing health inequities within as well as between cities, urban health does not yet appear high on the global public health and research agenda. More than half of the world's population is now living in cities and most of the population growth in the coming decades will take place in urban areas, primarily in Africa and Asia. An estimated one billion live in poor, overcrowded informal settlements and this population is expected to double in the coming 20 years. Although the relevance of the social and physical environment for health has long been known, health policies often prioritize single issues, reactive approaches, and disease-specific solutions that do not sufficiently take into account the life-context of the population (beyond life-style) and the need for systemic intersectoral action at all levels to address the structural driving forces of (health) inequities.

The paper by Dr Joanna Vearey documents well the combined challenges of migration, urbanization, informal livelihoods, and HIV. Post-apartheid South Africa has experienced a faster urban growth rate than other African countries and is also home to the largest population living with HIV globally. The highest HIV prevalence nationally is now found within crowded urban informal settlements and the paper contextualizes HIV in the city of Johannesburg, one of the largest metropolitan areas in the world, situated in the wealthiest province of South Africa. South Africa has now one of the most progressive constitutions in the world and acknowledges the right to health, but many people still lack access to the most essential public services and struggle to survive. Health systems are fragmented, under-resourced and under-staffed. Cross-border as well as internal migration add to complexity. The paper therefore conceptualizes HIV as a contextual and a central developmental challenge.

The studies by Dr Vearey have examined the upstream social determinants and her research confirms the diversity of migration experiences in rapidly urbanizing contexts, the unequal access to essential services and the need for improved action by local governments. Aspects of the studies in this paper contribute to the knowledge on “the causes of the causes” by delineating pathways that translate lower socio-economic and different migrant status into poorer health outcomes in urban settings in South Africa. As we read in the paper, the specificity of the rapidly changing urban context is often not acknowledged, while implications for health and development policy are not yet sufficiently understood by local governments. The paper identifies a number of central development challenges that need to be addressed: urban inequalities, migration, informal settlements, urban HIV prevalence, residents with weak rights to the city, and survivalist livelihood. The advent of new powerful actors in the contested space of cities, the power asymmetries, as well as the increasing influence of global processes on local policy and decision making and therefore also responsibility could be considered as well.

The paper focuses in particular on the role of local governments, but acknowledges the need for action at multiple levels by engaging with different actors. This is particularly relevant in South Africa, where the HIV epidemic has increased pressure on a health system that is fragmented, segmented, and overstretched by the demands made upon it and where TB and HIV need to be tackled together in a context of increasing drug-resistance and migration of human resources. The challenge to ensure health for all by developing a strong, staffed, and resourced national health system and to reduce inequities between cities demands also engagement by government at all levels and by the whole of South African society, as well as coherent policy and sustained support by global actors. The paper by Dr Vearey adds another relevant dimension that is still neglected in the current debate about priority setting and decision-making: context matters and the combined challenges demand a systemic approach. Public health needs to reconnect with urban planning and the social sciences.

Also, inter- and transdisciplinary approaches in urban health research are still limited. However, these are critical in order to better understand the linkages between health and environment, the context-specificty, the politics of urban planning as well as the decision-making processes and power assymetries at local, national and global levels. It is of interest that Dr Veary has explored mixed methods in order to capture the reality in peripheral informal settlements and inner-city Johannesburg, but also to give a voice to the hidden urban migrant communities. The various components of this study have underlined that current conceptual frameworks cannot account for the complex impact of the processes of migration, urbanization, informalization, and HIV. Concept mapping is proposed as a relevant tool to increase knowledge and to guide local governments. These conclusions point to a potential research agenda as indicated by Dr Vearey.

Overall, the paper highlights a number of important socio-economic and demographic changes that are both unique to post-Apartheid South Africa and at the same time typical of many other countries.

This paper confirms the urgency of reframing and reconnecting urban health research in order to address the gap in the evidence-base and to better understand the combined challenges that impact on population health and health equity in and between cities. It is clear that the extent to which these inter-linked and combined challenges are addressed at local, national and global level will have important implications for health and health equity.